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A MANUAL OF SURGERY 
 jfor StuDcnts ant) fcractitionets 
 
MANUAL OF SURGERY 
 
 jfor Stufccnts anfc practitioners 
 
 BY 
 
 WILLIAM ROSE, M.B., B.S., Lond., F.R.C.S., 
 
 Professor of Clinical Surgery in King's Collf.ge, London, and Senior Surgeon 
 to King's College Hospital, etc. 
 
 ALBERT CARLESS, M.S. Lond., F.R.C.S., 
 
 Surgeon to King's College Hospital, and Teacher of Operative Surgery 
 in King's College, London; Examiner in Surgery to Glasgow University, etc. 
 
 FIFTH EDITION 
 
 NEW YORK 
 
 WILLIAM WOOD & COMPANY 
 
 MDCCCCH, 
 
TO 
 
 LORD LISTER, ll.d., f.r.s., 
 
 President of the Royal Society, 
 
 THE FATHER OF ANTISEPTIC SURGERY, 
 
 THIS WORK IS, WITH PERMISSION, 
 
 gefoicatei) bn the Jluthors, 
 
 IN GRATEFUL ACKNOWLEDGMENT OF THE MANY ADVANTAGES 
 
 THEY HAVE DERIVED 
 
 WHILST ASSOCIATED WITH HIM IN HIS WORK 
 
 AT KING'S COLLEGE HOSPITAL. 
 
PREFACE TO FIFTH EDITION. 
 
 In issuing a fifth edition of this work within twelve months of the 
 fourth we would note that considerable modifications have been 
 made in order to bring it up to date and to fit it more satisfac- 
 torily to modern requirements. It seemed undesirable to per- 
 petuate any longer the idea that the first and most important 
 element in surgical practice is a knowledge of inflammation and 
 its treatment, and hence this subject has been removed from its 
 original position and has been located to one secondary to that 
 occupied by Bacteriology and the principles of Antiseptic and 
 Aseptic Surgery. Sundry other changes will be found which will 
 lead to a more harmonious pathological and clinical picture than 
 was previously presented. 
 
 In conclusion we must acknowledge our indebtedness to many 
 friends who have made valuable and useful suggestions ; to 
 Professor R. T. Hewlett, who has run over the sheets of the first 
 chapter and indicated various modifications to us which make it 
 more authoritative ; and to Mr. T. P. Legg, our Surgical Registrar 
 at King's College Hospital, who has undertaken at very short 
 notice the arduous task of revising the Index. 
 
 August, 1902. 
 
PREFACE TO 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 examina- 
 tions. At the same time, the requirements of the general prac- 
 titioner have not been overlooked, for we have taken care to 
 discuss in detail those conditions which are most likely to be met 
 with in ordinary practice. The main difficulty has been to com- 
 press into a small space the ever-increasing amount of material 
 available, so that we have only been able to sketch in out- 
 line much that could have been elaborately described did the 
 size of the book permit. For the same reason, historical and 
 bibliographical references have to a large extent been omitted, 
 whilst diseases of special regions — such as the eye, ear, and female 
 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, 
 
PREFACE TO FIRST EDITION 
 
 although at the same time we have endeavoured to preserve and 
 respect that which has been shown to be good and useful in the 
 laborious researches and accumulated experiences of bygone 
 generations. 
 
 In conclusion, our best thanks are due to Dr. St. Clair Thom- 
 son, who has kindly looked through the proofs of the sections 
 devoted to the nose and ear ; to Dr. Silk, who has fulfilled a 
 similar office in reference to the chapter on anaesthetics ; to Mr. 
 William Turner for preparing the index ; and to Dr. Arthur 
 Griffiths, late of the Bristol General Hospital, who has drawn 
 several of the pictures, and given other valuable assistance. 
 
 Many of the illustrations have been specially prepared for this 
 work, but we have also to acknowledge the loan of blocks from 
 Messrs. Veit and Co., of Leipzig ; from Messrs. Cassell and Co., 
 J. and A. Churchill, Longmans and Co. ; and from the editors of the 
 Lancet for the loan of Fig. 287 [296]. The various sources from 
 which these are derived are acknowledged throughout the book. 
 Illustrations of instruments are mainly derived from Messrs. 
 Down Brothers, who have kindly placed them at our disposal. 
 
 W. ROSE, 
 
 17, Harley Street, W. 
 
 A. CARLESS, 
 
 10, Welbeck Street, W. 
 London, 
 
 May 1, 1898. 
 
CONTENTS 
 
 CHAPTER PAGE 
 
 I. SURGICAL BACTERIOLOGY SEPSIS AND INFECTION 
 
 ANTISEPSIS AND ASEPSIS - - - - I 
 
 II. INFLAMMATION - - - - ' 2 3 
 
 III. SUPPURATION AND ABSCESS - - - " 4 1 
 
 IV. ULCERATION - - - - - 58 
 V. GANGRENE - - - - - 67 
 
 VI. INFECTIVE DISEASES - - - - 90 
 
 VII. TUMOURS AND CYSTS - - 150 
 
 VIII. WOUNDS ...--- igo 
 
 IX. HEMORRHAGE - - - - -...." 222 
 
 X. INJURIES AND DISEASES OF ARTERIES ANEURISM 
 
 LIGATURE OF ARTERIES ... - 246 
 
 XI. SURGERY OF THE VEINS .... 298 
 
 XII. DISEASES OF THE LYMPHATICS - - 312 
 
 XIII. AFFECTIONS OF NERVES .... 326 
 
 XIV. SURGICAL DISEASES OF THE SKIN AND OF THE 
 
 CUTANEOUS APPENDAGES - - - " 35 1 
 
 XV. AFFECTIONS OF MUSCLES, TENDONS, AND BURSE - 363 
 
 XVI. DEFORMITIES ------ 378 
 
 XVII. INJURIES OF BONES FRACTURES - - - 417 
 
 XVIII. DISEASES OF BONE ----- 495 
 
 XIX. INJURIES OF JOINTS DISLOCATIONS - - - 539 
 
 XX. DISEASES OF JOINTS ----- 573 
 
 XXI. INJURIES OF THE SPINE ... - 628 
 
CONTENTS 
 
 CHAPTER 
 
 XXII. DISEASES OF THE SPINE - 646 
 
 XXIII. HEAD INJURIES ..... 667 
 
 XXIV. DISEASES OF THE SCALP, CRANIUM, AND CRANIAL 
 
 CONTENTS ..... 705 
 
 XXV. AFFECTIONS OF THE LIPS AND JAWS - - 723 
 XXVI, AFFECTIONS OF THE NOSE AND NASO-PHARYNX - 753 
 XXVII. AFFECTIONS OF THE MOUTH, THROAT, AND OESO- 
 PHAGUS --..-. 772 
 XXVIII. AFFECTIONS OF THE EAR .... 813 
 
 XXIX. SURGERY OF THE NECK .... 822 
 
 XXX. SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST 838 
 
 XXXI. DISEASES OF THE BREAST - - - - 866 
 
 XXXII. ABDOMINAL SURGERY .... 89I 
 
 XXXIII. HERNIA ...... 970 
 
 XXXIV. INTESTINAL OBSTRUCTION - - - - IOOg 
 
 XXXV. AFFECTIONS OF THE RECTUM AND ANUS - * - IO25 
 
 XXXVI. SURGICAL AFFECTIONS OF THE KIDNEYS - - IO5O 
 
 XXXVII. SURGERY OF THE BLADDER AND PROSTATE - IO72 
 
 XXXVIII. AFFECTIONS OF THE URETHRA AND PENIS - - III7 
 
 XXXIX. AFFECTIONS OF THE TESTIS, CORD, SCROTUM, AND 
 
 SEMINAL VESICLES - - II43 
 
 XL. AMPUTATIONS - - - II65 
 
 XLI. ANAESTHESIA - - - I184 
 
 INDEX - - I 192 
 
LIST OF PLATES. 
 
 PLATE PAGE 
 
 I. Various Types of Bacteria - - To face i 
 
 II. Fig. i. — Early Stage of Abscess Formation - 44 
 
 Fig. 2. — Section of Abscess Wall Eight Days Old ,, 44 
 
 III. Fig. 1. — Military Tubercle with Giant Cell (Highly 
 
 Magnified) - - To face 142 
 
 Fig. 2. — Tuberculous Abscess from a Suppurating Lym- 
 phatic Gland (Low Power) - - - To face 142 
 
 IV. Exostosis of the Radius - - - ,, 165 
 V. Fig. 1. — Hard Glandular Carcinoma, with abundance of 
 
 firm Fibro-Cicatricial Stroma (Scirrhous Mamm.e) To face 180 
 Fig. 2. — Granulation Tissue from a Healing Wound ,, 180 
 VI. Skiagram of Hand, with Needle embedded in the Palm, 
 
 close to the Carpus - - - - To face 200 
 
 VII. Splinter of Glass in Hand, close to Metacarpal Bone, 
 of the Index Finger - - To follow Plate VI. 
 
 VIII. Fig. 1. — Section of a Wound Healed by First Intention 
 
 Ten Days after its Infliction - - To face 214 
 
 Fig. 2. — Scar from a Recently Healed Superficial Wound 
 
 (Low Power) - - To face 214 
 
 IX. Skiagram of Double Coxa Vara - - - 394 
 
 X. Oblique Fracture of Tibia, showing the Ends of the 
 
 Fragments shaped en bee de flute - To face 420 
 
 XL Impacted Fracture of Anatomical Neck of Humerus ,, 450 
 XII. Fracture of Surgical Neck of Humerus To follow Plate XI. 
 
 XIII. Separation of the Lower Epiphysis of the Humerus, with 
 
 Displacement Outwards, in a Young Person, a little 
 over the Age of Puberty - - To face 458 
 
 XIV. Fracture of Olecranon before Operation - ,, 460 
 XV. Fracture of Olecranon Two Weeks after Operation 
 
 To follow Plate XIV. 
 
LIST OF PLATES 
 
 PLATE I'AGE 
 
 XVI. Fracture of Olecranon Six Weeks after Operation 
 
 To follow Plate XV. 
 XVII. Fracture of Shaft of the Radius — Antero-posterior 
 
 View - - To face 462 
 
 XVIII. The same Fracture seen from the Side 
 
 To follow Plate XVII. 
 XIX. Colles's Fracture : a Simple Case, without much 
 
 Lateral Displacement of Hand - - To face 462 
 
 XX. Colles's Fracture : a Bad Case, with the Styloid 
 Process of the Ulna torn off' and much Outward 
 Displacement of Hand - - To follow Plate XIX. 
 
 XXI. Fracture of both Bones of the Forearm, with Dis- 
 placement Outwards - To face 466 
 XXII. Fracture of both Bones of the Leg, seen from in 
 
 Front - - - -To face 488 
 
 XXIII. The same Fracture as in Plate XXII., seen from the 
 
 Inner Side - - To follow Plate XXII. 
 
 XXIV. Bad Pott's Fracture, with well-marked Displacement 
 
 Outwards of the Foot, as well as of the Lower 
 Fragment of the Fibula and the Internal Malleolus. 
 (Skiagram taken from in Front) - - To face 490 
 
 XXV. Tuberculous Disease of Radius - - ,, 514 
 
 XXVI. Double Congenital Dislocation of the Hip - ,, 542 
 XXVII. Dislocation of Radius Forwards, and Fracture of 
 
 Upper Third of Ulna - - To face 558 
 
 XXVIII. Tuberculous Disease of Knee-joint, showing Invasion 
 
 of Patella - - - - To face 588 
 
 XXIX. Skiagram of Pelvis, showing Tuberculous Disease of 
 
 Right Hip-joint - - To face 616 
 
 N.B. — All the X-ray pictures in this work have been taken by Messrs. Allen and 
 Hanbury, 48, Wigmore Street, W., who have kindly placed the negatives at our 
 disposal. 
 
 ERRATUM. 
 On page 160, line 7, for ' p. 145,' read ' p. 181. 
 
PLATE I. 
 
 
 ., ^ t««, -*• 
 
 Fig. i. 
 
 Fig. 2. 
 
 Fig. 3. 
 
 Fig. 4. 
 
 Jo face ./. 1. ] 
 
 Fig. 5. 
 
 Fig. 6. 
 
A MANUAL OF SURGERY. 
 
 CHAPTER I. 
 
 SURGICAL BACTERIOLOGY — SEPSIS AND INFECTION — 
 ANTISEPSIS AND ASEPSIS. 
 
 Bacteriology, or the science devoted to the study of bacteria, 
 must necessarily be the basis of all scientific surgery, which apart 
 from such knowledge degenerates into little more than a technical 
 art. It is the surgeon's duty to understand the life-history and 
 methods of activity of bacteria, so that he may be able to prevent 
 their access to wounds, or, if they have gained a foothold in the 
 system, be able to combat them. To this latter end he must call 
 to his aid all the powers of resistance latent in the economy, and 
 should be able to add to these by the introduction of suitable 
 protective substances developed artificially. Of course, it is not 
 altogether desirable that an active operating surgeon should be 
 constantly working in the laboratory with virulent germs, but 
 he must have acquired a sound knowledge of bacteriological 
 technique, and be fully capable of appreciating the researches and 
 investigations made by others. 
 
 Bacteria, or schizomycetes, form a very important and numerous 
 class of minute vegetable organisms, which are in the present day 
 looked upon as the essential cause of putrefaction and of most of 
 the inflammatory diseases. They consist of minute masses of 
 protoplasm enclosed in a cell wall, and with sometimes a gelatinous 
 capsule or envelope, which may suffice to hold together two or 
 four elements or even larger colonies. 
 
 They vary in shape, size, and arrangement, and from a mor- 
 phological standpoint have been classified under the following 
 headings : 
 
 i. Micrococci, or Cocci, are roundish or oval cells, multiplying 
 rapidly by a process of fission (i.e., division into equal parts). 
 They may remain isolated, but, as a rule, are collected into 
 certain definite formations, and in consequence are termed staphy- 
 
 i 
 
A MANUAL OF SURGERY 
 
 lococci, or cluster-cocci (Fig. 3), when they are grouped like a 
 bunch of grapes, usually occurring thus in localized inflamma- 
 tions ; streptococci, or chain-cocci (Plate I., Fig. 1), when they 
 develop in chains or strings, the characteristic of spreading 
 inflammations ; diplococci, when they occur in pairs — e.g., the 
 gonococcus or pneumococcus, met with in gonorrhoea and pneu- 
 monia respectively. When they are grouped into packets of four 
 or eight individuals, they are usually termed sarcina (Plate I., 
 Fig. 2). Occasionally any of the above may occur in masses or 
 colonies, slimy or gelatinous in character (zooglcea). 
 
 2. Bacilli, or rod-shaped bacteria, are found in the form either 
 of long or short filaments, made up of an aggregation of individual 
 rods united end to end; or they may become curved, and so form 
 spiral rods, which may break up into the so-called comma-shaped 
 bacilli ; or they may persist in the body of their host as isolated 
 rods, free in the blood or lymph, or within the substance of the 
 cells invaded. They multiply by fission, or by the formation of 
 spores in their interior. These latter are much more resistant 
 and less easily destroyed than the parent rods. The spore may 
 develop in the centre of the bacillus, as in Bac. anthracis, or at 
 one end, as in the so-called drumstick-shaped Bac. tctani. 
 
 3. Spirilla (Plate I., Fig. 4) form corkscrew - like threads, 
 possessing active power of movement. They are of no surgical 
 interest, and in human pathology only occur in a few conditions, 
 such as remittent fever. 
 
 It will here only be possible to sketch in outline a few general 
 facts as to the life-history and mode of activity of these organisms. 
 
 Methods of Examination. — These are in the main threefold : 
 
 1. Microscopic Examination. — High powers of the microscope (e.g., -,V in- oil 
 immersion) are needed for this work, and even with them it is often difficult to 
 determine the characters of any particular form of microbe under examination. 
 Minute differences in the size and shape may assist, and the relative arrange- 
 ment in chains, clusters, etc. ; whilst the effect of different staining reagents is 
 also important. Into the various methods of demonstrating and staining 
 bacteria it is impossible to enter. 
 
 2. Cultivation in or on various nutrient media is of the greatest assistance in 
 determining the exact nature of any special organism under examination. For 
 this purpose the cut surface of a raw potato after sterilization of the exterior 
 suits excellently in many cases. Fluids, such as meat infusion, milk, or fresh 
 blood serum, are not very satisfactory, but similar materials, solidified by the 
 addition of gelatine or agar-agar, and either placed in test-tubes or on plates, 
 or meat infusion mixed with peptone, are the most suitable nutrient bases. In 
 testing the life-history of any microbe, it is important to note whether or not 
 it will develop in contact with the air. This may be accomplished by the use 
 of nutrient gelatine poured into test-tubes, some of which are allowed to cool 
 in the vertical position, and others on the slant. The former are inoculated 
 by puncturing the horizontal surface with an infected platinum wire (stab 
 culture), the latter by streaking it along the oblique surface (streak culture). 
 
 3. Inoculation experiments are really the most reliable means of examining 
 into the relations of micro-organisms to any particular affection ; but it must 
 be clearly recognised that animals are not necessarily affected in the same way 
 
SURGICAL BACTERIOLOGY 
 
 as man. Koch has insisted that the four following essentials must be fulfilled 
 in order to prove the infective character of any particular disease : 
 
 (i.) The organism must be present in every case, either in the tissues or in 
 
 the blood, 
 (ii.) It must be possible to cultivate it for many generations apart from the 
 
 body, 
 (iii.) Its inoculation into a suitable animal must be followed by the appear- 
 ance of the specific disease ; and 
 (iv.) The organism must be found in the tissues or blood of the animal 
 infected in this manner. 
 
 Habitat. — Bacteria are almost universal in their distribution. 
 Earth, air, and water are full of them, and especially so in 
 populous neighbourhoods. The greater the number of the 
 inhabitants, the larger the number of organisms in the air. In 
 isolated, and especially mountainous, districts there are com- 
 paratively few, whilst in the air of a crowded hospital ward 
 swarms of them are present, and these often of a most dangerous 
 type. Food-stuffs and fluids, such as water and milk, are fre-. 
 quently contaminated, and by these means disease is often intro- 
 duced into the system. The surface of the body is impregnated 
 with bacteria, which extend to a depth greater than can be 
 affected by mere domestic cleanliness, whilst the intestinal tract 
 teems with them from mouth to anus. It appears that whilst the 
 external auditory meatus and inferior meatus of the nose are 
 occupied by bacteria, the upper meati of the nose are sterile, as 
 also the upper part of the virgin vagina and the deeper portion 
 of the (uncontaminated) male urethra. The gall-bladder, as well 
 as the biliary and pancreatic ducts, is also normally free from 
 germs, whilst in a healthy individual the solid organs, the blood, 
 and lymph are also practically sterile. Any condition of general 
 weakness facilitates the entrance of germs into the system, or, 
 perhaps one should say, diminishes the resistance of the body to 
 their presence and activity, and hence lays the individual open to 
 the occurrence of diverse infective diseases. 
 
 Mobility. — The cocci are as a group incapable of active locomo- 
 tion, although they manifest, in common with all minute non- 
 living particles, ' Brownian ' movements. Most bacilli and 
 spirilla have in addition the power of moving from place to place, 
 accomplished by means of flagella, which develop at one or both 
 ends as single filaments or in bunches all over the organism. 
 These can be readily demonstrated in the Bac. typhosus (Plate I., 
 
 Fig- 3). 
 
 Multiplication. — The power of multiplying possessed by bacteria 
 is enormous, though not unlimited. Two methods have been 
 mentioned above — viz., fission and the formation of endospores. 
 Spore formation is not known to occur in the. cocci or sarcinae, 
 and, although common among the bacilli, is not invariable ; thus 
 the Bac. typhosus and the Bac. diphtheria are asporogenous. Only 
 one spore forms in each bacillus, and, as already stated, its 
 
 i — 2 
 
A MANUAL OF SURGERY 
 
 position varies in different species. The conditions favourable 
 to the development of spores have not yet been fully ascertained, 
 but in most varieties a free supply of oxygen is required ; it is 
 also a fact that spores rarely form amongst the living tissues of 
 the body. 
 
 Conditions of Growth. — The activity and development of bacteria 
 are physiological phenomena, carried out in accordance with the 
 general laws governing animal and vegetable life, and requiring 
 certain definite conditions to be present. The pabulum, or food- 
 stuff, differs somewhat with the particular species, but they all 
 require water, oxygen, hydrogen, nitrogen, carbon, and certain 
 inorganic salts ; they usually grow better on highly complicated 
 substances than on more simple materials. Desiccation arrests 
 bacterial growth, although the organisms are not killed thereby. 
 Temperature has also considerable influence upon their develop- 
 ment. Few germs grow well under 20 C, and pathogenic 
 organisms develop best at about 37 to 38 C. Cold checks all 
 growth, but does not kill the germs. Any degree of heat above 
 57 C, if allowed to act long enough, will suffice to kill most 
 bacteria, but spores require a much higher temperature for their 
 destruction. Light, especially direct sunlight, has a retarding 
 influence on the development of most micro-organisms. 
 
 The necessity or not for atmospheric air in their development 
 constitutes the basis of the division of microbes into aerobic and 
 anaerobic. When they can grow in, and, indeed, require for their 
 development, the actual presence of free air, they are termed 
 obligate aerobes. If, however, they have the power of acquiring 
 the oxygen they need from the tissues surrounding them, they are 
 then known as facultative anaerobes ; their development is then 
 rather less rapid than when aerobic conditions are present. 
 Obligate anaerobic organisms are those which require an atmosphere 
 around them, from which oxygen is rigidly excluded, and these 
 usually flourish best in nitrogen or hydrogen — e.g., the bacillus of 
 tetanus. It must be remembered, however, that although their 
 power of development is arrested by the presence of oxygen, it is 
 not destroyed ; the restoration of anaerobic conditions will at once 
 restore their vital activities. 
 
 Results of Growth. — Many different substances result from 
 bacterial growth, both in culture media and in the body, and upon 
 the characters of these depend to a large extent the symptoms of 
 the special diseases. Chief amongst them are the Toxins, which 
 are perhaps more intensely poisonous than anything else known. 
 Many of them are albuminous bodies (possibly albumoses) ; most 
 of them have a ferment-like action ; and not a few are capable of 
 liquefying gelatine or peptonizing proteids. The toxins formed 
 by putrefactive organisms {the ptomaines) are more or less peculiar 
 in that they are alkaloidal in nature — i.e., built up in the like- 
 ness of ammonium hydrate (NH 4 HO) — they unite with acids, 
 
SURGICAL BACTERIOLOGY— SEPSIS 
 
 and can be crystallized. The development of toxins in the body 
 is the all-important cause of the symptoms of disease ; locally, 
 they give rise to various inflammatory phenomena, and by their 
 general absorption produce either pyrexia alone, or peculiar and 
 characteristic manifestations, as in tetanus and diphtheria. 
 
 Other results of bacterial activity are less important, though 
 some are very obvious, i. Acid substances may be formed ; e.g., 
 the Bac. acidi lactici is the constant cause of the souring of milk. 
 2. Alkaline products may develop; e.g., the Diplococcus urea trans- 
 forms the urea of urine into carbonate of ammonia. 3. Gases, 
 often of a very penetrating odour, may be produced by others ; 
 e.g., Bac. coli communis, or Bac. cedematis maligni. 4. Various 
 colouring bodies are generated, but this property is mainly limited 
 to the non-pathogenic group. 5. Phosphorescence is also caused 
 by certain bacteria. 
 
 From their environment in pathological conditions, bacteria 
 are divided into two great classes, according to whether or not 
 they can develop in the living tissues. The pathogenic or parasitic 
 bacteria can do so, producing what are known as infective 
 diseases ; but when an organism can only develop in dead tissues, 
 such as masses of slough, or in exudations of blood, serum, or 
 pus, or in some non-living nutrient material, it is called a non- 
 pathogenic; saprophytic, or carrion microbe, and any inflammatory 
 reaction, local or general, thereby induced is due to the irritating 
 effect of the toxic bodies produced in this way, and not directly 
 to the action of the bacteria. Some of the pathogenic organisms 
 are capable of continuing their development in dead tissues as 
 facultative saprophytes, and this property is one of great danger, in 
 that it permits of extensive diffusion of the virus ; the tetanus, 
 anthrax, and malignant oedema bacilli, as also the pyogenic cocci, 
 are characterized by this property. 
 
 It is now possible to define the terms ' sepsis ' and ' infection ' 
 as employed in surgical practice. 
 
 Sepsis. 
 
 Sepsis is a term, somewhat loosely applied, to indicate that a 
 wound or sore has become infected w 7 ith micro-organisms in such 
 a way as to interfere with healthy reparative action. When it 
 involves an operation wound, it is due to contamination from a 
 dirty state of the skin, impure instruments, ligatures or sutures, 
 unsterilized hands of the surgeon or assistant, a faulty dressing, 
 etc. Sepsis may also develop in connection with any unprotected 
 sore or abrasion, and the offensive odour which accompanies 
 neglected syphilitic or cancerous sores is simply due to this, and 
 is no essential part of the causative affection. 
 
 The organisms present in septic affections vary considerably, 
 but are of two main types : (a) Various non-pathogenic microbes, 
 
A MANUAL OF SURGERY 
 
 especially the Proteus vulgaris, P. Hausevi, sundry forms of Sarcince, 
 and, under certain circumstances, the Bac. coli communis, and 
 (b) the ordinary pyogenic bacteria, especially the staphylococci 
 and streptococci, which are, of course, pathogenic. 
 
 The method of action of these organisms is somewhat diverse. 
 (a) The former, or non-pathogenic group, can only develop in 
 dead tissues or fluids, or in passive material such as blood-clot, 
 pus, or serum ; they may occasionally gain an entrance to the 
 general circulation, but are rapidly destroyed, and do no harm. 
 It is obvious, therefore, that a dry wound is less likely to become 
 septic than one in which there is much exudation of blood or 
 serum, so that absolute haemostasis and good drainage are two 
 most important preventive measures. 
 
 When once admitted to the part, the organisms rapidly 
 multiply, causing putrefaction or other changes in any suitable 
 pabulum present, and thus produce irritating or poisonous 
 chemical substances, upon the action of which the symptoms of 
 sepsis, whether local or general, depend. If a large quantity of 
 putrescible material is present, the wound or part may become 
 very offensive, and a sloughing process may ensue as a result of 
 the irritating local action of the toxins, whilst at the same time 
 general toxic symptoms are manifested, varying in severity with 
 the dose absorbed. 
 
 (b) The latter group of true pyogenic bacteria are capable of 
 growth in a similar manner, but in addition are able to invade 
 and develop in the tissues of the body (infection), and so may give 
 rise to spreading inflammation, such as erysipelas or cellulitis, 
 and to general infective diseases, such as pyaemia or septicaemia. 
 
 Into the question of local appearances and treatment it is 
 unnecessary to enter here,' but it is desirable to add a few words as 
 to the general conditions which are associated with a septic wound. 
 They are entirely due to the absorption of the toxins produced 
 in the inflammatory focus, and hence vary considerably in severity 
 with the dose. Thus three varieties have been described : 
 
 i. When the dose is small, but if it is absorbed regularly and 
 for a long time, a definite diurnal range of temperature follows, 
 known as hectic fever (p. 52). It is always associated with per- 
 sistent and prolonged suppuration. 
 
 2. Septic Traumatic Fever is due to the absorption of a some- 
 what larger amount of the poison after an operation or injury, 
 which is followed by septic inflammation. A burn or compound 
 fracture which is not rendered aseptic is always accompanied by 
 fever, ranging from 102 to io4°F. for some days, until the wound 
 is securely sealed off by the development of granulation tissue. 
 When once this has occurred, the fever usually disappears, unless 
 septic material is retained under pressure. The actual phenomena 
 connected with such an attack are in no way peculiar. 
 
 3. Acute Saprsemia, or Septic Intoxication, results from the 
 
SEPSIS AND INFECTION 
 
 absorption of a large dose of toxic material. This condition was 
 for long confounded with true infective septicaemia, and even 
 now, though clearly distinguished pathologically, a clinical dis- 
 tinction between the two is not always possible, except by await- 
 ing the result. Sapraemia is essentially a toxaemia, or condition 
 due to chemical poisoning ; the blood is not infective, and the 
 symptoms are directly proportionate to the dose. Any condition 
 in which there is a large mass of putrefying tissue or fluid from 
 which absorption can occur may lead to sapraemia — e.g., a portion 
 of decomposing placenta in the puerperal uterus, the existence of 
 septic pus under pressure in the peritoneal cavity, a joint, or else- 
 where ; or a mass of putrefying blood-clot, say, in the pleural 
 cavity after a penetrating wound. 
 
 The Symptoms usually commence, two or three days after the 
 cause has come into operation, with a severe rigor, followed by a 
 maintained high temperature, although sometimes it is subnormal 
 in the more serious cases. This is associated with loss of 
 appetite, a dry tongue, a quick pulse, rapidly becoming weak, 
 severe headache, and nocturnal delirium of some intensity. The 
 patient is at first constipated, but vomiting and diarrhoea may 
 ensue from gastro-intestinal irritation, followed by fatal exhaus- 
 tion and collapse, or he may become comatose and unconscious 
 for some time before death, according to whether the toxins act 
 chiefly upon the alimentary system or upon the cerebral centres. 
 Dyspnoea, from pulmonary congestion, and albuminuria, also 
 occur. Should, however, the putrefying mass be removed in 
 time, the fever will cease as by magic, the tongue cleans, the 
 appetite returns, the headache vanishes, and in twenty-four hours 
 the patient feels a different individual. 
 
 Post-mortem Appearances. — Decomposition is early, rigor 
 mortis feeble, and cadaveric lividity well marked, especially along 
 the lines 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 from the breaking up of the red blood-cells which occurs 
 in all septic and 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 membranes are well-marked petechia?, 
 especially under the pericardium and pleura. The lungs are 
 deeply congested, particularly at the back, and very cedematous ; 
 the liver, spleen, and kidneys are enlarged, pulpy, soft, and 
 congested, notably the spleen. The epithelium of most of the 
 secreting glands, if examined microscopically, gives evidence of 
 cloudy swelling. 
 
A MANUAL OF SURGERY 
 
 The Treatment of acute sapraemia 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 it 
 has been proposed to deal with the acute toxaemia of peritonitis 
 and similar conditions by the repeated injection into the veins of 
 large quantities of saline solution (7)i. ad Oi.), and excellent results 
 have been obtained by this means, the injections being followed 
 by diuresis and diarrhoea, which presumably assist in the elimina- 
 tion of the poison. (See also on Septicaemia, p. 102.) 
 
 Infection. 
 
 An infective process is one due to the activity of micro- 
 organisms, which are capable of developing in living tissues — 
 the true pathogenic bacteria or parasites. Such find an entrance 
 into the body in many ways, as through the healthy skin, or by 
 the mucous membranes of the alimentary canal, respiratory tract, 
 or genito-urinary apparatus, or through wounds and abrasions ; 
 and very often the manifestations of disease differ widely with 
 the channel of entrance. Occasionally they are absorbed into 
 the blood through some comparatively insignificant local lesion, 
 and although insufficient in numbers to produce general symp- 
 toms, yet they may find elsewhere some suitable spot for their 
 development, and there settle, giving rise to an acute outbreak of 
 mischief, which may attain grave proportions. Such a condition 
 is said to be due to auto-infection. (See Acute Osteomyelitis, 
 Chapter XVIII.) 
 
 It must not be imagined that mere exposure to infection 
 inevitably results in an outbreak of disease. Nature has pro- 
 vided us with very efficient protective agents, and many factors 
 enter into the question as to whether or not bacteria are able to 
 develop in the body. 
 
 1. The dose of the organisms is an all-important element, 
 especially in connection with the pyogenic bacteria, which are 
 those most commonly met with, and against the activity of which 
 we are fairly well protected. Much experimental work has been 
 undertaken to establish this point, and it is now well-known that 
 usually an enormous number of cocci have to be injected into the 
 blood-stream in order to establish general infection ; a smaller 
 number has but little, or, at any rate, a very temporary effect. 
 
 2. The vivulcnce of the organisms varies very considerably under 
 different circumstances, and bacteria which under one set of 
 conditions are comparatively harmless may under others become 
 intensely noxious. It is only necessary to mention the frightful 
 severity of some diffuse inflammatory attacks after, say, the 
 
SEPSIS AND INFECTION 
 
 prick of an infected pin to emphasize the potentialities for mischief 
 latent in some germs. 
 
 3. The resistance of the tissues is another factor in the case, the 
 nature of which we shall allude to anon. Here we would only 
 call attention to the fact that anything that diminishes this resist- 
 ing power favours the chances of infection. Thus exposure to 
 wet and cold, especially if prolonged, unquestionably leads to a 
 decided, if temporary, lowering of the vitality of the tissues, 
 which may then more easily fall a prey to the organisms which 
 are so constantly present and ever ready to take advantage of 
 any weak spot in our defensive armour. The effect of such 
 exposure varies with the individual, but in most cases his own 
 particular ' weak spot ' will be found out. In one a mere cold 
 in the head — i.e., a congestion of and hypersecretion from the 
 Schneiderian mucous membrane — will result ; in another the 
 mischief will extend more deeply, leading to pleurisy or pneu- 
 monia ; in a third some weak organ, such as the stomach or 
 bladder, may be involved ; whilst in another an attack of 
 rheumatism may be induced. A localized injury to the tissues, 
 whether in the nature of a burn, bruise, or crush, etc., will render 
 them more liable to microbic invasion ; whilst general con- 
 ditions of the blood, such as occur in chronic alcoholism, Bright's 
 disease, diabetes, etc., are always associated with a diminished 
 power of resistance. Want of fresh air, living in unsanitary 
 surroundings, overloading of the system with rich food, especially 
 if the excretory apparatus of the body is not effective — all such 
 conditions favour the activity of organisms, and render the subject 
 more prone to be attacked. 
 
 4. The amount of suitable and available pabulum has a distinct 
 influence, particularly in the case of the pyogenic organisms, 
 which are facultative saprophytes, and so may readily develop 
 in non-living material, such as blood-clot, etc., allowed to collect 
 in or on a wound. This is followed by a local development of 
 toxins, which, acting on the immediately contiguous living tissues, 
 cause them to become inflamed ; local diminution of resistance 
 follows, and may lead to actual infection, which otherwise the 
 patient could easily have resisted. Hence the importance of 
 draining all wounds where effective haemostasis has not been 
 attained, and of giving an exit to all collections of blood, etc., 
 which might become septic. In the healthy individual a wound 
 will often heal perfectly, in spite of the presence of organisms, 
 granting that it is dry and free from bruising. The existence of 
 blood-clot or exudation in which the cocci can develop would be 
 likely to favour suppuration. 
 
 A good deal of confusion has existed between the terms ' contagion ' and 
 ' infection '; and it is well to explain that by ' contagious ' is meant a disease 
 which can only be transmitted to a healthy person by direct contact with the 
 infected individual, or by the direct transmission of the virus through an 
 
A MANUAL OF SURGERY 
 
 intermediate individual or object, provided that the organism has not multiplied 
 outside the body. Syphilis is eminently contagious, either directly, from one 
 person to another, or indirectly, as by smoking an infected pipe. Thus, con- 
 tagion is merely a limited type of infection. On the other hand, many infective 
 diseases are due to organisms which can readily develop outside the body, 
 i.e., to the facultative saprophytes, but to these the term ' contagious ' should 
 not be applied. 
 
 Local Infective Processes are those caused at the spot of inocula- 
 tion 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 they are struggling with the 
 germicidal action of the tissues, and establishing their foothold in 
 the body — the bacteria begin to grow and multiply, and by the 
 deleterious products of their activity cause irritation of the tissues 
 and various degrees of inflammation. 
 
 These inflammatory foci may remain limited, or diffusion may 
 occur by the bacteria spreading with more or less rapidity by 
 continuity of tissue or along lymph channels ; or the organisms 
 may be widely disseminated through the body by the blood- 
 vessels in the shape of emboli. A certain amount of constitutional 
 disturbance may accompany these manifestations, due to the 
 absorption of the 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 infective processes may be classified 
 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, diph- 
 theria, 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 
 constitutional affections. 
 
 General Infective Processes are those in which the organisms 
 develop and multiply in the blood-stream, so that inoculation of 
 a sound person with 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 without 
 some local condition being present to explain its origin. Septi- 
 caemia, pyaemia, acute tuberculosis, the second stage of syphilis, 
 anthracaemia, and probably the exanthemata, are illustrations of 
 general infection (see Chapter VI.). 
 
 Resisting or Antiseptic Power of the Tissues — Immunity. — If 
 we are surrounded with, and if even our bodies are invaded by, so 
 great a swarm of enemies, many of which could under suitable 
 circumstances produce grave diseases, there must necessarily be 
 
SEPSIS AND INFECTION 
 
 present within us some potent natural means of resisting their 
 activity and development. If bacteriologists can only determine 
 how organisms are naturally kept at bay, we may hope to elaborate 
 along the same lines defensive measures which will be available 
 when the enemy has broken through the first line of defence, and 
 is actively attacking the body. 
 
 That a Natural Immunity to certain diseases is present in 
 various individuals is only hi accord with the observation that 
 various animals are capable of resisting the action of microbes 
 which can develop in others ; thus, rats are unharmed by anthrax 
 bacilli, whilst the dog, the goat, and the ass are practically 
 immune to tubercle. Again, negroes are relatively insusceptible 
 to yellow fever, whereas white people are extremely susceptible. 
 That this natural immunity is not absolute is also a fact, since 
 organisms which will have no effect on a healthy animal will 
 sometimes attack one which has been brought into an asthenic 
 condition. 
 
 It is also a well-known fact that immunity to certain diseases 
 may be acquired in various ways : (i) Thus, one attack of many 
 specific diseases frees the individual from the risk of contracting 
 it again — e.g., the exanthemata and syphilis — but this freedom is 
 not absolute, and second attacks, even of such an affection as 
 syphilis, are not unknown. In some infective diseases — e.g., 
 erysipelas — it seems probable that any immunity which develops 
 subsequently is of extremely short duration and quickly passes 
 away, leaving the patient, if anything, more prone to infection 
 than formerly. (2) Inoculation with the actual virus of an 
 infective disease has been utilized in the case of small-pox, 
 choosing such a time as suits the individual, and when he is in 
 good health. This practice has ceased since the introduction of 
 vaccination, but the method is still utilized in the case of certain 
 animals. Thus, an animal can be immunized by inoculating it 
 with minute doses of a specific organism, which are gradually 
 increased, until no more effect is produced, whatever the dose 
 given. (3) After Pasteur had made his brilliant and most valuable 
 discovery that the virulence of germs could be easily mitigated, 
 and that exposure to heat for a short time sufficed to attenuate 
 the virus in the majority of cases, much experimental work on 
 animals became possible, and considerable success has attended 
 the use of an attenuated virus in order to protect cattle from 
 anthrax. (4) Going one step further, it has been found that one 
 need not use the living organism at all, but that inoculation with 
 the sterilized products of bacterial activity (i.e., the dead bacteria, 
 together with their toxins) is in many diseases quite sufficient to 
 determine immunization. A minute dose is at first administered, 
 but as the degree of immunity increases the dose is gradually 
 augmented, until finally the animal can receive with impunity an 
 injection of many hundred times the dose which would have 
 
A MANUAL OF SURGERY 
 
 killed it at first. The typhoid and plague vaccines are of this 
 nature. (5) Lastly, it is now known that the blood serum of an 
 immunized animal has considerable protective powers, and what 
 has been termed passive immunity may be developed in this way. 
 Most of the serotherapy of the present day depends on this 
 property, and the serums known as antitetanic, antidiphtheritic, 
 and antistreptococcic are all of this najture. The immunity 
 conferred by this means is rapidly acquired, but does not generally 
 last long. 
 
 Much discussion has arisen as to the way in which the invasion 
 of infective organisms is repelled in the body, and two chief 
 schools of thought have arisen : (1) The French school, led by 
 Metchnikoff, maintains that the leucocytes, and also the larger 
 round cells derived from the connective-tissue corpuscles, described 
 elsewhere as ' fibroblasts,' have the power of taking into their 
 substance the microbes, and destroying them by a process of 
 digestion. This idea of Phagocytosis is based on the results of 
 microscopic examination, it being tolerably easy to demonstrate 
 the presence of bacteria within the living leucocyte (Fig. 1), 
 
 Fig. 1. — Phagocytosis. (Tillmanns.) 
 
 In the first figure the rod-shaped organism is being absorbed or swallowed by 
 the phagocyte ; in the second it is incorporated in its body ; and in the 
 third it is being disintegrated. 
 
 although opponents to this theory suggest that it is only dead or 
 dying organisms which are dealt with in this way ; whilst it is 
 also a well-known fact that the presence of organisms within cells 
 is no absolute evidence of phagocytosis, since the latter may be 
 invaded and finally destroyed by the bacteria, as in leprosy and 
 gonorrhoea. As an important outcome of this doctrine has arisen 
 the idea of Chemiotaxis, a term introduced to indicate an attractive 
 or repulsive power exercised upon the leucocytes by foreign bodies 
 or various chemical substances, particularly those dependent on 
 bacterial activity. By positive chemiotaxis is meant the attrac- 
 tion whereby leucocytes are gathered towards any tissues in which 
 bacteria have commenced to develop ; the organisms or their 
 products seem to have a power of causing active diapedesis and 
 exudation of plasma, as a result of which the spread of the 
 microbic invasion is more likely to be limited, and the inflamma- 
 tion thus caused is protective rather than destructive. Positive 
 
SEPSIS AND INFECTION 13 
 
 chemiotaxis is to be looked on, then, as one of Nature's defences 
 against an active and vigorous microbic attack. That it occurs 
 cannot be questioned, though no explanation as to its origin or 
 nature is at present forthcoming. It must be noted, however, 
 that its existence is no absolute evidence in favour of Metchnikoff's 
 theory, since where leucocytes are collected, there is also certain 
 to be an increased effusion of plasma or serum. Negative chemio- 
 taxis, on the other hand, is the term applied to a condition in 
 which the leucocytes are apparently repelled by the organisms, 
 probably on account of their virulent nature, though it is impossible 
 to prove that any active repulsion exists. Both phenomena can 
 be seen very well by inoculating the cornea of an animal with the 
 Aspergillus nigev, as was done by Leber ; the spot of inoculation 
 looks opaque and dull, owing to the development therein of the 
 mycelium of the fungus, and the necrosis caused thereby ; around 
 this is an area of clear corneal tissue which is necrotic, but free 
 from leucocytes owing to negative chemiotaxis. Outside this, 
 again, is a circle of infiltrated tissue, at first of a whitish-yellow 
 colour, and finally breaking down into pus, the result of positive 
 chemiotaxis. (2) More recently the theory of phagocytosis has 
 been very vigorously attacked by the German school of patho- 
 logists, and it has been maintained that the chief germicidal 
 powers of the body reside in the blood serum and its constituents. 
 This idea is certainly supported by the well-known fact that fresh 
 blood serum is a bad medium for the cultivation of bacteria. Its 
 inhibitory or germicidal properties can, however, be removed by 
 keeping it, or by exposing it to a process of dialysis, or by heating 
 it for about half an hour to a temperature of 55 C. Moreover, 
 as mentioned above, the blood serum of immunized animals 
 evidently contains certain substances of an antibacterial or pro- 
 tective nature, and may be used as a curative agent. Certain 
 special albuminous substances, more or less of the nature of 
 ferments, have been isolated, to which the name of Protective 
 Albumens or Alexines has been given. Probably there is truth 
 in both these theories, the two different powers being called into 
 play under varying circumstances and in different stages of the 
 disease, the phagocytes only coming in to complete the work 
 which has been already mainly effected by the blood plasma ; or 
 possibly the protective albumens are developed by the leucocytes 
 and set free into the serum. 
 
 The inflammatory phenomena which supervene upon a localized 
 infection are to be looked on as Nature's means of repelling the 
 bacterial invasion. The irritation induced by the toxins calls 
 forth an increased supply of blood (hyperaemia), and that involves 
 an increased flow of blood serum, whilst leucocytes are gathered 
 together from all parts by a process of chemiotaxis ; indeed, so 
 marked is this latter detail that sometimes leucocytosis is induced, 
 and a blood count will often indicate whether or not an infective 
 
14 
 
 A MANUAL OF SURGERY 
 
 process is being satisfactorily resisted (p. 47). Even should an 
 abscess form, that is merely to be looked on as one of the means 
 of eliminating bacteria from the system. Occasionally, however, 
 the virulence of the organisms may be so great, or the protective 
 powers of the individual so slight, that all opposition is borne 
 down, and the bacteria invade the system generally, perhaps 
 causing the patient's death. 
 
 An important outcome of modern ideas as to infection and 
 immunity is the development of means of treating infective 
 diseases or of securing protection against them by artificial sera, 
 containing suitable antitoxins (serotherapy). It may be antici- 
 pated that in the near future a considerable advance will be made 
 in this direction, but at present the chief sera in use are those 
 directed against diphtheria, tetanus, and streptococcal affections 
 (as preventive and curative agents). In the production of these 
 sera some suitable animal (frequently a horse) is gradually 
 immunized by increasing doses of the virus, and then the blood 
 serum, which presumably contains the antitoxin, is withdrawn 
 and utilized, after the addition of a small quantity of thymol as 
 a preservative. Sometimes the blood serum is dried, and needs 
 to be dissolved in sterilized water before use. The antitoxins act, 
 as already indicated, in one of two ways — either by preventing 
 the further development of organisms in the body — i.e., by im- 
 munizing the individual (inhibitory action) — or by counteracting 
 the effect of the toxins already produced (antitoxic action). Suit- 
 able reference as to the use of these agents will be found in the 
 sections on Tetanus, Erysipelas, etc. 
 
 Having now indicated in outline how Nature repels from within 
 a bacterial invasion of the body, and what assistance may be 
 given to her by means of serotherapy, it only remains in this 
 chapter to point out the methods adopted by surgeons in protect- 
 ing their operation wounds from external contamination with 
 micro-organisms. In this connection the name of Lord Lister 
 will ever stand pre-eminent as that of the man who applied to 
 surgery the principles which were being taught by Pasteur as to 
 the microbic origin of disease. It is no exaggeration to say that 
 Lister by the introduction of antiseptic surgery completed the 
 revolution of surgery which had already commenced twenty or 
 thirty years earlier owing to the discovery of anaesthesia. 
 
 Antisepsis and Asepsis. 
 
 The Antiseptic plan of treating wounds, 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 
 the wound by the use of chemical agents, some of which are true 
 germicides, capable of destroying the bacteria, whilst others merely 
 prevent or inhibit their growth. Innumerable methods of apply- 
 
ANTISEPSIS AND ASEPSIS 15 
 
 ing this treatment have been adopted, and multifarious antiseptic 
 agents have been used, promiment among them being carbolic 
 acid, corrosive sublimate, iodine, iodoform, salicylic acid, boric 
 acid, etc. 
 
 Carbolic Acid, the first antiseptic introduced by Lister, has a direct germi- 
 cidal action in strong solutions, and an inhibitory effect in weaker ones. The 
 crystals, when heated with 10 per cent, of water, constitute an oily fluid known 
 as pure or liquefied carbolic acid, which is a powerful though superficial 
 caustic, and may be employed without much fear to infected lesions, in order, 
 if possible, to sterilize them. Thus, it is always well to treat tuberculous 
 wounds with this fluid after scraping them, in order to destroy any portions 
 of tuberculous material which may have escaped the spoon. The liquid 
 carbolic dissolves in water on the application of a little warmth, and the 
 1 in 20- and 1 in 40 solutions are those mainly employed ; the former is an 
 efficient and potent antiseptic, but must be used carefully on delicate skins. 
 Carbolic acid is frequently somewhat crude and impure, and many of the 
 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 a rise in temperature and some 
 intestinal irritation, whilst diseased kidneys may be seriously affected. It is 
 more likely to occur when weaker solutions are employed than when the 
 liquefied or pure acid is applied. The latter is seldom absorbed. 
 
 Corrosive Sublimate is a valuable though very poisonous remedy, which 
 is usually employed in solutions of 1 in 2,000, 1 in 1,000, or 1 in 500. Occa- 
 sionally 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. They have less power of penetration than carbolic acid, but have 
 no hardening or roughening influence on the skin. If, however, a dressing 
 soaked in a sublimate solution (1 in 2,000) is kept for long in contact with the 
 skin, it acts as. a direct irritant, and may lead to an abundant formation of 
 pustules, owing to the activity of the germs in the deeper parts of the cutis 
 which have not been destroyed by the antiseptic. Instruments should not be 
 placed in sublimate solutions, as, even if plated, they soon lose their bright 
 appearance. It must be remembered that individuals very sensitive to the 
 action of mercury may be salivated by this agent. 
 
 Biniodide of Mercury is a potent antiseptic, which has been chiefly employed 
 in the form of a 1 in 500 solution in 70 per cent, methylated spirit for the puri- 
 fication of the hands or of the skin of the patient. It is, of course, extremely 
 toxic. 
 
 Boric or Boracic Acid is a mild and weak antiseptic, which may be utilized 
 when stronger remedies might prove harmful — e.g., in plastic operations and 
 for infants. It is also useful when antiseptic fomentations are required in 
 treating inflammatory phenomena. 
 
 Iodoform is a yellow powder of characteristic and unpleasant odour, which 
 probably acts by being decomposed in the tissues and slowly giving off iodine. 
 Commercial iodoform is usually contaminated with a variety of germs, as may 
 be shown by dusting it over a film of nutrient gelatine and allowing them to 
 develop. It is therefore wise to wash the iodoform before use in 1 in 20 
 carbolic lotion or some such antiseptic. Its chief value is in septic or tuber- 
 culous wounds, and, indeed, it seems to have a specific inhibitory action upon 
 the development of the Bat. tuberculosis. It may be suspended in glycerine 
 (10 per cent.), and after sterilization by heat 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 
 
16 A MANUAL OF SURGERY 
 
 chief symptoms, but delirium and collapse often supervene. There is always 
 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. Perhaps the best means of obviating the odour is to 
 mix it with Jj part of Coumarin, the active principle of the Tonquin bean, 
 which has a powerful aroma. 
 
 Chinosol is a yellow substance, harmless and free from toxic qualities ; it is 
 freely soluble in water, and possesses powerful antiseptic properties. 
 
 Lysol is another useful antiseptic derivative of coal-tar. It is freely soluble 
 in water, and as a 2 per cent, solution may be used in syringing out cavities, 
 such as the vagina, external ear, etc. One of its great advantages is that the 
 solution is somewhat sticky, and tends to cling to the tissues and prolong its 
 action. 
 
 Permanganate of Potash, Sanitas, and Peroxide of Hydrogen all act in the 
 same way as oxidizing agents ; they are necessarily unstable and cannot be 
 utilized for dressings, and are therefore chiefly employed in the disinfection 
 of cavities or wounds already contaminated. The most potent of these is 
 peroxide of hydrogen, which is sold as a fluid capable of setting free 10 or 20 
 times its volume of nascent oxygen. It is quite unirritating, and may be poured 
 directly into a septic wound, or even into the peritoneal cavity ; forthwith 
 it commences to effervesce, liberating its oxygen, and forming a frothy foam, 
 which is likely to bring to the surface any loose foreign bodies. Its use is 
 particularly indicated in the treatment of septic ulcers, carbuncles, sloughy 
 abscess cavities, and the like. Sanitas and permanganate of potash are used 
 in solutions of varying strength, and act more slowly ; the latter has the dis- 
 advantage of staining the tissues with which it is brought in contact. 
 
 Whilst the practice differs in various surgical schools as to the 
 antiseptics employed and the details of their application, yet the 
 principle in some form or other is now generally adopted. We 
 shall here merely sketch out the routine usually practised in 
 undertaking an operation or in the treatment of a wound. 
 
 1. The hands of the surgeon are rendered pure by scrubbing 
 them thoroughly with soap and hot water (preferably sterilized) ; 
 the nails are cut, if need be, and cleansed, special attention 
 being directed to the semi-lunar folds of skin at the base, where 
 septic material is so apt to collect. For this purpose a purified 
 nail-brush is employed with advantage. The hands are then 
 immersed in an efficient antiseptic lotion, such as 1 in 40 carbolic, 
 or 1 in 2,000 sublimate solution, preceded, perhaps, for a few 
 moments by a 1 in 500 solution of biniodide of mercury in 70 per 
 cent, methylated spirit. The hands, once purified, should not be 
 dried except on a sterilized towel ; but, indeed, it is better to keep 
 them moist and redip them from time to time during the operation 
 either in the 1 in 40 carbolic or 1 in 2,000 sublimate solution, 
 or in intraperitoneal work in sterilized salt solution (~)\. to 1 pint). 
 Another plan which has been used successfully and gives good 
 results consists in immersing the hands and forearms in a saturated 
 solution of permanganate of potash, after thorough washing with 
 soft soap and water until they become a deep mahogany-red 
 colour. They are then placed in a warm saturated solution of 
 oxalic acid until completely decolorized, and are finally washed 
 over with sublimate solution. This method causes a certain 
 
ANTISEPSIS AND ASEPSIS 17 
 
 amount of irritation of the skin of the forearms. It is possible 
 that in many instances complete sterilization of the hands is not 
 effected, but the surgeon must always keep complete asepsis of 
 his hands before him as an ideal to be attained. On several 
 occasions when our hands and those of our assistants were tested 
 bacteriologically after the use of the biniodide of mercury and 
 sublimate solutions they were found to be sterile, even scrapings 
 from beneath the nails giving no reaction. Some authorities have 
 been so concerned at the imperfection of their results that they 
 are in the habit of operating in sterilized gloves ; it has, however, 
 been demonstrated that such is no real protection. Careful 
 attention to the skin after operations— e.g., the application of 
 glycerine at night, so as to prevent it becoming rough and harsh 
 — is a most important element in success. 
 
 2. All instruments are sterilized in a bath of carbolic lotion 
 (1 in 20), which, it must be remembered, takes an appreciable 
 time to destroy microbes, and therefore if during an operation a 
 fresh instrument is suddenly called for, which has not been 
 previously purified, it is not enough just to momentarily immerse it 
 in the solution, but it is first placed in liquefied carbolic acid for a 
 few seconds, and then rinsed through the 1 in 20 solution. Special 
 care is directed towards the forceps, to see that the teeth and 
 serrations are free from dried blood-clot and other dirt. Should 
 an instrument fall on the floor during an operation it is, of course, 
 not used again until thoroughly repurified. Boiling the in- 
 struments either in carbolic lotion or, better, in a weak solution 
 of bicarbonate of soda (1 per cent.) for five or ten minutes, is 
 even a more certain means of rendering them aseptic, and 
 although the surgeon may ordinarily trust to immersion in 
 carbolic lotion, he should always boil his instruments after using 
 them for a septic case. The water should be boiling before they 
 are immersed, and thus discoloration will be avoided. 
 
 3. Sponges, unless very carefully treated, are a fertile source of 
 mischief. They should be thoroughly purified in 1 in 20 carbolic 
 lotion before use, and wrung out of a 1 in 40 solution or a 1 in 
 2,000 solution of sublimate during the operation. Unless the 
 surgeon can be absolutely certain of the nurse it is better to use 
 only a limited number of sponges — say two — and for the assistant 
 to cleanse them in a bowl of lotion placed in a suitable position. 
 Portions of wool, Gamgee tissue or gauze, soaked in a carbolic or 
 sublimate lotion, or thoroughly sterilized, are often advantageously 
 employed instead of sponges. It is never advisable to use sponges 
 for tubercular disease or rectal operations, or for any conditions 
 where pus is present. 
 
 In cleansing sponges after an operation the following procedure 
 is adopted : They are first thoroughly wrung out of cold water, 
 and then placed to soak for an hour or so in a fairly strong 
 solution of washing soda. They are then again well rinsed in 
 
 2 
 
A MANUAL OF SURGERY 
 
 cold or hot water, so as to remove all the soda, and finally 
 immersed in a solution of carbolic acid (i in 20), in which they 
 are kept till required. 
 
 4. The ligatures and sutures of catgut or silk are soaked for 
 some hours in 1 in 20 carbolic lotion before use. Silk requires 
 very thorough purification ; in order to prevent stitch suppuration, 
 it is advisable to boil it thoroughly for at least half an hour before 
 placing it in carbolic lotion ; it should be in loose coils, and not 
 wound on a reel, as then only the outside strands are sterilized. 
 Catgut, on the other hand, must not be boiled or immersed in 
 carbolic lotion for too long, as it is apt to become rotten and 
 break when used. It may, however, be boiled in cumol at a 
 temperature of 165 C. for an hour without harming it ; it is then 
 dried at a temperature of ioo° C. in a hot-air oven for two hours, 
 and is transferred to sterilized test-tubes. Mayo Robson has 
 advised the sterilization of catgut in xylol, which is kept at the 
 temperature of boiling water for half an hour. A special metal 
 cylinder with a screw top is required. The catgut is loosely 
 wound on a reel or slide, and sufficient xylol is placed in the 
 cylinder to cover the catgut ; the top is then screwed down, 
 and the cylinder is placed in a saucepan of cold water, which 
 is gradually brought to the boil, and allowed to remain boiling for 
 half an hour. The catgut is then removed, and kept in a 5 per cent, 
 carbolic solution in alcohol. Another simple and effective method 
 is to place the catgut wound loosely on a glass reel in a 5 per cent, 
 solution of formalin for twenty-four hours ; it is then immersed in 
 boiling water for five. minutes, and subsequently kept in a solution 
 of corrosive sublimate, 1 part, glycerine, 250 parts, and methy- 
 lated spirit, 1,000 parts. 
 
 5. The skin of the patient is shaved prior to operation if the 
 part is hairy, and then thoroughly washed with soap and water, 
 and covered with an antiseptic compress for some hours. When 
 the patient is on the table and anesthetized, a final cleansing is 
 undertaken. The part is first well rubbed with turpentine or 
 ether, to remove all fat and grease, and then with soft soap ; 
 finally, it is flushed over with strong carbolic lotion, or even 
 scrubbed, but not too energetically, with a nail-brush. Corrosive 
 sublimate (1 in 1,000) or biniodide of mercury in rectified spirit 
 (1 in 500) is sometimes used instead of carbolic acid. It must 
 not be forgotten that a very vigorous use of carbolic acid will be 
 followed by local irritation, as well as by its absorption into the 
 blood-stream, especially in protracted operations. 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 
 probably bathes once a year, with that of a child or of a lady, 
 which is soft, clean, and delicate), but it also differs in various 
 regions of the body, and hence the process of purification must be 
 modified according to the thickness of the integument. Any part 
 
ANTISEPSIS AND ASEPSIS 19 
 
 where dirt may accumulate demands scrupulous attention — e.g., 
 the umbilicus, external ear, toes, or corona glandis in persons 
 with long foreskins. 
 
 When the operation has been completed, the skin around is 
 again cleansed with warm carbolic (1 in 40) or sublimate (1 in 
 2,000) lotion, after a piece of dressing has been placed as a 
 protection over the wound. This cleansing should always be 
 accomplished by wiping peripherally away from the centre, and 
 any sponge or swab which has been utilized for this purpose 
 should not be allowed to touch the wound until repurified. 
 
 6. The area of the operation or wound is surrounded with 
 mackintoshes, and these are covered by towels wrung out of hot 
 carbolic lotion. The latter are first soaked in a solution of 
 1 in 20, and then wrung out of the hot 1 in 40 solution, and 
 kept warm until required ; the skin may be burnt if a stronger 
 solution is used. During the operation the wound may be occa- 
 sionally irrigated with a 1 in 40 carbolic solution, or with corrosive 
 sublimate (1 in 2,000) ; but such is not always advisable, as 
 it increases the amount of subsequent oozing, and is really un- 
 necessary if one is certain as to the aseptic condition of every- 
 thing employed. When dealing with the peritoneal cavity or the 
 interior of a joint, the less one employs antiseptics the better, 
 since they are always more or less irritating, and lead to desqua- 
 mation of the endothelial lining, which it is so important to 
 maintain intact. In fact, the rule of practice which we are 
 endeavouring now to establish is the strictest antisepsis for the external 
 parts, but asepsis for the interior of the wound ; one cannot always be 
 certain, however, that this ideal has been attained, and then anti- 
 septic irrigation may be resorted to. 
 
 7. Before closing the wound, the surgeon must use every 
 endeavour to secure absolute haemostasis. It must be well 
 cleansed with a sponge wrung out of hot carbolic lotion, or, 
 if necessary, irrigated with sterilized salt solution ; it may be 
 advisable, especially in large wounds of vascular parts, to insert 
 a suitable drainage-tube and stitch it flush with the surface, but 
 in many cases this is unnecessary. The incision is then closed. 
 Wounds communicating with septic cavities, such as the mouth 
 or rectum, should be purified with a solution of chloride of zinc 
 (40 grains to 1 ouncej, and then powdered with iodoform, and 
 either left open or lightly plugged ; septic contamination is by 
 this means delayed, and even when it does occur, it may be kept 
 under control by frequent dressing and irrigation. 
 
 8. Finally, a carefully arranged antiseptic Dressing is applied, 
 and the part bandaged and put on a splint or in a sling, as may 
 best suit the requirements of the case, absolute rest and quiet 
 being essential if rapid healing is to be obtained. 
 
 As to the different forms of dressing, we must content ourselves 
 with a few words as to those ordinarily employed. Lord Lister 
 
 2 — 2 
 
A MANUAL OF SURGERY 
 
 pointed out some years back that the main essentials of a good 
 dressing consisted in its containing some trustworthy antiseptic 
 ingredient ; in this agent being so stored up that it cannot be 
 dissipated before the next dressing ; in its being entirely un- 
 irritating ; and in the capacity of the fabric to readily absorb 
 blood or serum that may ooze from the wound. The original 
 antiseptic dressings, viz., the carbolic and eucalyptus gauzes, and 
 even the alembroth gauze and wool, failed to fulfil these require- 
 ments ; but in the double cyanide of mercury and zinc gauze we 
 have a material which is to all intents and purposes perfect. It 
 should be moistened with carbolic lotion (i in 40,), and may then 
 be applied to the wound without fear. Over this fresh portions 
 are placed, taken from the stock supply, which is always kept in 
 a mackintosh covering after being damped with carbolic lotion 
 (1 in 20), 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. The best material for bandages is 
 butter-cloth, since it is light and adapts itself easily to the outlines 
 of the part. 
 
 Other dressings, such as boric lint, iodoform gauze, etc., are 
 occasionally employed, but they are not so satisfactory for general 
 use as the cyanide gauze. 
 
 9. 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 ; there is no advantage in keeping it in longer, 
 since it is only required for the removal of the sero-sanguineous 
 fluid which exudes immediately after the operation. Should the 
 discharge be very abundant and soak through the dressings, there 
 is no need to remove them and redress during the first twenty- 
 four hours ; all that should be done is to damp the stained external 
 bandages with 1 in 20 carbolic lotion, and then pack on some 
 more gauze or wool. This may even, if necessary, be repeated a 
 second time. 
 
 Of late years many Continental and American surgeons have 
 been attempting to eliminate the irritating properties of chemical 
 antiseptics by the adoption of what is called Aseptic Surgery. In 
 this, asepsis is obtained by means of heat, the most powerful 
 germicide in our possession ; the instruments are boiled, and 
 dressings are sterilized by placing them for an hour or more in 
 a hot-air chamber, raised to such a temperature as to destroy all 
 germs, or by boiling them. Antiseptics are, however, generally 
 used in order to purify the skin of the patient and the hands of 
 the surgeon and his assistants, as also the ligatures and sutures. 
 Elaborate precautions are also taken as to the dress both of 
 
ANTISEPSIS AND ASEPSIS 
 
 the surgeon and his assistants, and even of onlookers ; whilst 
 operating theatres, tables, etc., are disinfected in a careful 
 manner. This plan has been employed with much success, 
 but requires more attention to details than does the antiseptic 
 method. Where our assistants are constantly changing, as in a 
 large teaching hospital, and where many hands are engaged in 
 the work, there is much greater risk of failure. It is only natural 
 that we, who have had the privilege of working with Lord Lister, 
 and have seen the excellent results following the intelligent use 
 of antiseptics, should still to a large extent cling to that line of 
 practice, which certainly can be carried out with more precision 
 under .all circumstances, both in private and hospital, than the 
 other plan, the objects of which may at any moment be defeated 
 by some slight inadvertence or oversight. At the same time, we 
 are free to admit that aseptic methods have much to commend 
 them ; all antiseptics are more or less irritating, and there can be 
 no question that the less we use them the better. Moreover, boiling 
 the instruments is more certain to disinfect them than immersion 
 in antiseptics ; they are subsequently laid in a bath of sterilized 
 salt solution, or even water. Sponges are replaced by swabs of 
 sterilized tissue or gauze ; aseptic wounds are washed out with 
 salt solution, if any irrigation is required ; and the towels around 
 the area of operation are merely sterilized by placing them in a 
 hot-air chamber or are boiled. To sterilize towels or textile 
 fabrics generally, it must be remembered that they must be 
 placed loosely in the sterilizer, as otherwise the heat cannot reach 
 between their various folds and layers. Dressings may be merely 
 sterilized, but when one's work lies in a large city hospital, with 
 impure and often contaminated air around, we believe that the 
 welfare of our patients is best consulted by employing antiseptic 
 dressings, and the results we have obtained with the double 
 cyanide gauze are such that we can wish for nothing better. 
 
 A few other micro-organisms exist besides the bacteria, but as 
 they play a comparatively insignificant part in surgery, no lengthy 
 notice of them is required. 
 
 i. Some of the Fungi, especially the Hyphomycetes, are characterized by 
 the growth of a mycelium or mass of interlacing fibres or threads, arising 
 from which are the spore-bearing conidia, whence multiplication of the growth 
 ensues. A great variety of fungi is found in Nature, but the more important 
 pathological conditions due to their development in the body are as follows 
 . Thrush, due to the Oidium albicans. 
 
 Ringworm, due either to the Microsporon Audoini (the common type), or to 
 the Tricophyton megalosporon endothrix or ectothrix. 
 
 Favus, arising from the Achorion Schonleinii. 
 
 Pityriasis versicolor, due to the Microsporon furfur. 
 
 Keratomycosis, or parasitic ulcer of the cornea, is due to fungi of the 
 aspergillus or mucor type (common moulds), which mav also be found 
 developing in the bronchi (pneumomycosis), or in the external auditory 
 meatus (otomycosis). 
 
A MANUAL OF SURGERY 
 
 Actinomycosis (p. 148) is dependent on the growth in the tissues of the ray 
 fungus, or Actinomyces, although there is some question as to whether these 
 organisms should not be classed as bacteria. 
 
 2. The Yeasts or Blastomycetes multiply by a process of gemmation or 
 budding. They are responsible for many forms of fermentation, e.g., the 
 alcoholic or acetous, and are found in certain peculiar forms of dermatitis. 
 The hypothetical parasite of cancer is now regarded as belonging to this class. 
 
 3. The Protozoa constitute a group which can be classed either as animal 
 or vegetable, and consist in their earlier stages of masses of naked nucleated 
 protoplasm, which may later on become covered with membranous envelopes, 
 through openings in which pseudopodia are protruded. They form a large 
 and varied class, the simplest type being the amct'ba ; but their influence 
 in pathology is not yet fully worked out. It is supposed that the following 
 varieties are of pathological importance : 
 
 Amoeba are known to occur in certain forms of colitis, and also in some 
 varieties of hepatic abscess. 
 
 Malaria is due to the development of a protozoon, the Plasmodium malaria. 
 
 The Psorospermia, which occur not unfrequently in animals, are members 
 of this group, and it is still a moot question whether the coccidia-like bodies 
 found in Paget's disease of the nipple are really living parasites, and if so, 
 whether they have any causative effect on the origin of the disease (p. 174). 
 Molluscum contagiosum is another condition which has been attributed, 
 probably on very insufficient grounds, to these organisms. 
 
CHAPTER II. 
 
 INFLAMMATION. 
 
 ' Inflammation is the succession of changes which occur in a 
 living tissue when it is injured, providing the injury is not of such 
 a degree as to at once destroy its structure and vitality.' Such 
 was the definition given in 1870 by Burdon Sanderson, and 
 it is sufficiently accurate if one amplifies the term ' injury ' to 
 include bacterial invasion, and excludes the final processes 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 it is often 
 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, how- 
 ever, the tissue reaction called into existence by bacterial invasion 
 is so severe as to increase, rather than diminish, the risks of the 
 patient. 
 
 The actual phenomena of inflammation are perhaps best studied 
 in the web of a frog's foot. If this is spread out and examined 
 under the microscope, the following evidences of normal physio- 
 logical activity may be seen : (a) the flow of blood through the 
 vessels, as indicated by the movement of the corpuscles, the red 
 ones, each separate from the other, flowing in the central or axial 
 current, the leucocytes occasionally seen amongst the red, or here 
 and there one may be noticed rolling lazily along in the inert 
 corpuscle-free peripheral portion of the tube ; (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 (c) the changes which occur in the 
 pigment-cells, which represent the connective tissues of the part, 
 and which are mainly due to the influence of light, the cells con- 
 tracting or expanding as the light is increased or diminished. 
 
 If now a crystal of common salt, or some such irritant, is 
 applied to the web, the early vascular phenomena contributing to 
 inflammation may be readily observed. 
 
24 A MANUAL OF SURGERY 
 
 I. — The Vascular Changes in Acute Inflammation. 
 
 A momentary contraction may perhaps be noticed in the 
 arterioles of the part, but this is only apparent in inflammations 
 produced artificially, and is of no known significance. It is 
 followed by a condition of Hyperemia of the inflamed area, as 
 manifested by a rapid and lasting dilatation of the vessels, accom- 
 panied by an increase in the rapidity of the blood-flow (accelera- 
 tion). This is a peculiarly vital phenomenon, and opposed to the 
 hydrostatic law that when fluid is flowing through a tube or 
 channel at a fixed pressure, if the lumen is suddenly widened, the 
 rate of the blood-flow is diminished. 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 ; then a period of oscillation will be noticed, 
 the blood-current swaying forwards and backwards, and finally a 
 condition of stasis or still-stand is arrived at, which may or may 
 not end in actual thrombosis or intravascular coagulation. During 
 this period changes have occurred in the behaviour of the blood 
 contained in the vessel, due in all probability to certain invisible 
 changes in the vessel walls and not to any alteration in the blood. 
 Thus, almost as soon as dilatation occurs, the leucocytes collect 
 along the walls in the peri-axial inert layer, seeming, as it were, 
 to fall out of rank ; this process first commences in the veins, 
 but can be observed in all the vessels. The red corpuscles also, 
 which formerly had flowed along separately, now tend to adhere 
 to the vessel walls and to each other, running into rouleaux. 
 
 The second factor in the vascular changes must now be con- 
 sidered, viz., Exudation, a proceeding which becomes evident at 
 a very early stage. Every element in the constitution of the 
 blood participates in this process. It has been already mentioned 
 that the leucocytes collect in the peri-axial layer, a phenomenon due 
 partly to the retardation of the blood-stream, whereby the relatively 
 heavier bodies separate from' the lighter, and in part due to 
 positive chemiotaxis (p. 12). 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 move- 
 ment ; a small arm or outgrowth of the leucocyte (pseudopodium) 
 is inserted between the endothelial 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. 2). The migration of the leucocytes only lasts as long as 
 the blood in the vessel is actually circulating ; as soon as throm- 
 
INFLAMMATION 
 
 25 
 
 bosis occurs, migration ceases. When the white corpuscle has 
 escaped into the peri-vascular tissues, it may undergo various 
 changes. In the first place, it may die and be at once dis- 
 integrated, setting free fibrin ferment, and thus assist in the 
 production of the inflammatory coagulum to be shortly described ; 
 or, again, it may serve as pabulum for the larger fibroblastic cells 
 which soon make their appearance, arising apparently from the 
 multiplication of the connective-tissue corpuscles in the neighbour- 
 hood ; or, once more, it may find its way back into the circulation 
 
 Fig. 2. — Diagrammatic Representation of the Vascular Phenomena 
 of Inflammation. (After Keen and White.) 
 
 Two thin-walled venules are seen, and several capillaries. The red corpuscles 
 are still occupying the axial portion of the tubes, whilst the periphery is 
 crowded with leucocytes, which in several places are in process of migra- 
 tion into the surrounding cellular tissue. 
 
 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 to remove any dead tissue 
 which exists in the neighbourhood of the inflammatory focus, 
 whilst a phagocytic or microbe-destroying function is also sub- 
 served. In fact, the leucocytes may be looked on as the scavengers 
 of the body, or as advanced guards, which, at the onset of mis- 
 chief, are thrown out from the vessels as Nature's first line of 
 defence against the invading forces, their chief duty being to 
 
26 A MANUAL OF SURGERY 
 
 remove all damaged and noxious material, and then, having 
 limited the spread of the destructive process, they in turn give 
 place to the larger and more useful fibroblastic cells which are the 
 active agents in the process of repair. 
 
 The red corpuscles pass through the walls of the capillaries by a 
 process of diapedesis, the result of simple mechanical pressure ; 
 this usually occurs only in very acute attacks. When once 
 external to the vessels they are broken up and their colouring 
 matter diffused through the tissues. 
 
 The liquor sanguinis is also extravasated. This is merely an 
 exaggeration of a normal process, although in health the lym- 
 phatics are capable of removing all the fluid exuded. In patho- 
 logical conditions the amount of plasma which passes through 
 the walls is excessive, and although for a time the lymphatics of 
 an inflamed region do increased work, yet the transudation is 
 soon greater than they can deal with. If the fluid escapes into 
 the tissues, it undergoes coagulation by meeting the necessary 
 coagulating media developed from the breaking-down leucocytes ; 
 inflammatory lymph forms locally, whilst the serum collects in the 
 meshes of the tissues, constituting an inflammatory 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 
 either 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 = Hyperemia + Exudation. 
 
 In addition, however, to these vascular phenomena, which can 
 be readily seen in a frog's web, there are others which cannot be 
 so easily observed, and which may be described as 
 
 II.- -The Tissue Changes in Inflammation. 
 
 Great differences of opinion have been in existence as to the 
 part played by the tissues in inflammation ; but although there 
 may still be points to be elucidated, yet the general opinion of 
 pathologists is at the present day tolerably well defined. Formerly, 
 in accord with Virchow's cellular pathology, it was held that the 
 tissues were the all-important element, and that the immense 
 number of cells which collect in an inflamed area was entirely due 
 to the proliferation of the connective-tissue corpuscles. Lister, 
 as far back as 1858, maintained the passive condition of the 
 tissues ; and when Cohnheim, in 1867, described the migration of 
 the leucocytes, everything in the process of imflammation was 
 attributed to them. Since that date Senftleben and many others 
 
IN FLA MM A TION 25 
 
 have worked at the same problem, and a considerable amount of 
 fresh light has been thrown on the subject by experiments con- 
 sisting in the insertion of foreign bodies into the peritoneal cavity, 
 and by others directed towards demonstrating the phagocytic 
 functions of leucocytes and the influence of chemiotaxis. Much 
 of the difficulty which has enshrouded the question has arisen 
 from a confusion between the processes of inflammation and 
 repair. At one time repair was always looked on as of an inflam- 
 matory nature ; but it is now admitted that although no lesion in 
 the body can occur without a certain amount of local inflammatory 
 reaction, yet the true process of repair is not of that nature. 
 Again, it is important to differentiate between the changes which 
 occur in acute and chronic forms of inflammation, and between 
 those met with in superficial and deep parts, whilst the bacterial 
 origin or not of the process must also be taken into account. 
 
 In acute parenchymatous inflammation there is now no question 
 that the primary effect on the tissues, at any rate in inflammations 
 due to bacterial activity, is to paralyze them ; as they become 
 infiltrated with the products of microbic multiplication, the proto- 
 plasm within the cells coagulates and refuses to take up the 
 ordinary stains, constituting a condition known as Coagulation 
 Necrosis. This necrotic tissue is in time entirely absorbed by the 
 leucocytes, or is liquefied by the activity of bacterial toxins, so 
 that it is replaced by a mass of small round cells, sometimes 
 known as Embryonic Tissue. According to the relative vitality 
 and vigour of the individual and the bacteria, this mass may in 
 turn either be replaced by larger round cells derived from the 
 connective tissues (fibroblasts), by means of which most of the 
 leucocytes are absorbed, and repair is brought about ; or the 
 whole mass may be liquefied and break down into pus. In non- 
 bacterial inflammations of superficial parts the amount of effusion 
 between the individual cells may be so excessive as to separate 
 and disintegrate them, and thus Colliquative Necrosis may be 
 induced, as occurs in the formation of blisters after a burn. Once 
 more, acute inflammation of mucous membranes may be associated 
 with active proliferation of the surface epithelium, as in catarrhal 
 and gonorrhoeal affections. 
 
 In chronic inflammations, on the other hand, active cell pro- 
 liferation 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. 
 
 Terminations of Acute Inflammation. 
 
 These vary according to the cause of the mischief, the intensity 
 of the process, and the powers of resistance possessed by .the 
 individual attacked. The causes described at p. 33 naturally fall 
 
28 A MANUAL OF SURGERY 
 
 into two main classes, according to whether or not they are asso- 
 ciated with bacterial activity. Speaking generally, lesions not 
 caused by bacteria, such as those following a blow or a burn, are 
 characterized by much exudation of fluid, which is of low specific 
 gravity, does not contain much albumen, and does not coagulate 
 in the tissues ; the amount of cellular infiltration is slight, no 
 peptonizing ferment is present, and the results are usually 
 localized. Bacterial irritants, on the other hand, produce more 
 infiltration of the tissues, since the exudation, which is rich in 
 albumen, coagulates in the tissues ; disintegration is likely to 
 follow, as peptonizing ferments are often present, and the 
 inflammation is more likely to be of a spreading nature. The 
 intensity of the irritant also modifies the process, since, if slight, it 
 has a somewhat stimulating effect on the tissues, whilst severe 
 lesions may result in tissue destruction, even amounting to gan- 
 grene. Then, too, the type of tissue affected is important, since 
 the same cause may lead to very different results. The more 
 highly organized and important parts are always more vulnerable 
 than the simpler forms of connective tissue, and this in spite of 
 the fact that the former are usually better supplied with blood. 
 Thus, the growing end of the diaphysis in a child is a most deli- 
 cately 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 sub- 
 cutaneous connective tissues. 
 
 The actual terminations of acute inflammation may be described 
 under five distinct headings : 
 
 i. Resolution, or the restoration of the part to its natural condi- 
 tion and function. This can only occur when the injury has not 
 been so severe as to destroy the vitality of the affected tissues, 
 and when the vascular changes have not gone further than stasis. 
 When once thrombosis has taken place in a vessel, the parts can 
 never be restored to the status quo ante. The phenomena of reso- 
 lution are merely those of inflammation in a retrograde order — 
 viz., an oscillatory movement first manifests itself amongst the 
 corpuscles, and then the blood-stream is gradually restored, slowly 
 at first, and more and more rapidly afterwards. The adhesiveness 
 cf the corpuscles disappears by degrees, but it will be some time 
 before the peripheral inert layer can be seen. The exuded leuco- 
 cytes find their way back into the circulation either through the 
 vessel walls, or to a greater extent via the lymphatics, or else they 
 are disintegrated in the tissues and absorbed. The fluid exuda- 
 tion is removed by the lymphatics. For some time after an acute 
 attack the vessels of the part are dilated from simple loss of tone, 
 but this also gradually disappears. 
 
 2. Organization, or Fibroid Thickening, occurs when the in- 
 flammatory process is not arrested until after the supervention 
 of thrombosis, but has stopped short of suppuration. The parts 
 
INFLAMMATION 29 
 
 are then not restored to their original condition, but changes 
 take place in the cellulo-plastic exudation and in the connective 
 tissue around, which result in its transformation into cicatricial 
 tissue, and hence the details of the process will be similar to 
 those described under the heading of ' Repair of Wounds ' 
 (Chapter VIII.). Very similar conditions follow when the in- 
 flammatory process becomes chronic, as is not uncommonly the 
 case. 
 
 3. Suppuration is always due to invasion of the affected region 
 by pyogenic organisms, which disintegrate and liquefy not only 
 the tissues involved, but also in part the exudation (Chapter III.). 
 
 4. Ulceration is produced on the surface of either skin or 
 mucous membrane by the action of an irritant of such nature 
 and intensity as to destroy its vitality, though without evident 
 sloughing (Chapter IV.). 
 
 5. Gangrene is a less common result of inflammation, and is 
 due either to the intensity of the virus or to the weakness of the 
 tissues attacked (Chapter V.). It occurs not unfrequently in 
 bone, constituting the condition known as necrosis, and is then 
 due mainly to the strangulation of vessels within the narrow 
 lumen of the Haversian canals by an exudation which is often 
 relatively small in amount. 
 
 Clinical Signs of Inflammation. 
 
 These may for practical purposes be described under the four 
 headings given by Celsus, viz., heat, redness, swelling, and pain, 
 with the addition of a fifth, viz., impairment of function. 
 
 Heat. — An inflamed part feels hot to the touch, and the tem- 
 perature, if taken by a surface thermometer, is definitely raised 
 above that of the surrounding skin. The cause of this is the 
 increased amount of blood flowing through it, 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. Necessarily, where 
 active chemical and pathological changes are occurring, as in an 
 inflamed tissue, a certain amount of heat is produced ; but it is 
 relatively so infinitesimal in quantity that it may be neglected. 
 The cause of the increased temperature of the blood is noted 
 elsewhere (p. 32). 
 
 Redness is due to the hyperaemic condition of the inflamed part, 
 and its intensity and characters vary considerably. In the early 
 active hyperemia the colour is a bright rosy-red, fading quickly 
 on pressure, and returning with equal rapidity. In the stage of 
 retardation the redness is more dusky, since the blood is longer in 
 passing through the capillaries, and so loses more of its oxygen ; 
 the colour does not disappear or return so rapidly, and a slight 
 yellowish tinge often remains from extravasated haemoglobin. 
 When stasis is reached, and a fortiori when thrombosis, pressure 
 
A MANUAL OF SURGERY 
 
 does not remove the red colour, and, should such a state persist 
 for long, permanent pigmentation may remain. 
 
 The redness is not always most marked at the focus of the 
 disturbance, since the portion inflamed may be non-vascular, 
 e.g., the cornea or articular cartilage ; in the former of these, the 
 redness is most marked in the ciliary region as a zone of deep 
 pink injection. The same absence of redness is observed in an 
 inflamed iris, owing to the excess of pigment hiding the dilated 
 vessels ; but in both cornea and iris, the inflammation may in rare 
 cases be so prolonged or acute as to cause these structures to 
 become evidently vascular — in the one case from the formation of 
 new vessels, and in the latter by the total removal and absorption 
 of the pigment. 
 
 Swelling arises from the same two causes, viz., hyperaemia 
 of, 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. In some cases where the inflamed area 
 is covered by a thick and firm fascia, not only is the tensive 
 pain very considerable, but swelling may occur away from the 
 inflamed area, e.g., over the back of the hand in palmar abscess ; 
 where the inflammatory products escape into lax tissues, the 
 subjective phenomena are minimized. Similar illustrations of the 
 occurrence of cedema at a distance are to be seen in inflammations 
 of the sole of the foot, in the swelling of the eyelids when the 
 scalp is inflamed, and of the cheek in inflammation of the dental 
 periosteum. Swelling due to inflammation, though diminishing 
 post-mortem, does not entirely disappear. 
 
 Pain. — This results from the mechanical irritation of the peri- 
 pheral nerve terminals, both by the increased arterial tension and 
 by the pressure of the exudation, so that it is much greater if, 
 from the density of fascial or fibrous investments, swelling cannot 
 readily occur, e.g., in the palm of the hand, or in the eye or testicle. 
 Possibly the exudation may also have some direct chemical action 
 on the nerve terminals. 
 
 A marked feature of inflammatory pain is that it is always 
 aggravated by pressure, whether intrinsic — i.e., by increasing the 
 blood-pressure — or extrinsic, from outside agencies. Thus, if an 
 inflamed finger or hand is allowed to hang down, the pain is much 
 increased, whereas elevation causes speedy relief. 
 
 The pain of suppuration is throbbing in character ; of an inflamed 
 mucous membrane, scalding, burning, or gritty ; of an inflamed 
 serous membrane, stabbing ; of inflamed bone, 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 some- 
 
INFLAMMATION 
 
 3i 
 
 times 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 the 
 two joints have a similar nervous supply. 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 so-called 
 ' belly-ache ' of dorsi-lumbar disease. 
 
 Impairment or Loss of Function is due sometimes to the 
 mechanical difficulty 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 can see but little; 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. 
 
 General or Constitutional Symptoms. 
 
 These vary considerably according to the part involved and the 
 cause of the inflammation, (a) If an important organ, such as the 
 heart or kidney, becomes inflamed, grave mechanical and physio- 
 logical trouble may result, (b) Inflammations due to traumatism, 
 in which bacteria play no part, are not uncommonly associated 
 with a temporary pyrexia, probably due to some such substance 
 as fibrin ferment, (c) When of septic or pyogenic origin, inflam- 
 mation is almost always associated with well marked fever, and it 
 is sometimes astonishing to note how much disturbance a small 
 bead of pus under tension will produce, (d) In certain infective 
 inflammations a characteristic toxaemia is produced, due to a 
 specific action of the toxin — e.g., in tetanus, convulsions are 
 caused ; whilst in diphtheria, fever and perhaps paralytic pheno- 
 mena are alike produced. 
 
 It is only necessary at this place to deal very briefly with the 
 subject of Fever or pyrexia. The general characteristics of the 
 febrile state consist in a greater or less elevation of temperature, 
 accompanied with a corresponding acceleration of the rate of the 
 heart-beat and of the respirations. If it continues for any length 
 of time, the patient becomes thin and emaciated, and loses muscular 
 power. The mouth is dry and the tongue furred ; and in the 
 later stages, where a fatal issue is apprehended, the lips and 
 teeth are usually covered with sordes (or accumulations consisting 
 of inspissated mucus and food debris). The appetite is impaired, 
 digestion is imperfect, and the bowels constipated ; any motion 
 
32 A MANUAL OF SURGERY 
 
 passed is 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 controlled 
 by a principal heat-governing centre in the medulla, assisted possibly by 
 accessory centres in the cord, and is maintained by the establishment 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 voluntary muscles. 
 Pyrexia is necessarily due to one of two causes, viz., a decreased 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 th-3 
 urine. In all probability this increased activity is due to the excitement of 
 the heat-producing centre by some pyrogenous body developed in connection 
 with the local inflammatory process. Experiments have shown that the fibrin 
 ferment, as well as many of the toxins produced by the action of micro- 
 organisms, if injected into the circulation in a pure state, possesses 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 path- 
 ologists '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, inasmuch as their function is 
 largely impaired. The salivary and buccal glands are unable to excrete the 
 normal amount of saliva, and hence the mouth becomes dry. Gastric diges- 
 tion is interfered with in the same way. The bile is not efficiently produced, 
 and hence its fat-emulsifying properties are diminished, as also its cathartic 
 powers, whilst the patient cannot properly digest fats, and is constipated. 
 
 Various terms have been applied to different types of surgical 
 fever, e.g., sthenic and asthenic, which sometimes depend as much 
 upon the constitution of the patient as upon the nature or cause 
 of the affection. By Sthenic inflammatory fever (Greek, a-devos, 
 strength) is meant that condition in which pyrexia and all its 
 accompanying symptoms are well marked. It occurs mainly in 
 young healthy adults of sound constitution, as, for example, when 
 a young man is suddenly attacked by acute pneumonia, or when 
 an acute abscess is forming. Asthenic inflammatory fever (Greek, 
 do-Oevos, without strength) is characterized by the tendency to 
 
INFLAMMATION 
 
 exhaustion and collapse associated therewith. It is met with in 
 debilitated subjects and those exhausted by vicious habits, but 
 may also occur at the close of a long period of pyrexia, e.g., in 
 the third week of typhoid fever ( = the typhoid state). The absorp- 
 tion of products of putrefaction and the occurrence of acute 
 infective blood-poisoning also induce fever of this type. 
 
 Causes of Inflammation. 
 
 Predisposing Causes. — The conditions which predispose to in- 
 flammation may be conveniently divided into the local and the 
 constitutional. 
 
 The local causes include the following more important conditions : 
 i. Defective circulation whether due to chronic anaemia, as in 
 a limb with rigid calcareous arteries, or to passive congestion, as 
 in a leg with varicose veins. 
 
 2. Loss or impairment of the nervous supply to a part, render- 
 ing it less resistant to external irritation either from loss of 
 sensation, diminished trophic control of the nervous centres, or 
 circulatory changes. 
 
 3. One attack of inflammation often leaves a part weaker and 
 more liable to recurrence. 
 
 The general or constitutional predisposing causes are those which 
 tend to depress the general vitality, e.g. : 
 
 1. Old age, when the body as a whole suffers in its nutrition. 
 
 2. Weak action of the heart, disturbing the vascular supply of 
 the' organs and members of the body. 
 
 3. An unhealthy condition of the blood, as from (a) the addition 
 of some abnormal constituent, as in alcoholism, plethora, lead, 
 mercury, or phosphorus poisoning, septic diseases, diabetes, etc. ; 
 (b) the insufficient elimination of excreta, as in Bright's disease 
 or gout ; (c) the absence of some normal constituents, as in albu- 
 minuria or anaemia. 
 
 4. The presence of some constitutional disease, dyscrasia or 
 diathesis, as syphilis, tubercle, rheumatism, etc. 
 
 Exciting Causes. — The active agent in the production of any 
 inflammation is the existence of some irritant which acts for a 
 shorter or longer period upon the tissues. The different forms of 
 irritants are infinite in number, but may be grouped under the 
 following four headings : 
 
 1. Mechanical or traumatic causes, such as direct violence, 
 friction, tension, pressure, etc. 
 
 2. Causes which act through changes of temperature, either 
 heat or cold. 
 
 3. Electricity, either as applied by the surgeon in the form of 
 the faradic or galvanic current, or through the agency of lightning 
 or the strong currents used for lighting purposes. 
 
 4. Toxic irritants, under which may be included : 
 
 (a) Chemical agents, such as strong acids or alkalies. 
 
 3 
 
34 
 
 A MANUAL OF SURGERY 
 
 (b) Vegetable irritants, e.g., croton-oil, oil of mustard, etc. 
 
 (c) Animal irritants, such as cantharides, and insect or 
 
 reptile bites. 
 ((/) The development of micro-organisms within or without 
 the body (see Chapter I.). 
 
 Varieties of Inflammation. 
 
 Many different terms are used to indicate 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, 
 which in the 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. Pathologically, this pro- 
 cess is accompanied, as are all active inflammatory changes, 
 by hyperaemia and exudation. At first the mucigenous function 
 of the membrane is abrogated, and any extravascular exuda- 
 tion 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 this is an exception rather than the rule. Microscopic 
 examination 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 inflamma- 
 tion is caused by bacteria, or by the action of local irritants, or to 
 what is known as ' taking cold.' 
 
 A Croupous (or plastic) inflammation 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 membrane, 
 such as the pleura, peritoneum, or synovial membrane, it gives 
 rise to a layer of plastic lymph, which may organize into adhe- 
 sions ; 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 
 readily be detached, leaving an injected surface below, with merely 
 one or more oozing points, and no loss of substance. 
 
 A Diphtheritic inflammation is due to a special organism — the 
 Bacillus diphtheria — and is characterized by the formation of a 
 membranous exudation with which are incorporated the superficial 
 layers of the epithelium, so that it cannot be removed without 
 leaving a raw surface. The bacilli develop in this false membrane 
 and produce toxins, which by their absorption give rise to the 
 constitutional symptoms of the disease. 
 
IN FLA MM A TION 
 
 35 
 
 The term Phlegmonous is now but rarely employed. It was 
 formerly applied to any superficial inflammation where the local 
 phenomena were well marked. 
 
 Parenchymatous and Interstitial are terms which indicate that 
 in an inflamed organ or gland the process is mainly limited, either 
 to the actual and active substance of the organ, or to the support- 
 ing 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 away almost 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. 
 
 Treatment of Acute Inflammation. 
 
 It is only possible to deal here with the general principles 
 which guide us in the treatment of inflammatory affections. The 
 method of application of these to different parts of the body will 
 be described hereafter. 
 
 The Local Treatment may be indicated under four headings : 
 i. Remove the exciting cause, if evident, 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 embedded in the conjunctiva or cornea, or a piece of 
 dead bone lying at the bottom of a sinus. Inflammatory tension 
 from pent-up effusion is readily relieved by an incision, or an 
 abscess opened. In some cases, due to bacterial invasion, it may 
 be practicable to totally excise a local focus — e.g., a malignant 
 pustule — whilst in others, such as a carbuncle, one has to trust 
 to scraping away the sloughy and infiltrated tissue with a 
 Volkmann's spoon, and then, after purification with liquefied 
 carbolic acid or peroxide of hydrogen, the wound is carefully 
 stuffed with gauze. In bacterial inflammation of a more diffuse 
 type, it is usually impossible to remove the cause, and one has 
 then to trust to other measures. 
 
 2. Keep the inflamed part at vest. Wherever inflammation exists, 
 both physical and physiological rest should be obtained as far as 
 possible. Thus, an inflamed joint is immobilized by a splint ; an 
 inflamed mamma needs both support and the fixation of the arm, 
 whilst if in a condition of physiological activity this must be 
 checked by suitable treatment ; an inflamed cornea requires the 
 application of a pad and bandage to prevent the friction of the 
 eyelid ; an inflamed retina must be given physiological rest by 
 exclusion of the light. 
 
 3. Reduce the local blood -pressure and hyperaemia, and thus 
 diminish both exudation and pain. Elevation of an inflamed 
 
36 A MANUAL OF SURGERY 
 
 limb may secure this end, and is a most essential element in the 
 treatment of all inflammatory conditions of the leg, for it is a 
 well-known fact that emptying the veins by gravity in an 
 elevated limb leads to reflex contraction of the arteries. Local 
 blood-letting by leeches, punctures, scarification, and wet or dry 
 cupping, is useful in suitable cases, and sometimes gives imme- 
 diate relief. It may be as well to mention that a leech can 
 withdraw about 2 to 4 drachms of blood, and that it should not 
 be applied over a large subcutaneous vein, or to parts, like the 
 scrotum or eyelids, where there is much subcutaneous tissue of a 
 loose texture, in which extravasation readily occurs. The bleeding 
 from a leech-bite usually ceases spontaneously, but may require 
 the application of slight pressure. 
 
 In diffuse inflammation of the cellulitic type free incisions are 
 beneficial, partly on account of the relief of tension and pain 
 which follows the escape of blood and retained discharges from 
 the tissues, but also because it determines a free flow of blood 
 serum, and as this possesses antitoxic and germicidal properties, 
 it assists in bringing the inflammatory process to an end. 
 
 Cold wisely utilized is of the greatest service in combating 
 inflammation, causing contraction of the arterioles, and so re- 
 ducing the hyperaemia. It should only be used in the early stages, 
 and never when suppuration is threatening, as, although it may 
 cause local depletion of the bloodvessels, it at the same time 
 depresses the vitality of the part, and so may do more harm than 
 good. Again, it should be used with the greatest care in old 
 people, from fear of causing sloughing 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 carefully to the inflamed region. Under any circum- 
 stances the cold must be continuous, and not intermittent, as 
 otherwise the alternating periods of anaemia and hyperaemia will 
 have a baneful rather than a beneficial influence. 
 
 Heat, especially when combined with moisture, is very largely 
 used in treating inflammatory affections, and acts in a diametri- 
 cally 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. When suppuration is threaten- 
 ing, the application of warmth and moisture hastens the process. 
 For subcutaneous lesions, fomentations, medicated or not with 
 opium or belladonna, or spongiopiline wrung out of hot water, or 
 simply dry heated cotton-wool, may be employed. When an 
 abscess is forming, nothing can be more soothing and satisfactory 
 
INFLAMMATION 37 
 
 than a linseed-meal poultice, provided that the abscess is not 
 allowed to burst into it. Poultices should never be applied to an 
 open wound or abscess, unless the latter is in a very septic con- 
 dition, and then they can be rendered more or less aseptic by 
 making them with hot carbolic lotion (1 in 30). The boracic 
 poultice or fomentation is most useful in many superficial inflam- 
 matory affections due to sepsis, dirt, and want of attention. It 
 consists in the application to the part of a portion of boracic lint 
 wrung out of a hot boric acid solution (1 in 20), and covered with 
 oiled silk or guttapercha tissue. 
 
 4. Prevent the access of fresh sources of irritation or infection, such as 
 those due to putrefactive changes in an open discharging wound. 
 
 The General Treatment of inflammation varies considerably 
 with the condition of the patient, and as to whether he is strong 
 and healthy, or weakly. Those who are depressed in health, or 
 who may be expected readily to become so from the continuance 
 of the febrile state, need to be carefully supported by a tonic plan 
 of treatment, whilst at the same time attention must be directed 
 to the elimination of toxic bodies by suitable purgatives, dia- 
 phoretics, and diuretics. Quinine may be given with great benefit, 
 as also diffusible stimulants, such as ether or carbonate of 
 ammonia, whilst the recovery of patients lying in a typhoid state 
 of exhaustion will absolutely depend on the administration at short 
 intervals of nourishing fluids, combined with stimulants. In the 
 sthenic type of inflammatory fever, ' antiphlogistic ' means may 
 be freely employed so as to reduce the general blood-pressure and 
 remove irritating matters from the system, e.g., a smart purge, 
 followed by low diet and abstinence from alcohol for a few days ; 
 but in other instances where the blood-tension is high, as indicated 
 by a large and full pulse, and the local signs (pain, etc.) are well 
 marked, it may be also necessary to administer such drugs as 
 antimony, aconite, full doses of acetate of ammonia, colchicum or 
 ipecacuanha, to reduce the general blood-pressure, as also to 
 obtain diaphoretic action. In a few cases, e.g., acute meningitis, 
 venesection may be needed, and it is possible that this is an agent 
 too little employed in the present day. In some forms of inflam- 
 mation due to the specific diatheses, suitable drugs must be 
 employed to combat such tendencies — e.g., salicylate of soda or 
 salicin in acute rheumatism. 
 
 In inflammation of infective origin serotherapy (p. 14) may be 
 found of use, but at present the only diseases that are much 
 affected by this means are diphtheria, tetanus, and erysipelas. 
 (See on Erysipelas and Tetanus.) 
 
 Chronic Inflammation. 
 
 The phenomena of chronic inflammation are essentially the 
 same as those of the acute process, though the manifestations are 
 
38 A MANUAL OF SURGERY 
 
 somewhat different. Hyperemia and exudation occur, but the 
 tissue reaction is much more prominent. The main differences 
 between the two are as follows : 
 
 i. The hyperaemia is less in amount, but longer in duration, 
 owing to the fact that the causative irritant is less intense in action, 
 although often applied for a longer time. The local manifesta- 
 tions 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 
 the prolonged distension, and thus there is a 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 mem- 
 branes the cavities are distended with fluid of a much lower 
 specific gravity than that of blood serum. 
 
 3. The greatest difference in the acute and chronic processes 
 lies in the reaction of the tissues. In the former they are in a 
 depressed or paralysed condition, but in the latter they become 
 infiltrated with round cells, derived rather from the connective- 
 tissue elements than from the leucocytes, and hence organization 
 is much more marked than in the acute form. Tissue destruc- 
 tion, consequently, is less prominent in the early stage of chronic 
 inflammations, although as a secondary change, especially in 
 tuberculous and syphilitic diseases, it is often seen. 
 
 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 manifestations met with in surgical practice are due to syphilis, 
 tubercle, gout or rheumatism, and one should never treat cases of 
 this nature without carefully inquiring as to the possible existence 
 of some such taint. 
 
 The Results vary according to the part of the body affected, and 
 also with the predisposing diathetic state, and we can here only 
 indicate a few points worthy of notice. 
 
 In Simple chronic inflammation the part becomes infiltrated and 
 enlarged, mainly from proliferation of the connective tissues, and 
 if allowed to persist, this will result in fibrosis or sclerosis. Thus, 
 a bone is thickened and condensed in chronic osteitis {osteosclerosis), 
 whilst in chronic periostitis a new subperiosteal formation of bone 
 may occur. Glands become enlarged and indurated, mainly by 
 hyperplasia of the connective tissue, whilst if the skin is involved 
 it may either become hypertrophied and thickened, or entiiely 
 loses its characteristic structure, being converted into granulation 
 
INFLAMMATION 
 
 39 
 
 or fibro-cicatricial tissue, with or without an intervening ulcera- 
 tive stage. True suppuration rarely occurs, although certain 
 organisms of low virulence occasionally lead to its development. 
 
 In chronic Tuberculous inflammation the affected part is occu- 
 pied by pulpy oedematous granulation tissue, scattered through 
 which are definite tubercles, which may run together and lead to 
 the formation of caseating foci ; these in turn may either result in 
 suppuration or ulceration, or may undergo calcification, and their 
 extension be limited by a sclerosing process around them. A 
 diffuse overgrowth forms the earliest stage, and this is often 
 followed by destruction of the involved tissues, and possibly dis- 
 organization of the parts, with or without suppuration. 
 
 In chronic Syphilitic inflammation (tertiary) the most marked 
 feature is an invasion of any of the connective tissues by a fibro- 
 cellular exudation and hyperplasia, which may be diffuse or 
 localized ; if the former, general sclerosis of the part results, e.g., 
 in the stony-hard tertiary testicle ; in the latter, a gumma is 
 developed, which, owing to its want of blood vessels, usually 
 undergoes central degeneration and bursts, giving exit to a 
 gummy fluid, and perhaps leaving a leathery-looking slough be- 
 hind. 
 
 In all these varieties of chronic inflammation a marked pro- 
 liferation is always found in the tunica intima of the arteries of 
 the inflamed area, the result of an associated chronic endarteritis. 
 
 Constitutional symptoms are but little evident, beyond those 
 dependent on the diathetic condition to which the local phenomena 
 are due, or to septic changes developed secondarily. 
 
 The Treatment of chronic inflammation is usually more pro- 
 longed and difficult tha.n that of acute cases, because of the con- 
 stitutional dyscrasia which exists so frequently behind it. 
 
 i . The cause must be removed whenever possible. Dead or diseased 
 bone must be removed, and tuberculous material got rid of, by 
 the knife or sharp spoon, whilst it is often desirable to supplement 
 this by subsequently swabbing the parts over with liquefied car- 
 bolic acid. A chronic abscess increases the action of the original 
 irritant through the tension engendered by its presence, and hence 
 it should be dealt with as early as possible (p. 54). 
 
 2. Keep the part at rest. This is just as much an essential as in 
 the treatment of acute inflammation. Joints should be immo- 
 bilized ; 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. Thus, friction with the hand, or with stimulating 
 embrocations, produces a hyperaemic condition of the skin, and 
 promotes local activity in the superficial parts which may react 
 
4 o A MANUAL OF SURGERY 
 
 beneficially on deeper structures. Scoffs 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 firmly with soap 
 plaster, spread preferably on chamois leather. Iodine paint is 
 another useful application, whilst blisters are most valuable in 
 suitable cases. The moxa, a wound produced by burning a 
 spirituous solution of saltpetre on the skin ; the issue, the mainte- 
 nance of a raw surface, however produced, by the constant presence 
 of some irritant, such as the insertion 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 inflammation of 
 bones and joints. 
 
 4. Pressure is a most important element in the treatment of 
 chronic inflammatory disorders, and probably acts by artificially 
 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 
 most satisfactory methods of application. 
 
 5. A most valuable means of treating chronic inflammations, 
 and indeed many other affections, consists in Massage. It is 
 impossible in a text-book of this size to give a full account of the 
 methods employed, but we may state that the chief of them are 
 known as effleurage, petrissage, and tapotement. Effleurage con- 
 sists 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, 
 vaseline, or some stimulating embrocation, and the rubbing, at first 
 light, so as only to affect the skin and subcutaneous 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 absorption of exuda- 
 tions. 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. 
 
 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. 
 
CHAPTER III. 
 
 SUPPURATION AND ABSCESS. 
 
 When the inflammatory process results from the action of certain 
 micro-organisms, known as pyogenic, liquefaction of the inflamed 
 tissue and of the exudation follows, the liquefied material being 
 known as pus, and the process which leads to its formation as 
 suppuration. Any localized collection of pus is known as an 
 abscess, and of such two chief varieties are described — the acute 
 and the chronic. Sometimes the pyogenic infection involves the 
 cellular tissue to a considerable extent, and the pus is widely 
 diffused through the substance of the limb or part ; such a con- 
 dition is usually known as cellulitis (p. 90). 
 
 Acute Abscess. 
 
 Etiology. — A large amount of experimental work has been 
 undertaken to ascertain the relations of bacteria to acute sup- 
 puration, and from the mass of evidence — mainly concordant, 
 but occasionally conflicting — the following conclusions may be 
 drawn : 
 
 (a) That bacteria are present in all acute abscesses, either in the pus, 
 or in the abscess wall, or in both. Ogston of Aberdeen was the 
 first to proclaim this fact, and it is now generally accepted. In 
 some chronic abscesses, notably in the liver, the pus is occasionally 
 found to be sterile ; this is probably due partly to the organisms 
 having died, owing to their low vitality, and partly to the activity 
 of the surrounding tissues, which has led to the encapsulation of 
 the focus. 
 
 (b) That such bacteria can reach the inflamed area either from 
 without the body or from within. The former method is the more 
 common, 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. Suppuration in wounds is most commonly due to 
 infection from without, but there can be no question that auto- 
 
42 A MANUAL OF SURGERY 
 
 infection occurs, by means of which an abscess can be produced by 
 infection from within the body. This can only happen when the 
 vitality of the patient is considerably depressed, and some local 
 condition exists favourable to bacterial development. Thus, given 
 a blood-clot or inflammatory serous exudation in an unhealthy indi- 
 vidual, whose germicidal power is low, suppuration can ensue from 
 auto-infection, the organisms being carried by the blood to the 
 affected area ; an abscess thus produced is termed an idiopathic 
 infective abscess. Occasionally the microbes are carried either 
 en masse (zooglcca condition), or in the substance of a small portion 
 of blood-clot, as an embolus, from one part of the body where an 
 infected wound or injury exists to some other part, thus originating 
 an embolic infective abscess. Pyaemic abscesses are of this type, and 
 similar results occur after gonorrhoea, and after typhoid and other 
 fevers. 
 
 (c) That ordinary irritating c/iemical products or 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, an inch and a quarter long, and an inch and a 
 half wide, the result of the bursting of a soda-water bottle, was cut 
 out of the neck of a hotel porter ten months after it had entered ; 
 it had caused no suppuration. Experiments, moreover, have been 
 made with sterilized croton-oil and other irritants, in which the 
 substance securely sealed up in a thin glass capsule is implanted 
 amongst the spinal muscles of an animal, and after a delay to 
 allow the thorough healing of the wound is set free by a blow. 
 A collection of putty-like fibrinous material is found at the site of 
 operation, and much discussion has arisen as to whether or not 
 this is to be looked on as true pus. On the other hand, injections 
 of metallic mercury, or of the ptomaines produced by bacteria 
 (e.g., cadaverin, putrescin, etc.) certainly result in suppuration. 
 
 In conclusion, therefore, although we have to admit that 
 suppuration may be experimentally induced in animals in the 
 absence of micro-organisms, in man for all ordinary conditions sup- 
 puration does not occur apart from the presence and vital activity of specific 
 bacteria. 
 
 The causes of an acute abscess may for practical purposes be 
 grouped under the three following headings: (i) The individual 
 affected is possibly in a depressed and unhealthy state, and the 
 germicidal properties of his tissues may be defective. (2) A local 
 nidus must exist, which is in a condition of lowered vitality, 
 from injury, cold or otherwise ; and (3) this spot must become 
 infected with pyogenic organisms brought to it either from within 
 or without the body. 
 
 Bacteriology. — As already stated, the pus of all acute abscesses contains 
 living organisms, the nature of which, however, varies with circumstances. 
 When suppuration occurs in wounds in which there is but little putrescible 
 material, or arises idiopathically, it almost always results from direct in- 
 
SUPPURATION AND ABSCESS 
 
 43 
 
 fection with one or more of the pus-producing pathogenic bacteria. In many 
 so-called septic wounds, however, non-pathogenic bacteria are also present, 
 leading to putrefaction of the discharge. The most important Pyogenic 
 Organisms are as follows : 
 
 i. Staphylococcus pyogenes aureus is that commonly found in all foci of 
 localized suppuration (Fig. 3). It can readily be cultivated on nutrient 
 gelatine, agar-agar, or blood serum. On plate cultures it forms in two days 
 golden-yellow colonies, as also in tube preparations. It is very resistant to 
 chemical and thermal reagents, requiring several minutes' boiling to ensure 
 its destruction. It produces no gas and no stinking odour in its growth, and 
 is capable both of peptonizing albumen and of liquefying gelatine. It is a 
 facultative anaerobe (p. 4 ). 
 
 2. Staphylococcus pyogenes albus. 
 
 3. Staphylococcus pyogenes citreus. 
 
 These two forms are mainly distinguished from the former by the colour of 
 the colonies formed in their growth ; all their other properties are the same 
 except that perhaps the citreus is a little slower in rendering gelatine fluid. 
 
 t*SP B . i ■: 
 
 V,t ' 1:1 
 
 2* 
 
 t 
 
 Tig. 3. — Staphylococci in Pus. 
 (From Crookshank's ' Textbook 
 of Bacteriology.') 
 
 Fig. 4. — Streptococci in Pus. (Re- 
 duced from Crookshank's ' Text- 
 book of Bacteriology.') 
 
 whilst the albus is apparently not so virulent. The latter organism is very 
 similar to, if not identical with, the Staph, epidermidis albus, which is widely 
 scattered over the skin, and is usually found in the small abscesses developing 
 in connection with tense stitches. 
 
 The staphylococci are mainly associated with the formation of localized 
 abscesses. Thus, if a culture is rubbed into the skin of the forearm, a plentiful 
 crop of boils, or perhaps a carbuncle, will result ; if injected beneath the skin, 
 a subcutaneous abscess may be formed, or even a typical carbuncle, if a 
 sufficient number has been introduced, and if they are unfiltered so as to 
 retain their toxins; if the peritoneal cavity is infected, suppurative peritonitis 
 follows, provided that a sufficient quantity of the organisms is present ; if a 
 joint, suppurative arthritis. When injected into the blood-stream, there is 
 but little effect if only a few are introduced ; but when many, multiple 
 abscesses in any and every part of the body may occur, as in pyaemia, or more 
 frequently true septicaemia ; if, soon after the injection of an amount not large 
 enough to produce general infection, a bone or joint is injured, acute infective 
 osteomyelitis or arthritis will follow ; whilst if the cardiac valves are arti- 
 ficially damaged, a typical ulcerative endocarditis ensues. All these con- 
 ditions can be produced artificially in animals, and, from the similarity of the 
 symptoms and the microscopical appearance of the parts, we conclude that 
 similar affections in man are due to exactly the same causes, except that the 
 
44 A MANUAL OF SURGERY 
 
 infection is not artificial, but comes either from without, as a result of local 
 injury, or from the blood-stream. 
 
 4. Streptococcus pyogenes (Fig. 4 ) is an organism of great importance in path- 
 ology, and it is the main exciting cause of many inflammatory conditions. It 
 is probable that there are several distinct species included under this title- 
 indeed, it is claimed that six different forms have been isolated; further 
 researches are, however, needed to make certain of this fact. It can be readily 
 cultivated on most nutrient media, but grows slowly at the ordinary tempera- 
 ture of the air, and not very rapidly even at blood heat. It does not liquefy 
 gelatine nor produce any colouring reagent, and does not form any proteolytic 
 ferment. It occurs in chains of varying length, which may occasionally 
 bifurcate. 
 
 The Streptococcus pyogenes is mainly associated with spreading inflammations 
 of the cellulitic type, whilst it is a common cause of pyaemia, and even of acute 
 septicaemia. It has also been found in many acute localized abscesses, in 
 empyema, and in some forms of suppurative arthritis. It is probable that the 
 streptococcus of erysipelas should be included in this group. 
 
 5. The Bacillus coli communis is an organism to which much attention has 
 been directed of recent years. It is identical with the microbes formerly 
 known as the Bac. pyog. fcetidus and the Bac. lactis aerogenes. It exists normally 
 in the intestinal canal, extending from mouth to anus, but most frequently 
 in the duodenum and colon, and probably plays a considerable part in the 
 normal process of disintegration of food-stuffs. So long as it remains within 
 the bowel, it is perfectly innocent; but as soon as it is able to pass into or 
 through the intestinal wall, as a result of any loss or diminution in its vitality 
 or abrasion of its surface, it is liable to become intensely virulent, producing 
 suppurative inflammation of the most acute type, or even necrosis. Hence it 
 is the most common cause of acute suppurative peritonitis in all cases where 
 the infection arises from within the bowel, whilst it is mainly responsible for 
 the formation of abscesses in the neighbourhood of the tube, as in appendi- 
 citis, acute ischio-rectal suppuration, etc. One of its most characteristic 
 features is that — even when cultivated in a test-tube — it produces a most 
 offensive and penetrating odour, somewhat similar to that of decomposing 
 fasces; such is also noticed in the pus produced by the organism. It is also 
 the most constant organism found in the bladder in cases of cystitis, but has 
 no power of rendering the urine alkaline. 
 
 6. The Bacillus pyocyaneus is occasionally met with in wounds, producing 
 what is described as blue or green pus. It is of little clinical importance, 
 except that in a few cases it has been known to give rise to general infection. 
 
 7. The Pneumococcus and Bacillus typhosus may also give rise to suppuration 
 after pneumonia and typhoid fever respectively, but they are not specially 
 virulent, and the abscesses are usually of a subacute type. 
 
 8. The Gonococcus must also be included in this category. 
 
 Pathological Anatomy of an Abscess. — The phenomena associ- 
 ated with the formation of an acute abscess are merely a further 
 stage of those detailed previously as characteristic of inflamma- 
 tion. The vessels of the affected area become distended, and the 
 various elements of the blood pass through the walls. As the 
 organisms develop, the vascular phenomena of retardation and 
 stasis followed by thrombosis occur successively, whilst the exuda- 
 tion of cells becomes so great that the original tissue of the part 
 disappears, after passing through a stage of coagulation-necrosis 
 (Plate II., Fig. 1). This removal of the infiltrated tissues, though 
 due in part to the defective blood-supply resulting from the 
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SUPPURATION AND ABSCESS 45 
 
 caused by their liquefaction owing to the peptonizing power of 
 the bacteria present. In streptococcal infections where a proteo- 
 lytic ferment is absent, the solution of the tissues is probably 
 brought about by the direct action of the many phagocytes 
 present in the effusion, a process favoured by the damaged and 
 degenerative condition of the cells of the part ; this absence of a 
 ferment may explain why the onset of suppuration is sometimes 
 slow. The inflamed focus, therefore, consists merely of an irregularly 
 shaped mass of round cells, the central portion of which liquefies 
 and breaks down into pus. When once this has commenced to 
 form, it depends entirely upon the character of the irritant, and the 
 nature and behaviour of the surrounding tissues, as to what will 
 subsequently supervene ; but there is usually a tendency for the 
 pus to increase steadily in amount. It may then find its way to 
 the surface and point ; it may burrow along fascial or muscular 
 planes ; or it may, somewhat less frequently, become circum- 
 scribed, and more or less chronic. As soon as the acute or 
 extending process comes to an end, repair begins to manifest 
 itself in the vascularization of the embryonic tissue, and its trans- 
 formation into granulation tissue. Should the abscess point, the 
 normal tissues in the line it travels along are in their turn trans- 
 formed into embryonic tissue, which becomes liquefied as soon 
 as it is formed, whilst granulations spring up from the floor and 
 sides of the cavity, endeavouring, as it were, to obliterate the track 
 the abscess has followed. Thus, a definite distinction must be 
 drawn between the structure of its wall in the early and late 
 stages, which, however, we often see co-existing in the same 
 abscess. In the former or early stage of tissue destruction (Plate II., 
 Fig. 1), the following zones are met with in passing from the centre 
 to the periphery : (1) The central collection of pus ; (2) a layer of 
 breaking-down embryonic tissue infiltrated with bacteria ; (3) em- 
 bryonic tissue showing a trace of the original structure of the part 
 in a state of coagulation-necrosis, with the vessels thrombosed and 
 many bacteria present ; (4) tissue of the part infiltrated with leuco- 
 cytes and organisms, and with the blood-stream either stopped 
 completely or retarded ; (5) hyperaemic and slightly infiltrated 
 tissue of the part, gradually shelving off into normal tissue. It 
 must be clearly remembered, however, that the inflammatory 
 focus is at first diffuse, and that the zones indicated here are 
 quite artificial. The early abscess cavity is extremely irregular in 
 outline, and the lining wall very variable in character, one part 
 being possibly thick, and another quite thin and yielding readily 
 to the extension of the proces. In the later stages (Plate II., 
 Fig. 2), where the inflammation is not spreading, the structure 
 of the abscess may be thus described: (1) The central focus of 
 pus ; (2) a layer of granulation tissue to a large extent free from 
 bacteria ; (3) a layer of fibro-cicatricial tissue gradually merging 
 into (4) the normal tissue, somewhat infiltrated and hyperaemic. 
 
46 A MANUAL OF SURGERY 
 
 The Clinical Signs and Symptoms of an acute subcutaneous 
 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, elastic, 
 and fluctuating, 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 the part, suppuration beneath a 
 resisting membrane, such as the palmar fascia, being always 
 intensely painful. If left to itself, an abscess sooner or later 
 points and bursts. As it increases in size, it exerts pressure in 
 all directions, and naturally seeks to find an exit in the line of 
 least resistance, and so may either find its way to the surface, or 
 may burrow along muscular and fascial planes, or into adjacent 
 cavities. This is not merely a mechanical, but also a vital process, 
 as already described. The actual bursting of an abscess is often 
 due to some injury — it may be a slight one — but is usually pre- 
 ceded by ulceration of the integument, or perhaps, if the abscess 
 is a large one, by necrosis. 
 
 2. Pressure effects are mainly due to the mechanical influence of 
 the swelling upon surrounding structures. The most evident 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 bloodvessels are 
 involved, the tissue around them disappears, and they are left in 
 the abscess cavity as bands, surrounded by granulation tissue. 
 Thrombosis and the subsequent obliteration of the vessel may 
 result, or occasionally ulceration and haemorrhage (ulcerative 
 periarteritis), preceded perhaps by an aneurismal dilatation of 
 the vessel, owing to its loss of external support. Such effects are 
 more common in chronic than in acute 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 some stimulating influence reaching the thermogenic 
 centres of the medulla, and determining a sudden increase of 
 activity. 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 
 and hot, and the temperature of the body rapidly rises. The 
 sensation of cold is partly due to the contact of air at a main- 
 tained 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 com- 
 mencing to act. Finally there is a rapid fall of temperature 
 
SUPPURATION AND ABSCESS 47 
 
 accompanied by profuse perspiration, which leaves the patient 
 more or less exhausted. 
 
 Leucocytosis is the term employed to indicate an increase in the 
 number of white corpuscles in the blood. Normally about 8,000 
 leucocytes are found in each c.mm., although the number is some- 
 what increased immediately after meals. When suppuration is 
 occurring, the proportion may be enormously increased, even up 
 to 100,000 per c.mm. It is best seen in cases of severe infection, 
 well resisted, and is not a very obvious feature when the infec- 
 tion is so acute as to break down all resistance, or so slight as to 
 cause little constitutional disturbance. A blood-count may be 
 advisably undertaken in some cases of doubtful diagnosis. 
 
 Pus and its Constituents. — Normal, or as it was formerly called 
 healthy, or laudable pus is a thick, creamy fluid, having a specific 
 gravity of about 1030, an alkaline reaction, no smell (unless putre- 
 fying or under special circumstances), and containing 85 to go per 
 cent, of water. If allowed to settle, it separates into two layers, 
 the upper or fluid part, liquor puris, consisting of liquefied tissue 
 and serum, and containing about 6-7 per cent, of proteid material 
 (i.e., rather less than in normal blood serum) ; whilst the lower 
 layer includes the solid elements present, viz., dead and living 
 pus corpuscles, fatty and granular debris, perhaps micro-organisms, 
 and possibly a few red blood cells. All the pus cells look alike 
 when examined under the microscope on a cold slide ; but if 
 placed on a warm slide, a difference is soon noticed. Dead pus 
 cells are rounded in outline, about 0500 inch in diameter, coarsely 
 granular in texture, and show two or three nuclei, which become 
 more evident on the addition of dilute acetic acid. The living 
 pus corpuscles are fewer in number, and, though spherical at 
 first, soon manifest amoeboid movements ; their protoplasm is 
 finely granular, and the single nucleus is not readily observed ; 
 the proliferation of the nucleus is always an evidence of degenera- 
 tion and approaching death. It must be clearly understood that 
 both the living and dead cells are derived from the same sources, 
 viz., principally from the extravasated leucocytes, but also possibly 
 from proliferation of the fixed connective-tissue corpuscles of the 
 part. 
 
 As already stated, the pus in an acute abscess contains bacteria, which are 
 best demonstrated in the following way : A drop of pus is placed between 
 two cover-slips, which are each evenly coated by a thin layer of the fluid by 
 sliding one over the other. These are dried by passing them through the 
 flame of a spii it-lamp, only sufficient heat being employed to set the albumen 
 without destroying the corpuscles. A drop of methyl-violet solution is now 
 placed over the pus film, and allowed to remain for about a minute, being 
 then washed away by a stream of distilled water. The slip should be again 
 dried slowly, and mounted in Cana.da balsam. The cocci will be found stained 
 deeply, whilst albuminous and fatty granules are not coloured at all, or but 
 slightly (Figs. 4 and 5). 
 
 When pus is mixed with blood, it is termed saDious (short for 
 
4 8 A MANUAL OF SURGERY 
 
 sanguineous) ; when thin and acrid, it is ichorous ; curdy, when 
 mixed with curdy shreds, as is more usually seen in chronic 
 suppuration of a tuberculous nature ; muco-pus, when mixed with 
 mucous, arising from inflammatory conditions of mucous mem- 
 branes. The occurrence of stinking pus apart from putrefaction 
 has been already explained as generally due to the activity of the 
 Bacillus coli communis. 
 
 Occasionally an abscess is found to contain not only pus, but 
 also gas. This may be due to the existence of a direct com- 
 munication with some hollow viscus — e.g., the stomach or intestine 
 — and hence is met with in subphrenic abscess and in some of 
 the many types of abscess associated with appendicitis ; but it is 
 sometimes the result of infection with a gas-producing organism — 
 e.g., the Bacillus arogenes capsulatus or Bacillus cedematis maligni. 
 This latter type is rare apart from spreading gangrene ; but we 
 recently opened a perineal abscess in a diabetic patient from out of 
 which the gas literally whistled, whilst in a few days emphysema 
 had spread over the whole trunk, in spite of incisions to limit its 
 progress. Very extensive sloughing followed, and the patient 
 died. The Bacillus adematis maligni was isolated in this case. 
 
 The Diagnosis of an acute superficial abscess usually presents 
 no difficulties, the sense of fluctuation supervening in the midst 
 of an area previously inflamed and brawny being quite charac- 
 teristic ; sometimes, however, all that can be detected is a feeling 
 of elastic resistance in the centre of the hyperaemic indurated 
 focus, but this, to the practised finger, is quite as conclusive of 
 the presence of fluid as fluctuation. When the pus is placed 
 deeply under muscular and fascial planes, very careful examina- 
 tion may be needed in order to determine its presence ; the 
 surgeon must not be misled by the sense of fluctuation obtained 
 across the fibres of a muscle ; none is noticed, however, by pal- 
 pating along the course of its fibres. 
 
 Treatment of Acute Abscess. — When an inflamed area is 
 threatening 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 cold and evaporating lotions, 
 may sometimes succeed in accomplishing this, together with the 
 administration of quinine and iron. The hypodermic injection 
 of powerful antiseptics — e.g., pure carbolic acid — has also been 
 employed to destroy the pyogenic organisms in situ, whilst in 
 some cases (e.g., in acute periostitis) a free incision through 
 the inflamed tissues is permissible. 
 
 In a few regions of the body, pus may be absorbed after its 
 formation, but only when situated in a cavity of highly-absorbing 
 powers, such as the anterior chamber of the eye (hypopyon), or 
 perhaps some of the serous cavities, e.g., the peritoneal. In the 
 former the process of absorption may certainly be observed under 
 the influence of local and general treatment. 
 
SUPPURATION AND ABSCESS 49 
 
 As a rule, however, one encourages suppuration by applying 
 fomentations or poultices to the part, and then as soon as pus is 
 evident, an incision is made to evacuate the abscess cavity. 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 septic contamination, and in such 
 a direction that movements of the part do not close it. In 
 dealing with deep abscesses in dangerous regions, Hilton s method 
 may be advantageously employed. It consists in merely dividing 
 the skin and superficial structures, and then thrusting a director 
 into the abscess cavity ; a pair of sinus or dressing forceps is now 
 passed along the groove, and on forcibly separating the blades a 
 sufficient opening is made to insert the finger, and subsequently 
 a drainage-tube. 
 
 Methods of Opening Various Abscesses. — Axillary Abscess. — Cut in the 
 median line of the axilla towards the chest from above downwards, and use 
 Hilton's method, thus escaping the three main sources of danger, viz., the 
 axillary vessels above, the long thoracic in front, and the subscapular vessels 
 behind. 
 
 Inguinal Bubo. — Make a vertical incision from below upwards, the patient 
 standing erect against a wall or lying down. When he sits the incision gapes, 
 and so accumulation is prevented. 
 
 Intramammary Abscess. — Cut in a direction radiating from the nipple to 
 prevent injury to the galactophorous ducts, and pass a finger in so as to open 
 up all the dilated lobules. 
 
 Submammary Abscess. — Open along the lower margin of the breast, and, if 
 possible, towards the outer side, carefully avoiding the glandular tissue. 
 
 Retropharyngeal Abscess. — Incise along the posterior border of the sterno- 
 mastoid for about an inch ; draw that muscle and the carotid sheath forwards ; 
 open by Hilton's method, pushing a director inwards to the middle line 
 immediately in front of the transverse processes 
 
 Ischio-rectal Abscess. — Place the patient leaning over the back of a chair, 
 or in the lithotomy position if an anaesthetic is employed, and incise vertically 
 and very freely, as far from the anus as possible ; healing may ensue without 
 opening the rectum. In some cases where the skin is undermined, a crucial 
 incision should be made, the resulting corners of skin being removed. 
 
 In opening a Palmar Abscess, care must be taken not to wound the super- 
 ficial palmar arch or its digital branches. It is best accomplished by entering 
 the knife immediately in a line with the centre of the metacarpal bones, cutting 
 forwards to the base of the finger ; the upper limit of this incision should not 
 transgress the centre of the palm. 
 
 A Whitlow should be opened in the middle line of the finger by a knife held 
 with its back towards the wrist, and it often happens that the patient, if 
 conscious, unwittingly assists at his own operation by withdrawing his hand, 
 thus effectually completing the incision ; care must, of course, be taken hot 
 to let the knife travel too far or too deeply. 
 
 It is advisable to gently squeeze an abscess after opening it, 
 especially if sloughs are present, or when it has burrowed ; if 
 the cavity is large, it should be explored with the finger. All that 
 is subsequently needed, if there is no complication, such as the 
 presence of dead or diseased bone, is to arrange for drainage, as 
 by inserting a drainage-tube or a slip of protective, and to exclude 
 sepsis by a carefully applied antiseptic dressing ; in other cases 
 
 4 
 
50 A MANUAL OF SURGERY 
 
 it may be desirable to pack the cavity with gauze soaked in an 
 iodoform emulsion (10 per cent.). There 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 relief of 
 tension ; but this usually ceases of itself, or yields to moderate 
 pressure. When once the abscess has been evacuated, no move pus is 
 formed if the cavity is kept aseptic, the discharge being merely serous, 
 and the wound rapidly closing and healing. Our colleague, 
 Mr. G. L. Cheatle, has pointed out that, although no more pus is 
 formed, the cavity and its lining wall still contain bacteria, and 
 perhaps in a state of virulence, but they are evidently unable to 
 develop or do any harm, possibly from the tissues being immunized 
 or protected against them. Pus which stinks on its escape loses all 
 smell in a day or two, the wound pursuing a normal course, unless 
 the abscess communicates directly with the bowel. In some cases 
 the original opening at the spot where the abscess pointed may not 
 give efficient drainage ; a counter-opening should then be made by 
 pushing the finger, or a probe, through the abscess wall amongst 
 the tissues, making it protrude beneath the skin at some dependent 
 spot, and cutting down upon the finger or probe in this direction. 
 
 Chronic Abscess (syn. : Cold or Congestive Abscess). 
 
 A chronic abscess may be defined as a collection of pus which 
 forms slowly without any signs of active inflammation. Although 
 a few cases are due to infection with pyogenic microbes or to 
 chronic pyaemia, yet the vast majority are tuberculous in origin ; 
 and, indeed, when a chronic abscess is spoken of, it may be taken 
 for granted that it is tuberculous, unless otherwise stated. It 
 must be clearly understood that, although we speak clinically 
 of a chronic tuberculous abscess, it is a question whether the 
 term is correct, and whether the fluid contained therein is pus ; 
 certainly its method of origin and characters are very different 
 to those of an acute abscess. For the present, however, it is 
 convenient to retain the terms ' pus ' and ' abscess ' in this con- 
 nection. 
 
 Wherever tubercle can be deposited, a chronic abscess may 
 form ; but it occurs most commonly in connection with bones, 
 joints, and lymphatic glands. Into the details of these causative 
 affections it is unnecessary to enter here ; suffice it to state that 
 the abscess arises from the degeneration and liquefaction of a 
 tuberculous focus ; that it forms a soft fluctuating swelling, 
 gradually increasing in size, and possibly by its pressure effects 
 becoming painful ; that it may come directly to the surface if 
 there is no dense fascia to prevent it, but that, being often placed 
 deeply, there is a great tendency to burrow along fascial planes, 
 and hence to become superficial at a spot far removed from its 
 original source. Thus, an abscess arising in connection with 
 tuberculous disease of the dorsi-lumbar region of the spine may 
 
SUPPURATION AND ABSCESS 
 
 51 
 
 travel in many directions : it may pass backwards, and be opened 
 at the side of the spine as a lumbar abscess ; it may infiltrate the 
 superficial fibres of the psoas muscle, and travel down the sheath 
 to the groin, pointing either above or below Poupart's ligament 
 (Fig. 5) ; or it may find its way into the pelvis and escape by the 
 side of the rectum. The far-reaching extent of these abscesses, 
 the impossibility of dealing adequately with the lining membrane, 
 together with the infective nature of the disease and the often 
 inaccessible position of 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 should the cavity of the abscess once become septic, there is 
 but little hope of again purifying it, and the result is an increased 
 discharge of pus, absorption of the chemical products of putrefac- 
 tion, aggravation of the original disease, and only too frequently 
 death from exhaustion or blood-poisoning. 
 
 The pus contained in a chronic abscess may be of the ordinary 
 type, consisting of cells and bacteria ; but if of tuberculous 
 origin, there are only a few cells, and those in a condition of fatty 
 
 degeneration, whilst masses of 
 curdy debris of variable size and 
 consistency are often present, if 
 the abscess is of long standing, 
 an abundance of cholesterine 
 crystals is often seen, a fact re- 
 cognised by the naked eye by the 
 glistening sheen or greasy appear- 
 ance imparted to the pus ; micro- 
 scopically, they appear in the 
 shape of rhomboidal plates, with 
 one corner notched out. It is 
 unusual to find either cocci or 
 bacilli in the pus of a chronic 
 tuberculous abscess, and this in 
 spite of the fact that inoculation 
 of animals with the pus results in 
 tuberculosis. Probably the bacilli 
 have been broken up by the sup- 
 purative process, but the more 
 resistant spores are still present. 
 
 The microscopic appearance of a 
 tuberculous abscess wall is quite 
 characteristic (Plate III., Fig. 2). 
 
 The method of extension along the The Cavit y I s lined b Y a la y er of 
 psoas tendon and into the thigh g ra y» yellowish-gray, or pinkish, 
 is well seen. pulpy granulation tissue, contain- 
 
 ing 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 
 
 DUE TO 
 
 Fig. 5. — Psoas Abscess 
 
 Disease of the Upper Lumbar 
 Vertebrae. (After Albert.) 
 
52 A MANUAL OF SURGERY 
 
 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 mentioned that endar- 
 teritis 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-cicatricial 
 material, which forms the outer part of the wall, and from which 
 it can often be readily detached by the finger or a sharp spoon. 
 This, in turn, gradually shelves off into the normal tissue which 
 surrounds the abscess. In non-tuberculous cases the lining wall 
 consists of granulation tissue passing over into the normal 
 structure of the part, which is more or less sclerosed, according 
 to the duration of the mischief. 
 
 Natural Cure. — A tuberculous abscess, if left to itself, does not 
 necessarily come to the surface and burst. Occasionally in the 
 dead-house one meets with a mass of putty-like consistency lying 
 in front of the spine in 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 
 solid elements left behind, encapsuled and perhaps infiltrated with 
 lime salts. Such debris can become the seat of recurrent inflam- 
 matory mischief when the original disease has been quiescent for 
 years ; suppuration may suddenly occur, giving rise to what is 
 known as a residual abscess. Probably a large amount of choles- 
 terine will be found amongst its contents. The prognosis of such 
 an abscess is good ; in more than one instance we have cured 
 them entirely by one tapping and free lavage. 
 
 Results of Long- continued Suppuration. — When a chronic abscess 
 is emptied antiseptically, and maintained in an aseptic condition, 
 the formation of pus ceases ; the wound may remain open for 
 months, but the discharge is merely serous, and no constitutional 
 results will be manifested. The temperature is normal, and the 
 general health unimpaired, if no other disease is present. Should 
 such an abscess become septic, the condition of affairs is at once 
 changed ; the discharge becomes profuse and purulent, fever 
 supervenes, and grave visceral changes occur, which sooner or 
 later may lead to the patient's death from exhaustion. Long-con- 
 tinued suppuration, then, is always an evidence of sepsis, and from it two 
 conditions may arise, viz., hectic fever and lardaceous disease. 
 
 Hectic Fever may be defined as a chronic toxaemia or condition of 
 blood-poisoning, due to the continual absorption of small doses of 
 toxins, and is met with not only after opening chronic abscesses, 
 but also in any condition of chronic sepsis, e.g., after acute or 
 chronic suppurative affections of bones or joints, in tuberculous 
 disease of the lungs, and in septic syphilitic or cancerous disease. 
 It is characterized by a regular diurnal elevation of temperature, 
 which runs a tolerably typical course. It commences to rise 
 during the afternoon, the face becoming flushed (hectic flush of 
 the cheeks), the eyes bright and sparkling, the pupils dilated, 
 
SUPPURATION AND ABSCESS 53 
 
 and the patient feeling better and stronger. The pulse, how 
 ever, is small, compressible, and ten or twenty beats quicker 
 than it should be ; the tongue becomes red at the edges and tip. 
 This condition continues till late in the night, by which time the 
 temperature may have risen four or five degrees. It then com- 
 mences to fall as rapidly as it had formerly risen, and usually 
 drops to the normal, or even below it, and in the early morning a 
 profuse perspiration breaks out which soaks the patient's clothes, 
 and leaves him in a much-exhausted condition. Day by day this 
 
 ^ %':'%fm^-y 
 
 c- 
 
 
 Fig. 6. — Amyloid Kidney in Early Stage. (Ziegler.) 
 
 (Treated with Miiller's fluid and perosmic acid, x 300.) a, Normal capillary 
 loop; b, amyloid capillary loop; c, fatty epithelium of glomerulus; Cy fatty 
 epithelium of capsule ; d, oil-drops on the capillary wall ; e, fatty epithelial 
 cells in situ ; /, loosened fatty epithelial cells ; g, hyaline coagula (forming 
 ' casts ') ; h, fatty cast in section ; i, amyloid artery; k, amyloid capillary ; 
 I, infiltration of connective tissue with leucocytes ; m, round cells (leuco- 
 cytes) within a uriniferous tubule. 
 
 continues, the fever and sweating together causing a marked 
 diminution in the patient's strength. 
 
 Amyloid, Albumenoid, or Lardaceous Disease of various organs 
 is also present in cases of long-standing suppuration. As to the 
 cause of this curious condition, but little is known ; either from 
 the deleterious effects of toxic compounds circulating in the blood, 
 or from the loss of some special substance in the discharge, 
 e.g., alkaline phosphates, the walls of the smaller arteries and 
 
54 A MANUAL OF SURGERY 
 
 the protoplasm of certain of the 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 homogenous material, 
 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, and the capillaries and muscular coats of the arterioles 
 (Fig. 6, b and i) are the parts first attacked, the change gradually 
 spreading to the parenchyma of the organ. 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 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. The kidneys become similarly enlarged, 
 the change commencing in the arterioles leading to the glomeruli 
 (Fig. 6), but the capillaries and the tubal epithelium are also 
 early affected. In this stage the urine is very abundant (from the 
 increased filtration through the degenerated walls), pale, limpid, 
 and containing a few hyaline 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 increased transudation of the 
 fluid 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-indica- 
 tion to operation, are rather to be considered as a sign that radical 
 treatment 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 dis- 
 appear. 
 
 Treatment of Chronic Abscess. — In former days the rule always 
 given was to leave a chronic abscess alone as long as possible, 
 and never to interfere unless forced to do so ; sepsis, followed by 
 hectic and increased rapidity of the disease, almost always resulted 
 from such interference. But when asepsis can be maintained, 
 
SUPPURATION AND ABSCESS 
 
 there is no reason to depart from the ordinary rule of surgery, 
 that the abscess should be evacuated as soon as possible after its 
 formation. It is, however, most important to recognise the fact 
 that one slip in the technique may lead to a fatal issue, and 
 therefore none should interfere with these cases unless they are 
 prepared to take the time and trouble needed to keep them aseptic. 
 Again, from the risk of sepsis being admitted during the dressing 
 of the case, those methods should be preferred which admit of the 
 immediate total closure of the wound. Many plans of treatment 
 of chronic abscess have been suggested and practised ; we can 
 here only allude to the more important. 
 
 1. Simple aspiration has been known to effect a cure, but only in excep- 
 tional circumstances, viz., where the causative lesion is absolutely passive, 
 and when the patient's health and constitution are vigorous. It often fails 
 from the blocking of the aspirator needle by curdy debris, and there is always 
 a fear that much of this material will be left behind, forming a possible source 
 of future re-infection. The rapid emptying of the sac, moreover, often leads 
 to haemorrhage, and the blood thus collecting will form a favourable soil for 
 the development of the spores remaining in the curdy masses, or of the bacilli 
 within the pyogenic membrane. 
 
 2. Tapping the abscess with thorough irrigation is another plan of treatment 
 which under favourable circumstances is occasionally successful. We have 
 seen a large psoas abscess cured by one thorough washing out. The modus 
 operandi is as follows : The skin is incised, and through the opening a large 
 trocar and cannula is inserted into the abscess cavity, which is emptied as 
 completely as possible. It is now distended with a warm solution of carbolic 
 acid (i in 80), or with a sublimate lotion (1 in 5,000), or simply with sterilized 
 water or salt solution (5i. ad Oi.), at a temperature of 105 to 110° F. The 
 abscess is then well kneaded with the fingers, and the fluid with the curdy- 
 masses and broken-down pyogenic membrane is allowed to escape. The 
 process is repeated again and again until the escaping fluid is nearly clear, 
 or only slightly opalescent. The cannula is now withdrawn, the wound 
 firmly stitched up, and an antiseptic dressing applied, using sufficient pressure 
 to obliterate, if possible, the abscess cavity. The patient must be kept quiet, 
 and carefully watched for a time, to ascertain if there is any reaccumulation, 
 when the same process may be repeated. 
 
 3. Opening the abscess and scraping out the interior with Barker's flushing gouge 
 combines the irrigation of the previous method with the more or less complete 
 removal of the tubercle-containing pyogenic membrane. The instrument 
 employed consists of a gouge or sharp spoon with a long hollow handle, 
 which communicates by a tube with a reservoir of fluid placed at some height 
 above the patient. During its application the constant rush of water or lotion 
 through the handle clears the gouge, and removes the debris. It is admirably 
 adapted for certain cases, but its use needs considerable care, as the sharp 
 edge can readily scrape through an abscess wall, and do much mischief. It 
 is a convenient means of dealing with abscesses of bones and joints in the 
 more superficial parts of the body. The wounds should be subsequently 
 closed, and an attempt made to gain immediate healing of the denuded cavity. 
 
 4. Injection of an antiseptic into the sac after tapping is a method introduced 
 by Professor Velpeau in France, and has been received with much favour. 
 Various reagents have been employed, but the majority contain iodine either 
 in the form of the tincture, or as iodoform, which latter may be suspended in 
 glycerine or olive-oil (10 per cent.), or dissolved in ether (5 per cent.). The 
 method of introducing these compounds is quite simple, the amount varying, 
 but as a rule not more than a drachm of iodoform should be used. When 
 
56 A MANUAL OF SURGERY 
 
 the ethereal solution is injected, the ether immediately volatilizes and hilly 
 distends the abscess cavity, which becomes tense and tympanitic ; it must 
 therefore never be used for abscesses communicating with the interior of the 
 thorax, death having in one or two recorded cases resulted from heart failure, 
 due to such distension. There is some danger, too, that serious toxic 
 symptoms may arise from absorption of the iodoform. This treatment is 
 most likely to be efficacious when all active bone or joint disease has dis- 
 appeared, and is frequently employed as an adjunct to one of the above- 
 described plans. 
 
 5. If the above methods fail, or are for any reason inapplicable, the original 
 antiseptic method of simple incision with drainage can always be adopted. This 
 is perfectly safe, so long as asepsis is maintained ; but the great objections to 
 it are the length of time (months, or even years) often required to bring about 
 healing, especially in cases where, although a free incision is made, the actual 
 seat of the disease is not reached, and the risk of contamination during one of 
 the repeated dressings that are required. 
 
 6. 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 is feasible, it is the most satisfactory plan to adopt. Should the 
 posterior wall of the cavity be adherent to important deep structures, it should 
 be thoroughly scraped so as to remove all pyogenic material, and disinfected, 
 e.g., with liquefied carbolic acid or solution of zinc chloride (40 grains to 
 1 ounce). An attempt may then be made to gain healing by first intention, 
 or the cavity may be stuffed and allowed to granulate. 
 
 7. Laying the cavity freely open, scraping away the pyogenic tissue, perhaps 
 purifying with carbolic acid, plugging the wound firmly with gauze infiltrated 
 with purified iodoform, and allowing it to granulate from the bottom, or 
 the open method, may be used advantageously in cases where abscesses have 
 burrowed between muscles, and along fascial planes. Sulphur has also been 
 used instead of iodoform, but has no special advantage, whilst it causes a good 
 deal of sloughing of the surrounding tissues owing to its transformation into 
 sulphurous, and finally into sulphuric acid. Friar's balsam (1 part in 8 of 
 castor oil or glycerine) may be employed in the same way, and is innocuous 
 and useful. 
 
 Sinus and Fistula. 
 
 When an abscess has been opened, and does not completely 
 heal, 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 lined with granulations, penetrating 
 into the tissues, open at one end and closed at the other ; the dis- 
 charge is purulent or merely serous according to whether or not 
 sepsis is present. A Fistula is an abnormal communication be- 
 tween two cavities, or between a cavity and the external surface. 
 When such conditions result from the non-closure of a chronic 
 abscess, the walls consist of exactly the same structures as 
 those of the original abscess, viz., an external fibro-cicatricial 
 vascular layer, merging into healthy tissues, and an internal 
 lining of pyogenic membrane containing tubercles, if the origi- 
 nating disease was tuberculous. If the fistulous track is short, 
 there is a tendency for the granulating wall to become covered 
 with epithelium, and under such circumstances it cannot be ex- 
 pected to close until the epithelium has been removed, and a raw 
 surface again exposed. 
 
SUPPURATION AND ABSCESS 57 
 
 It is often a matter of the greatest difficulty to secure the heal- 
 ing of a sinus or fistula, and the following are the main causes of 
 their non-closure : (1) 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 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) in- 
 sufficient 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 
 tuberculous deposit at the bottom of the sinus ; (6) the growth of 
 epithelium down the sinus or round the margin of the fistula ; or 
 (7) constitutional debility. 
 
 The orifice of a sinus is often depressed from the amount of 
 infiltration around, but in cases where foreign bodies are lodged 
 within, or where diseased bone exists, it is usually surrounded by 
 prominent fungating granulations. 
 
 Treatment. — The removal of the cause is the first thing to 
 accomplish 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 purification of the part by pure carbolic acid 
 or chloride of zinc must also be undertaken, and the wound 
 dressed by plugging 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 immobilize 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 thoroughly destroy the lining granulation tissue by scraping 
 or cauterising, and then to plug the wound, allowing it to heal 
 from the bottom by granulations. 
 
 Should a fistula have become lined with epithelium, the edges 
 will require paring, and some form of plastic operation must be 
 undertaken to close the opening. 
 
 The term ' fistula ' is also applied to conditions other than those 
 tracks remaining from the non-closure of an abscess. Three 
 classes may be described : 
 
 1. Congenital fistula, e.g., branchial, umbilical urinary or faecal, 
 etc. 
 
 2. Traumatic fistula, e.g., aerial, pharyngeal, salivary, recto- 
 vesical, recto-vaginal, etc. 
 
 3. Pathological fistula, or those secondary to abscess or disease, 
 e.g., biliary, faecal, perineal urinary, fistula-in-ano, etc. 
 
 Each of these will be referred to later on under its appropriate 
 heading. 
 
CHAPTER IV. 
 
 ULCERATION. 
 
 Ulceration has been denned as the ' molecular or particulate 
 death of a part,' by which is meant the disintegration of the super- 
 ficial tissues, which liquefy and disappear, and usually without 
 any obvious slough. It differs from gangrene in that the latter 
 term is used to denote the simultaneous loss of vitality 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 visible to the naked 
 eye, whereas in the latter the necrotic portions, if superficial, can 
 always be seen. 
 
 Three main classes of ulcers are met with in surgical practice : 
 
 I. Ulcers due to traumatism or to the ordinary pyogenic bacteria, e.g., 
 the spreading, healing, chronic, etc. 
 
 II. Ulcers due to specific* bacteria, e.g., soft chancre, lupoid, 
 tuberculous, syphilitic, etc. 
 
 III. Malignant ulcers, e.g., rodent, epitheliomatous, scirrhous, 
 and fungating. 
 
 Causation. — Ulceration is due to the application of an irritant 
 to the surface of such an intensity, and for such a period, as to 
 lead to local inflammation resulting in the destruction of the 
 tissue affected. Any form of irritant, whether chemical, thermal, 
 mechanical, or infective, may accomplish this end, and all the 
 factors predisposing to inflammation will hasten its occurrence. 
 Thus, faulty nutrition, whether from anaemia or from long-standing 
 congestion, is particularly liable to further the ulcerative process. 
 Moreover, when any part becomes anaesthetic, or is cut off from 
 its trophic centres, the continued presence of an irritant may not 
 be appreciated, and hence destructive inflammation occurs, e.g. 
 
 * It may be well to note that whilst the term infective is applied to any 
 condition due to an invasion with bacteria, the word specific denotes that the 
 lesion is due to one special or specific organism. Nearly all inflammatory 
 ulcers are infective in nature, but only those in Group II. are specific; many 
 different types of organisms may give rise to the ulcers in Group I. 
 
ULCER A TION 59 
 
 corneal ulcer following section of the fifth nerve, or perforating 
 ulcer of the foot in tabes. In malignant disease the projection of 
 the mass of the growth may expose it unduly to irritation ; but 
 the chief cause of ulceration is the replacement of the deeper 
 layers of the skin or mucous membrane by the cells of the 
 neoplasm, so that when the superficial epithelium wears off or is 
 lost, it cannot be reproduced. 
 
 I. Ulcers due to Traumatism or to the ordinary 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 transi- 
 tion, 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, the ulcer proper disappears, and merely a 
 superficial loss of substance, the result of the preceding ulceration, 
 remains. 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 
 may 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, 
 considerable in amount, thin, sanious, and often irritating and 
 offensive, rarely purulent ; margins, thickened and inflamed, and 
 the surrounding tissues often cedematous and infiltrated ; edge, 
 sharply cut and well defined ; the base of the ulcer is thickened 
 and fixed to the underlying structures. 
 
 Microscopically, all the phenomena of inflammation may be 
 observed progressing to thrombosis and tissue necrosis, so that 
 in approaching the surface from the healthy tissues one would 
 pass through zones of active hypersemia, of retarded blood-flow 
 with infiltration of leucocytes and plasma, of stasis and throm- 
 bosis, whilst the tissues are in a state of coagulation-necrosis. 
 
6o A MANUAL OF SURGE NY 
 
 Treatment of First Stage. — This resolves itself into removing 
 the cause, protecting the surface from all sources of mechanical 
 irritation, and purifying it from all septic contamination. The 
 inflamed part must be kept at rest, and if necessary raised from 
 a dependent 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 poultice. When the parts are 
 very offensive, a charcoal and linseed-meal poultice may be first 
 employed. The state of the bowels and constitution must be 
 attended to, and probably a mild purgative will be needed. 
 
 Stage II. : The Transition Period comprises all the changes which 
 occur from the termination of the ulcerative process proper to the 
 time w r hen 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, and the septic element has been eliminated, the surface 
 of the ulcer begins to clean, and becomes, as it were, glazed 
 over ; sloughs and portions of dead tissue are either removed 
 in the dressing or absorbed by the activity of the leucocytes and 
 fibroblasts. The discharge becomes less abundant and more 
 serous in character, and the angry red blush is replaced by a 
 rosy hyperaemia. 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 vascularization of this newly-formed 
 material, and its conversion into granulation tissue. 
 
 Microscopic Appearances. — When the action of the irritant has 
 ceased, the migration of the leucocytes lessens, and the destruction 
 of tissue comes to an end. The surface of the ulcer is now 
 covered with a layer of round cells, mainly derived from the pro- 
 liferation of the neighbouring connective-tissue elements, and 
 intermixed with fibrin in such a way that the cells lie in the 
 interstices of the fibrillae ; this constitutes the film mentioned 
 above. The vessels in the area, where merely stasis has occurred, 
 become patent, and the circulation in the neighbourhood of the 
 ulcer is thus restored. The vascularization of this superficial 
 film is next undertaken, according to the process described in 
 Chapter VIII. The wound thus becomes covered with granula- 
 tion tissue, and with its formation the processes included in the 
 second stage come to an end. 
 
 All the forms of chronic ulcer which are neither spreading nor actively 
 
ULCERATION 61 
 
 healing may be 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 life. The size varies 
 greatly, but they are sometimes so extensive as to involve the 
 whole circumference of the limb. It may also follow large burns 
 on any part of the body ; healing 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 
 granulations from their source of nutriment. 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 considerably above the surface, 
 whilst the skin around may be heaped up over the edge, and 
 either covered with sodden cuticle or congested. The skin of the 
 limb is often deeply pigmented from chronic congestion, the pig- 
 mentation 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, fasciae, etc. ; and this 
 constitutes one of the main difficulties in healing, as contraction 
 of the sore is thus prevented. If the ulcer extends to the 
 periosteum, as happens not unfrequently when placed over the 
 shin, chronic periostitis, or even osteitis, results, and a sub- 
 periosteal node is formed, corresponding exactly to the size and 
 situation of the ulcer, forming a mushroom-shaped projection, and 
 possibly going on to necrosis, or to enlargement of the whole 
 bone. In some very chronic cases the superficial lymphatics and 
 veins are so much compressed as to cause chronic oedema of the 
 foot, often of a very solid, brawny type, and the limb may even 
 pass into a condition of pseud-elephantiasis. 
 
 The so-called Irritable Ulcer is usually met with in this stage. 
 Its chief peculiarities are the position, generally in the neigh- 
 bourhood of the ankle, and the pain which accompanies it. The 
 surface of a healing or chronic ulcer can usually be touched with- 
 out the patient complaining ; but in this variety the pain is ex- 
 cessive, 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 will be indicated as the chief seats of 
 the pain, the rest being insensitive. In all probability, nerve fila- 
 ments are there exposed, as the pain has a very marked burning 
 or shooting character. 
 
 The Varicose Ulcer occurs in the leg of a patient who is the 
 subject of aggravated varicose veins. The skin becomes passively 
 congested, and its nutrition is consequently impaired ; any injury 
 or abrasion, which would readily heal in a sound limb, is likely 
 
62 A MANUAL OF SURGERY 
 
 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 may be due 
 to the yielding of the thinned skin which forms the only covering 
 of a much dilated vein, an accident often leading to severe haemor- 
 rhage. The characters of a varicose ulcer vary considerably, but 
 in the main they correspond to those of the second or transitional 
 period, and are usually found on the inner and lower portions of 
 the leg, whilst syphilitic sores are more often placed nearer the 
 knee and on the outer side. 
 
 The Treatment of ulcers 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, all that is needed is to con- 
 tinue the same course of treatment as was adopted at an earlier 
 period of the case, 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 relieve the 
 congested condition of the limb ; whilst if the surface is foul, a 
 charcoal poultice may be beneficial, or the sore may be dusted 
 over with iodoform, and boracic poultices applied. This may be 
 preceded in some cases by touching the surface with nitrate of 
 silver, or with a solution of chloride of zinc (40 grains to 1 ounce). 
 
 Pressure has been found of considerable service in the treatment 
 of these ulcers ; an ordinary bandage, reaching from the toes to 
 the knee, will suffice 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. Martin's india- 
 rubber bandage is more useful when the veins are much enlarged. 
 
 The method of dealing with chronic ulcers suggested by Pro- 
 fessor Unna, of Hamburg, has given excellent results. It con- 
 sists in the use of an adhesive plaster, made up as follows : 
 Gelatine, 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 thoroughly 
 washed with soap and water, and purified with carbolic lotion 
 (1 in 20). It is then wrapped round with a single layer of anti- 
 septic 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 much varicosity of the veins, the paste should 
 extend from the ankle to the knee, the foot being also included 
 in some cases. If there is much discharge, the ulcer should not 
 
ULCER A TION 63 
 
 be covered, or the dressing should be reapplied in a day or two ; 
 but after it has diminished in amount, the paste may be carried 
 right over the sore, and the whole 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., 
 the whole surface, as well as the surrounding skin, is blistered, 
 and then a suitable dressing applied. A more satisfactory method, 
 but requiring an anaesthetic, is to thoroughly scrape the surface 
 with a sharp spoon, and then to rub in a strong solution of 
 chloride of zinc. As soon as healthy action is established, skin- 
 grafting may be undertaken, if necessary, but it is useless to 
 undertake this unless the patient can promise to rest up for a 
 prolonged period, and even then elastic support will be sub- 
 sequently required. In very bad cases where a considerable 
 portion of the circumference of the limb 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 is unable to indulge in much rest, amputation may be 
 the best treatment. It will often be found that Faraboeuf s amputa- 
 tion at the site of election can be undertaken with advantage. 
 
 Where varicose veins exist, treatment is of little avail unless 
 these are efficiently dealt with either by operation or by some 
 suitable support. Unna's paste often answers this purpose most 
 admirably. 
 
 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 applications 
 are needed, such as lead lotion, and when once the acute stage 
 has passed, tarry preparations (liq. carbonis detergens, 1 ounce to 
 1 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 with ichthyol may be utilized. 
 
 Stage III. : Repair having now been fully established, we have 
 merely 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 with healthy granulations ; these present a florid red 
 appearance, are painless, 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, 
 either septic or antiseptic, the discharge is merely serous ; but 
 
64 A MANUAL OF SURGERY 
 
 0/ 
 
 should the wound become septic, or be dressed with irritating 
 antiseptics, ordinary pus is formed. The surrounding skin is 
 soft, flexible, and free from inflammatory congestion ; the base is 
 similarly free from fixity : whilst 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 layer of epithelial cells which cannot be seen 
 except in a good light ; next comes a thin dusky purple or blue 
 line, where the granulations are covered by a few layers of 
 epithelium, 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 finally covered with epithelium. For 
 full description see Chapter VIII. 
 
 Occasionally if emollient applications are used too freely and 
 too long, the granulations become pale, protuberant and cedema- 
 tous, and the healing process is temporarily checked. A depressed 
 general condition of the patient, or a varicose condition of the 
 veins, may also account for this, and the term a weak ulcer is 
 applied to it, whilst the prominent flabby granulations are popu- 
 larly known as proud flesh. 
 
 The Treatment of a healing ulcer is simple in the extreme. All 
 that is needed is to guard the surface from irritation, and Nature 
 will rapidly bring about a cure. The part must be kept at rest, 
 and if the leg is the seat of the trouble, it should not be allowed 
 to hang down. The wound is dressed with any simple unirritating 
 antiseptic, and perhaps boric acid lint is as good as any ; a piece 
 of protective, the exact size of the sore, may with advantage be 
 interposed between the lint and the wound, or boric acid ointment 
 may be spread on the lint. If the granulations become too promi- 
 nent, they may be lightly touched with nitrate of silver, and a 
 more stimulating lotion applied, such as that known as lotio rubra 
 (R. Zinci sulphatis, gr. ii. ; tinct. lavandulae co., spir. rosmarini, 
 aa TT1_ xx. ; acidi borici, gr. x. ; aquam. destill. ad 5 i.). 
 
 Large ulcers require some assistance in order to obtain expe- 
 ditious healing, otherwise a time comes when the contraction of 
 the cicatricial tissue interferes with the nutrition of the granulations, 
 and retards the healing process. Various plastic operations have 
 been adopted to obviate this difficulty, and also the different 
 methods of skin-grafting. 
 
 Skin-grafting, or the transplantation of more or less of the 
 thickness of the skin from a healthy to a healing part, was intro- 
 duced by Reverdin in 1869, and has since been much elaborated. 
 The following 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 
 
ULCERATION 65 
 
 tissue is pinched up with or without forceps, and removed by a 
 pair of sharp curved scissors. In thickness 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 
 placed cutis downwards on the surface of the granulations and 
 covered with protective, purified in boric acid. Many of these 
 may be applied at the same time, and the whole w r ound carefully 
 dressed and protected. If there is much discharge, the grafts will 
 not 'take'; but if the wound is merely discharging serum, 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 epithelium of the cutis spreads, and 
 makes itself visible as a distinct centre of repair. The greatest 
 gentleness is needed in handling the graft, as it readily perishes. 
 
 2. Transplantation of large portions of cuticle as suggested by 
 Thiersch. This method consists in removing wide strips of 
 cuticle with a razor, and implanting them on a fresh wound or 
 on a raw surface previously denuded of all granulations. The 
 ulcerated surface is first scraped, and the resulting haemorrhage 
 stayed by pressure with a sponge, a layer of protective being, 
 however, interposed, so that when the sponge is subsequently 
 removed the bleeding shall not recur. The strips of cuticle are 
 then cut, care being 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. When it is thought that 
 sufficient material has been obtained, the sponge and protective 
 are removed, and the grafts gently transferred, being applied in 
 such a way that they overlap each other and also the margins of 
 the defect. There is always some tendency for the edges of the 
 graft to turn in, and this must be prevented. They are then 
 covered with protective, or thin silver-foil, and the whole dressed 
 antiseptically. There is usually no need to look at the wound for 
 some days. The outer sides of the thigh or arm are the best 
 places from which to take the grafts. By this method subsequent 
 contraction is to a large extent prevented. 
 
 3. The whole thickness of the skin is used in some instances. 
 Thus, the preputial tissue removed in circumcision is most 
 valuable for this purpose, being soft and flexible. All redundant 
 and fatty tissue must be removed, and only the skin applied. 
 The granulations should always be previously scraped away, and 
 the graft stitched down to the underlying cicatricial tissue with 
 fine catgut. It may also be applied 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 
 
 5 
 
66 A MANUAL OF SURGERY 
 
 different parts of the book. It will suffice here to mention 
 them : 
 
 Soft Chancre (Chapter XXXVIII.).— This may be taken as a 
 type of all infective ulcers, clearly showing the stages of infection, 
 incubation, ulceration, and repair. 
 
 Ulcers due to Syphilis (Chapter VI.) : 
 
 (a) The primary sore. 
 
 (b) Secondary ulcers, mainly of mucous membranes, but 
 
 sometimes involving the skin, and due to the breaking 
 down of so-called tubercular syphilides. 
 
 (c) Intermediate, rupial, or ecthymatous sores. 
 
 (d) Tertiary ulcers from the disintegration of gummata, 
 
 either superficial and multiple, or deep and single. 
 
 In inherited syphilis, any or all of the above varieties may be 
 seen, except the primary sore. 
 
 Phagedenic ulceration (p. 125) is usually associated with syphilis, 
 but whether the phagedena is itself due to a specific organism 
 is a little doubtful. 
 
 Ulcers due to Tubercle : 
 
 (a) The lupoid ulcer, due to a cutaneous tuberculosis 
 
 (Chapter XIV.), or 
 
 (b) The tuberculous ulcer, arising as a rule from the 
 
 bursting of a subcutaneous or submucous tuberculous 
 abscess (Chapter XIV.). 
 
 (c) Various other tuberculous ulcerative lesions of the skin 
 
 are described by dermatologists under the title 
 'scrofulodermia,' whilst Bazin's disease (or erythema 
 induratum) is possibly tuberculous in origin. 
 Malignant Pustule, due to the Bacillus anthracis (p. 1 13). 
 
 III. Malignant Ulcers. 
 
 These are due, as has already been pointed out, not to any 
 inflammatory process, but to the actual replacement of the skin 
 by the growth, so that loss of substance necessarily ensues. It 
 is only requisite to mention the varieties here ; a fuller description 
 will be appended later (Chapter VII.) : 
 
 (a) Rodent ulcer, a chronic cancer starting in the sebaceous 
 glands or hair follicles, and accompanied with very little over- 
 growth. 
 
 (b) Epitheliomatous ulcer, arising from cancer of the skin or 
 mucous membranes. 
 
 (c) Scirrhous ulcer, resulting from destruction of the skin over 
 a scirrhous tumour. 
 
 (d) Fungating ulcer, where a neoplastic growth protrudes from 
 the skin. It may be caused by a soft encephaloid cancer, or a 
 sarcoma, whilst a cysto-adenoma mammae gives rise to a similar 
 appearance. It constitutes the condition formerly known as a 
 ' fungus haematodes.' 
 
CHAPTER V. 
 
 GANGRENE. 
 
 By gangrene is meant the simultaneous loss of vitality of a con- 
 siderable 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, 
 necrosis is said to have occurred, and 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 : 
 
 i . Loss of pulsation in the vessels. 
 
 2. Loss of heat, since no warm blood is brought to it. 
 
 3. Loss of sensation, although much pain may be experienced 
 whilst death is occurring, and such may be referred to the dead 
 part through irritation of the nerves above. 
 
 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 which depends on the 
 amount of blood in the part at the time of death ; if the limb 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 ligature of the main vessel 
 or by its embolic obstruction ; but if they continue for any length 
 of time, death is practically certain to ensue, and they will then be 
 rendered more obvious by the phenomena about to be described. 
 
 Changes occurring in the Dead Tissues.— The character of these 
 changes depends mainly on the condition of affairs at the time of 
 death, and whether or not putrefaction supervenes. The following 
 conditions are described : 
 
68 
 
 A MANUAL OF SURGERY 
 
 i. Dry Gangrene ( = death + mummification). — Such can only 
 occur when the tissue involved is, previous to its death, more or 
 less drained of its fluids, so that it readily shrivels up and loses its 
 moisture. The usual cause is chronic arterial obstruction, as 
 brought about by atheroma 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 diffu- 
 sion of the disintegrated haemoglobin (Fig. 7). The more fleshy 
 parts (for instance, the tissues above the ankle) rarely undergo 
 complete mummification, and the surrounding living tissues are 
 often considerably inflamed. If sepsis be admitted, the parts may 
 become horribly offensive. 
 
 2. Moist Gangrene arises when a part of the body full of fluid 
 
 Fig. 7. — Senile Dry Gangrene, affecting both Feet. 
 
 dies, and is especially associated with any obstruction on the side 
 of the veins, or with acute arterial thrombosis in a previously 
 sound limb, e.g., in traumatic gangrene due to pressure upon, or 
 rupture of, the main trunk. The loss of the vis-a-tergo derived 
 from the heart's impulse causes a negative pressure in the capil- 
 laries, which become filled by regurgitation from the veins. 
 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. Unhappily, this precaution is but 
 seldom adopted, or even available, and hence in the majority of 
 cases putrefaction occurs ; it must be clearly understood, however, 
 that it is no essential part of the gangrenous process. 
 
 Aseptic Moist Gangrene is characterized by the dead tissues 
 becoming 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 
 
GANGRENE 
 
 69 
 
 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 toxaemia may result 
 from the absorption of various products from the dead tissues. 
 
 Septic or Putrid Moist Gangrene (Fig. 8) is necessarily asso- 
 ciated 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 limb 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 
 
 f C 
 
 Fig. 8. — Septic Moist Gangrene of Leg. 
 
 way as is a catgut ligature. Such is often observed after slough- 
 ing 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 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. Thus, a child 
 came to the hospital with a portion of the outer table of the skull, 
 as large as the palm of a man's hand, quite bare and dead, as the 
 result of sloughing cellulitis ; it was treated antiseptically, and 
 granulations gradually sprang up through the bone in all direc- 
 tions, until finally the whole was absorbed, with the exception of 
 merely a small flake, the size of one's little finger nail, which 
 separated. The dead portion is first invaded by leucocytes from 
 the lymphatic spaces or vessels of the immediately contiguous 
 living tissues, and infiltrated by them and the accompanying 
 blood plasma. By a process of auto-digestion this infiltrated 
 portion disappears, and is replaced by granulation tissue (for the 
 origin of which, see Chapter VIII.), which in turn is converted 
 into a cicatrix, and covered with cuticle in the usual way. 
 
7 o A MANUAL OF SURGERY 
 
 (b) If the mass, though aseptic, is of such a size, or consists of 
 such tissues, as to prevent its total absorption, or if the vital 
 activity of the patient is lowered, a modification of the same pro- 
 cess results in partial absorption of the dead material, whilst the re- 
 mainder is cast off and separated by a simple process of anaemic 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 pabulum, owing to the contrac- 
 tion 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, by means of which 
 the latter is separated from the body. The size of the portion 
 thus cast off is distinctly less than that of the original necrotic 
 mass. Whilst this is occurring, there is 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 it is 
 possible for the soft tissues of a limb 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 bones 
 protrude. 
 
 (c) If the gangrenous portion is septic, its separation is accom- 
 plished by a distinctly 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 living tissues retaining their 
 normal hue. The irritation of the chemical products formed 
 in the necrosed mass causes in a few days inflammation in the 
 surrounding structures, resulting in hyperemia and subsequent 
 exudation of plasma and leucocytes ; the tissue of the part dis- 
 appears, and is replaced by a cell infiltration, which in turn breaks 
 down into pus, whilst a layer of granulation tissue forms at the 
 limit of the living portion, and thus the final line of separation is 
 produced. Clinically, one notices in this latter stage a bright 
 red line of hyperaemia 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 living and dead parts 
 are separated by 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 living tissues and the 
 gangrenous mass. This process, gradually extending through 
 the whole thickness of the limb, is attended by the local signs of 
 inflammation and by fever, the degree of the latter depending on the 
 
GANGRENE 
 
 71 
 
 amount of putrid material absorbed. The inflammatory process, 
 moreover, is not always limited 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 suppurative 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 vitality of the 
 limbs. Thus, the patient may be suffering from general asthenia, 
 such as results from preceding fevers ; or his circulation may lack 
 vigour either from weakness of the heart muscles or from some 
 valvular lesion ; or, again, his arteries may be so diseased, or 
 rendered so rigid by atheromatous or calcareous changes, that, 
 although a sufficient supply of blood may reach the extremities 
 for all ordinary circumstances of life, yet any unusual demand 
 upon the circulation cannot be met. Many evidences of mal- 
 nutrition usually manifest themselves before the onset of gangrene. 
 General diseases, such as diabetes and albuminuria, may be 
 present, as also the constitutional results of a vicious life. 
 
 (b) Those conditions depending on the presence and connection 
 with the body of the dead tissue. Various forms of septic or 
 ptomaine poisoning result, usually 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 sometimes liable to become exhausted from this cause, even 
 though he is protected by the surgeon's care from the dangers of 
 sepsis. 
 
 The Treatment of gangrene naturally divides itself into the 
 local and general. We shall not discuss the question of Local 
 treatment at this place, leaving it to be dealt with under the 
 appropriate headings hereafter. As to General treatment, but 
 little need be said beyond that the strength of the patient must 
 be maintained by plenty 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 excre- 
 tion of sugar and albumen. 
 
 Varieties of Gangrene. 
 
 Having thus traced in outline the general history of a case of 
 gangrene — the signs of death in the part, the various post-mortem 
 changes which may occur in it, the means whereby Nature rids 
 the body of such an encumbrance, and the various dangers, local 
 and general, the patient runs — we now turn to the different forms 
 
72 A MANUAL OF SURGERY 
 
 of the disease which are met with, and propose to discuss them 
 seriatim. The following classification is one which, though 
 admittedly imperfect, does in a measure group together allied types 
 of the affection, and will serve as a useful one for practical purposes. 
 
 I. Symptomatic Gangrene, or that predisposed to by preceding 
 vascular or general conditions, where a trauma, if present at all, 
 is of very slight significance. 
 
 (a) Gangrene from embolus. 
 
 (b) Senile gangrene. 
 
 (c) Gangrene from arterial thrombosis (non-senile). 
 
 (d) Diabetic gangrene. 
 
 (e) Raynaud's disease. 
 
 (/) Gangrene due to ergot. 
 
 II. Traumatic Gangrene, which may be due to direct or indirect 
 injury, and where the damage done to the vessels or tissues by 
 the trauma is the immediate cause of the loss of vitality. Two 
 varieties of this may be met with, viz. : 
 
 (a) The indirect, where the lesion involves the vessels of the 
 
 limb perhaps some distance above the spot where the 
 gangrene occurs. 
 
 (b) The direct, where the gangrenous process is limited to 
 
 the part injured. 
 
 III. Infective Gangrene, which arises from the activity and 
 influence of micro-organisms. 
 
 (a) Acute inflammatory or spreading traumatic gangrene. 
 
 (b) Wound phagedena and hospital gangrene. 
 
 (c) Necrosis of bone (most cases). 
 
 (d) Noma and cancrum oris. 
 
 (e) Carbuncle and boil. 
 
 IV. Gangrene from Thermal Causes — frost-bite and burns. 
 Each of these varieties must now claim separate and individual 
 
 attention. 
 
 I. Symptomatic Gangrene. 
 
 (a) Embolic Gangrene. (For general details as to emboli, see 
 Chapter XI.) When the main artery of a limb becomes blocked 
 by a simple embolus, the condition is exactly similar to that 
 which obtains after ligature — i.e., the vitality of the part is 
 diminished until such a time as the collateral circulation is 
 established. Under ordinary circumstances it should not lead to 
 gangrene ; but if either the general or local vitality is much 
 reduced, the obstruction of the main trunk may be sufficient to 
 determine the death of more or less of the limb. There are 
 two chief conditions under which gangrene is likely to follow 
 an embolus : (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 
 
GANGRENE 73 
 
 action- 'is weak, and the circulation possibly impeded by the 
 valvular lesion, so that the block 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 degenera- 
 tion, an occurrence not unusual in elderly people. 
 
 Emboli are most commonly arrested at the sites of division of 
 the main trunks (Fig. 9, 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 deposit thereon of fibrin, effectually closing 
 both branches (Fig. 9, B). In the lower limb it occurs at the 
 division of the femoral or popliteal ; in the upper, at the origin 
 of the superior profunda, or where the brachial divides. 
 
 Fig. 9. — Diagrams 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 obstructing the vessel ; in B both branches of the trunk are 
 blocked by the growth of the clot. 
 
 The chief early Symptom is pain experienced both at the point 
 of impaction and also down the limb along the course of the 
 vessel. Pulsation below the block ceases, sensation and tempera- 
 ture diminish, and the part feels heavy and useless. If the 
 vessels are healthy, stagnation of blood in the veins is an early 
 result, the terminal portion of the limb becoming congested and 
 cedematous, and finally passing into a condition of moist gangrene. 
 If, however, the terminal arteries are calcified or atheromatous, 
 so that the limb 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 
 circulation to maintain the life of the part. Such usually obtains 
 in the neighbourhood of a joint, since there is always a more free 
 anastomosis here than in the inter-articular portions of the limb ; 
 
74 A MANUAL OF SURGERY 
 
 thus, in the leg the gangrene is arrested either immediately above 
 the ankle or below the knee. The subsequent history depends 
 upon whether or not the dead tissue is allowed to become septic, 
 and requires no special notice. 
 
 Treatment. — The all-important requisite in dealing with a case 
 of this nature is to prevent the advent of sepsis, since it may 
 transform what would otherwise be a. condition associated with 
 but little danger into one of the gravest moment. As soon as 
 possible after the obstruction has taken place, and before any 
 absolute signs of death are manifest, scrupulous care must be 
 taken to purify the part. The nails should be cut, and the 
 whole limb thoroughly but gently scrubbed With carbolic lotion 
 (i in 20), special attention being directed to the intervals between 
 the toes and the semilunar folds of the nails. It should then 
 be wrapped in a layer or two of moist and purified gauze, 
 swathed round with salicylic, iodoform, or sterilized wool, and 
 lightly, though firmly, bandaged. The limb is kept slightly 
 raised, so as to prevent venous regurgitation without interfering 
 with the arterial supply, and by this means gangrene may be 
 prevented. If, however, these precautions are not successful, and 
 the part dies, the same measures as to the maintenance of asepsis 
 must be continued until a natural line of separation forms. In 
 old people with dry gangrene similar rules are followed as for the 
 senile type ; but in the moist form, occurring in young people, 
 the natural process of separation may be hastened by severing 
 the dead from the living and sawing through the bone, or 
 possibly amputation through the living tissues a little above may 
 be considered advisable, a more shapely stump being thus 
 obtained. Where sepsis has occurred, it is wise to amputate 
 through healthy tissue as soon as the gangrenous process has 
 finally ceased to extend. If, however, spreading septic inflam- 
 mation exists, one may be driven much higher up the limb 
 than would be otherwise necessary, whilst very acute septic 
 symptoms may determine amputation before any line of separa- 
 tion has formed. 
 
 (b) Senile Gangrene is a condition which, as the name implies, 
 occurs in elderly people, and is the result of imperfect nutrition 
 of the tissues. The toes are most frequently affected, but it is 
 also seen in the hand, and may attack the nose, ears, or even 
 the tongue. 
 
 Causes. — These are to be found mainly in the condition of the 
 circulatory organs. (a) Calcareous degeneration (Chapter X.) of 
 the smaller vessels of the limb or part is always present, as also 
 possibly atheroma of the larger arteries. The vessels in con- 
 sequence become pipe -like and inelastic, and incapable of accom- 
 modating 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, 
 
GANGRENE 75 
 
 whilst the tunica intima is often so rough as to predispose to 
 thrombosis with or without injury, (b) A iveak heart is generally 
 present, leading to low pulse tension, and increased difficulty in 
 propelling the blood through the rigid and narrowed vessels ; and 
 (c) the condition of the blood may be impoverished by albuminuria. 
 When such predisposing factors are present, anything that results 
 in (d) thrombosis either in the main trunks or in the peripheral arterioles 
 or capillaries is likely to determine the onset of gangrene. Throm- 
 bosis of the main vessels may be due to some injury to the limb 
 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 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 height to 
 which the gangrene spreads will vary accordingly. 
 
 Symptoms. — Preliminary evidences of malnutrition of the limb 
 will probably have been noticed for some time in the form of cramp 
 and pain in the muscles, which become fatigued rapidly, whilst 
 sensations of pins and needles or numbness are also complained 
 of. The circulation in the tibials may be so slight as to be 
 scarcely perceptible, and the whole limb feels cold and heavy. 
 The skin is frequently more or less congested, and extremely 
 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 is formed, which becomes dry 
 and black. The process gradually spreads from this focus with 
 more or less inflammation, so that it is sometimes known as 
 inflammatory senile gangrene. If, however, it results from throm- 
 bosis 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 is perhaps the commonest situation for the com- 
 mencement of the mischief, 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 gan- 
 grene 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. 
 
 The Treatment adopted until within the last few years was 
 governed by the observation that any attempt to remove the 
 dead tissues by amputating through neighbouring living parts is 
 doomed to failure, since the gangrenous process is certain to 
 
76 A MANUAL OF SURGERY 
 
 commence again in the flaps ; if merely cutting a corn suffices 
 to originate the malady, much more does so severe an injury 
 as an amputation. The parts were dusted with iodoform or 
 some similar antiseptic, and wrapped in cotton-wool to keep 
 them warm ; the surgeon then waited for a line of separation, and 
 even then did not amputate, but merely assisted Nature by 
 dividing tendons or bones. At the same time, the general health 
 was maintained by the judicious administration of suitable 
 nourishment, stimulants and tonics, whilst pain was alleviated by 
 the use of opium in such doses as the condition of the kidneys 
 allowed. In spite of every care, however, the enfeebled constitu- 
 tion of the patients often proved unequal to the task of ridding 
 the body of the dead mass, so that death from exhaustion or 
 blood-poisoning was the rule rather than the exception, and even 
 if the patient did recover, the prolonged and enforced stay in bed 
 considerably diminished his vital powers. 
 
 It has now, however, been clearly demonstrated that early 
 amputation performed under careful antisepsis, and well away from 
 the dead mass at a point where the surgeon considers the blood- 
 supply sufficient to nourish the flaps, and yet not so near the 
 trunk as to seriously threaten life through shock, holds out the 
 best prospects of relief. In order to determine the most favour- 
 able site for the amputation, the pulsation in the main artery 
 should be felt for, and if feasible no operation performed at a spot 
 where it appears to be occluded. The condition of the limb will 
 also influence the surgeon's decision ; if thin, attenuated, and 
 shrivelled, it will be wise to amputate high ; but if the limb is 
 fairly well nourished and with plenty of adipose tissue, the 
 operation may be performed somewhat lower. In operating, as 
 little damage as possible should be inflicted on the parts, the 
 flaps being nearly equal in length and not too flimsy, a circular 
 amputation, or some slight modification of it, being perhaps the 
 best. In cases 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. We have followed this line of practice 
 for some years, and have no reason to be dissatisfied with our 
 results. Dissection of the portions removed has always shown 
 that the vascular trouble was fully as advanced as we had 
 anticipated, and that no minor measures would have sufficed. 
 
 (c) Gangrene from Arterial Thrombosis (non-senile) is not a 
 common occurrence. It arises as a result of that curious affection 
 endarteritis obliterans, and also develops in some young people in 
 scattered patches about the skin without any of the characteristic 
 phenomena of Raynaud's disease. It sometimes occurs in connec- 
 tion with typhoid fever and other conditions of severe toxaemia as 
 an outcome partly of the increased coagulability of the blood, partly 
 
GANGRENE 77 
 
 of a localized endarteritis, due to the toxins present in it. 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 gan- 
 grene is usually of the dry type. It is wise to wait until a line of 
 demarcation has formed, and then amputate well above. 
 
 (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 commonly 
 met with in the subjects of acute diabetes, nor, as a rule, in people 
 below forty years of age. It results usually from some slight 
 traumatic or infective injury, and often commences on the under 
 side or at the 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, taking on a moist or 
 a dry type according to the amount of vascular disease. Not 
 uncommonly extensive suppurative infiltration of the soft parts of 
 a limb may be associated with a limited gangrene of a peripheral 
 segment. 
 
 In the Treatment an attempt should be made to reduce the 
 excretion of sugar by administering codeia and regulating the 
 diet, but too much time must not be lost. A careful investiga- 
 tion of the condition of the vessels is necessary. If they are 
 tolerably healthy, removal of the dead tissue by an amputation 
 not very much above the upper limit of the disease is justifiable ; 
 but should there be evidence that the main trunks are affected, 
 then either the separation of the necrosed mass must be left to 
 Nature, the surgeon merely assisting by the division of bones, or 
 preferably, if the patient's general state is good, a high amputation 
 may be undertaken. Under the latter circumstances, however, 
 there is some risk of the supervention of diabetic coma. The 
 same practice would be required if extensive inflammatory mis- 
 chief were present. 
 
 (e) Raynaud's Disease, or Spontaneous Symmetrical Gangrene, is 
 a condition usually met with in anaemic or neurotic young women 
 between the ages of fifteen and thirty. It is due to vaso-motor 
 spasm, dependent either on some deep unrecognised lesion of the 
 spinal cord, or in some cases to a peripheral neuritis. It occurs 
 in conditions of nervous exhaustion, and has been started by a 
 sudden fright. Three stages are usually described : (i.) local 
 syncope or anaemia, arising as the direct result of arterial spasm, 
 and characterized by pallor and painfulness of the part ; (ii.) local 
 asphyxia or congestion, in which the affected tissues are blue and 
 cyanosed from venous regurgitation ; and (iii.) necrosis, the part 
 becoming dry and black, though it is unusual for the gangrene to 
 extend at all deeply. The onset is often sudden, and the disease 
 
7 8 A MANUAL OF SURGERY 
 
 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 patches may occur on any part of the 
 body ; the process is non-febrile, but 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 joints, especially of the terminal phalanges, and 
 localized patches of anaesthesia, associated with pain of a neuralgic 
 type, are sometimes present, resulting from peripheral neuritis. 
 The condition somewhat resembles the later stages of a chilblain, 
 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 must in the early stages be directed to the pre- 
 vention of gangrene. The constitution should be built up by 
 iron, quinine, and if need be by stimulants, whilst menstrual 
 irregularities must be attended to. Frictions with stimulating 
 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 
 preferably in the shape of the electric bath, local or general as 
 required, and repeated either once or several times a day. When 
 actual gangrene is present, the dead tissue should be kept aseptic, 
 when sooner or later it will be absorbed or separated. 
 
 (/) Gangrene from Ergot is a rare phenomenon, but it has been 
 known to occur when diseased rye has been used in the manu- 
 facture 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. 
 
 By 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 ; but if it reaches the more fleshy 
 portions, the moist variety supervenes. 
 
GANGRENE 79 
 
 Where the gangrene is confined to the toes, Treatment consists 
 in waiting for a definite line of separation to form under an anti- 
 septic dressing, and then in assisting the natural processes at this 
 spot by dividing tendons and bones. Where, however, a con- 
 siderable area of the limb loses its vitality, and especially if the 
 dead tissue is moist and septic, 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. A few cases are on record in 
 which both vessels have been ligatured, or even portions of them 
 removed without leading to gangrene, 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 occlusion of both 
 afferent and efferent trunks is practically sure to determine tissue 
 necrosis. It may therefore be caused by the inclusion of both 
 vessels in a ligature, or 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 applied too tightly round a fractured limb. It may 
 even occur from the swelling up of a limb under a bandage which 
 has been originally applied with no undue tension. 
 
 A very similar result may be produced by the excessive 
 hyperaemia and exudation following the sudden relief of a tight 
 constriction around a part, which has thus been deprived of fresh 
 arterial blood for some time ; the vessel walls are thereby so 
 damaged that they are unable to resist the blood-pressure, and 
 the amount of exudation that follows is so abundant as to rapidly 
 bring the circulation to a standstill. Such an occurrence is met 
 with after frost-bite, and also in a loop of bowel, which has been 
 strangulated, after removing the obstruction to the circulation. 
 
 Gangrene may also result from 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 always of the moist type. (See Chapter XVII.) 
 
 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 sepsis. In some fractures and dislocations 
 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 warm and aseptic. Should gangrene supervene, 
 amputation will be required, its situation depending on the 
 
So A MANUAL OF SURGERY 
 
 character of the local lesion ; if it is not of a serious nature — e.g., 
 a clean fracture or simple dislocation — it is wise to wait for a line 
 of demarcation ; but if comminution of bone or other grave local 
 trouble is present, one would amputate above the injury. 
 
 (b) Direct Traumatic Gangrene, or that resulting from the imme- 
 diate 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 con- 
 tused, or even ' pulped,' but the bloodvessels may be torn, and 
 the resulting extravasation contributes to the result. The gan- 
 grene 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, there is not the 
 slightest use in delaying operation, since the patient may run con- 
 siderable risk from the onset of sepsis ; and therefore immediate 
 amputation should be undertaken. 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, 
 such as that which arises from injudicious splint pressure or in 
 the form of bedsores. Splint pressure as a cause of gangrene can 
 only be regarded as an accidental circumstance or the result of 
 carelessness. Where there is a marked tendency to displace- 
 ment of fragments after a fracture, it may be necessary to use 
 some considerable degree of pressure to counteract it, and then in 
 spite of every precaution necrosis of the superficial parts 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, as otherwise diffuse 
 suppuration may spread along the muscular and fascial planes, 
 and lead to considerable 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 first become red and con- 
 gested, and finally ulceration or actual gangrene supervenes. As 
 a general rule, bedsores are not very extensive or deep ; but 
 occasionally when the patient is debilitated, and especially if 
 a condition of lowered sensation is present, due to impairment of 
 
GANGRENE 81 
 
 the nerve-supply, as in paraplegia, the process may extend widely 
 and deeply, destroying fasciae, laying open muscular sheaths, and 
 even leading to necrosis or caries of bones. The spinal canal 
 itself has been opened in this way, and death from septic menin- 
 gitis has resulted. To prevent the occurrence of such sores, the 
 most scrupulous attention must be given to the parts exposed to 
 pressure. The nurse should see that the draw-sheet and bed- 
 linen are placed smoothly and without creases, and that no con- 
 tamination by urine or faeces is allowed ; if the patient is per- 
 spiring freely, the sheet should be frequently changed, so as to 
 prevent decomposition of the sweat. The skin of the back is 
 daily examined, washed with some unirritating soap, and rubbed 
 with a soothing, strengthening, and hardening application, such as 
 spirit of wine, methylated spirit, or perhaps, better still, a mixture 
 of brandy and white of egg. It is then dusted over with a mild 
 antiseptic powder, such as boric acid. If the skin becomes red, 
 it should be painted with collodion, or with a mixture of equal 
 parts of tincture of catechu and liquor plumbi subacetatis, which 
 when dry leaves a powdery film on the surface, and protected from 
 pressure by means of a circular hollow water-pillow. Paraplegic 
 patients or old people should at once be placed on a water-bed, 
 which must be sufficiently, but not excessively, distended. If 
 there is too little water, the weight of the body 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 
 was employed. When an open sore forms, it must be kept aseptic, 
 and dressed either with boric acid ointment, 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 in 8 of the 
 oil), is useful in this condition. 
 
 (hi.) The action of corrosive or caustic chemicals is followed by 
 a localized traumatic gangrene, 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. 
 
 All the forms of gangrene included in this group are charac- 
 terized by their origin in the development of micro-organisms, 
 which by the virulence of their products determine the death of 
 the affected tissues. 
 
 (a) Acute Spreading, Acute Emphysematous, or Spreading Trau- 
 matic Gangrene. — This disease is one of the most rapidly fatal 
 and serious met with in surgery. 
 
 Causes. — (i.) The individual attacked is often predisposed to 
 septic inflammatory conditions, as a result of vicious or careless 
 living, or from simple malnutrition. Those who are in the habit 
 
 6 
 
S 2 A MANUAL OF SURGERY 
 
 of consuming large quantities of alcohol, even if not actual 
 drunkards, are especially liable to this affection ; but some forms 
 of virus, which are particularly active, may lead to its development 
 even in a healthy person. It is sometimes seen in diabetics, but 
 an apparent glycosuria occasionally develops in the course of the 
 disease. 
 
 (ii.) The lesion from which it originates is usually severe, such 
 as a compound fracture or dislocation, especially if the soft parts 
 are much contused or very dirty. Less frequently it originates 
 from small and insignificant pricks, scratches, or abrasions, if 
 thereby a virulent organism gains access to the tissues. In this 
 way post-mortem porters, nurses, or pathological demonstrators 
 may become infected, and the gravest consequences ensue. 
 
 (iii.) An organism frequently present is the Bacillus of malignant 
 ccdema, first isolated by Koch. It is a rod-shaped microbe, 
 somewhat longer and more slender than that of anthrax. It is 
 anaerobic, and in its growth liquefies gelatine, and produces an 
 unpleasant penetrating odour. On injection into the subcutaneous 
 tissues of a mouse, the animal dies in eight to fifteen hours ; 
 locally, a spreading oedema is produced, the connective-tissue 
 spaces being filled with fluid containing bacilli, and perhaps gas- 
 bubbles. 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 Bac. pyogenes 
 capsulatus and the Bac. osdematis cevobius are also responsible for this 
 affection. The former is anaerobic, the latter aerobic. Careful 
 investigation of fifty-eight cases* of spreading gangrene resulted 
 in the discovery of the facts that in only fourteen cases was the 
 infection pure, and that with an anaerobic organism ; in forty- 
 four cases the infection was mixed, various septic organisms being 
 present in addition to the gas-producing microbe, which, according 
 to latest researches, is more frequently the Bac. cewgenes capsulatus 
 than the Bac. cedematis maligni. A special feature of infection with 
 the former is the large amount of gas produced, which is found 
 not only in the tissues, but also po3t-mortem in the vessels, and 
 notably in the liver, from which it can easily be squeezed, con- 
 stituting the ' foaming liver ' of some writers. 
 
 The Symptoms are those of a hyperacute cellulitis, accompanied 
 by general septicaemia. The wound early takes on an unhealthy 
 action, the surface becoming covered with sloughs, and a thin 
 serous or sero-sanguineous discharge escaping. The inflamma- 
 tory process rapidly spreads along the connective-tissue planes of 
 the limb, which becomes swollen, painful, and brawny. At first 
 it is of a dusky purplish colour, but soon the signs of actual 
 gangrene supervene, and the necrotic tissues become crepitant 
 
 * See Corner and Singer on ' Emphysematous Gangrene,' Trans. Path. Soc. 
 Lond., vol. Iii., 1901, p. 42; Welch's ' Shattuck Lecture,' Philadelphia Med. 
 Journ., August 4, 1900. 
 
GANGRENE S3 
 
 and emphysematous, partly from simple putrefaction, partly from 
 the gaseous developments associated with the growth of the 
 specific organism. Occasionally the emphysema spreads widely 
 and rapidly, with at first no other local evidence of mischief; 
 sloughing will, however, follow if the patient lives long enough. 
 Evidences of profound toxic disturbance soon manifest themselves, 
 the patient perhaps having a high temperature and being delirious; 
 but not uncommonly fever may be entirely absent, the tempera- 
 ture being subnormal and coma present. The outlook is exceed- 
 ingly grave, death usually ensuing in from five to seven days 
 after the onset. 
 
 The only Treatment which holds out any hope in dealing 
 with a limb where the disease is rapidly extending is a high 
 amputation, even through the shoulder or hip-joint. Any delay 
 is dangerous, although, in spite of the greatest promptitude, the 
 infection may have progressed so rapidly that death follows from 
 septicaemia, even after the limb has been removed. Perhaps it 
 may be wise to leave the wound widely open for a day or two so 
 as to permit the free discharge of secretions. In a few cases, 
 where the patient is seen early, it has been possible to save both 
 life and limb by freely incising the affected tissues, and immersing 
 them in a continuous warm antiseptic bath. At the same time 
 the general health must be attended to by giving plenty of fluid 
 nourishment, together with diffusible stimulants, such as ether 
 and ammonia. 
 
 (b) Wound Phagedena and Hospital Gangrene are conditions 
 affecting wounds which were seen often enough in the pre-anti- 
 septic era, but are now practically unknown, thanks not only to 
 antisepsis, but to the increased care directed to ventilation and 
 hospital hygiene. They consisted in a rapidly spreading ulcera- 
 tion or gangrene, which attacked operation wounds a few days 
 after their infliction, and as a rule led to rapid death. It is 
 fortunately unnecessary to describe or discuss them nowadays. 
 
 (c) Necrosis of Bone is practically always due to the develop- 
 ment of organisms, and may be either acute or chronic. In the 
 former, the inflammatory reaction is so severe that the vessels 
 are strangled within the bony alveoli ; in the latter, it is largely 
 due to an obliterative endarteritis, which accompanies the various 
 specific processes. (See Chapter XVIII.) 
 
 (d) Cancrum Oris and Noma. — Cancrum oris is an infective 
 gangrenous stomatitis, affecting young children living in squalid 
 surroundings in over-populated districts of large cities. The 
 patients are always in a low state of health, and frequently con- 
 valescing from one of the exanthemata, particularly measles. 
 Various special organisms have been described from time to time 
 as responsible for cancrum oris ; but it appears that any of the 
 many forms found in the mouth may be present, and probably 
 the Streptococcus pyogenes acting in conjunction with various 
 
84 A MANUAL OF SURGERY 
 
 saprophytic bacilli is the most important. 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-grey pultaceous slough forms on the inside of one of the 
 cheeks, and from this the most offensive discharge is poured into 
 the mouth and swallowed, the breath in consequence being 
 intensely fcetid. The gangrenous process 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, and gradually increases 
 in size. In the worst 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 sapraemia, 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 supervene. Rigors and high fever often 
 occur early in the case, but death is usually preceded by symptoms 
 of collapse and coma with a subnormal temperature. 
 
 The Treatment must be prompt and energetic if the child's life 
 is to be saved. The patient should be at once anaesthetized, and 
 all the pultaceous slough scraped from the interior of the mouth 
 by means of Volkmann's spoon, until healthy bleeding tissue is 
 reached. The denuded surface is then freely rubbed over with 
 pure carbolic or strong nitric acid. If the bones of the face are 
 involved, they must be removed, as also any offending teeth. 
 Afterwards the child should be well fed up, and of course for a 
 time with fluids ; the mouth is to be frequently washed out with 
 antiseptic lotions, such as a solution of sanitas (i in 10), boro- 
 glyceride (i in 20), or permanganate of potash, or with a gargle 
 of chlorate of potash (10 grains to 1 ounce). A mixture containing 
 chlorate of potash, dilute hydrochloric acid, and infusion of cin- 
 chona, may be administered for a few days, and then iron and 
 quinine. In the most severe cases the same treatment should be 
 adopted, even if the whole thickness of the cheek has been en- 
 croached on ; loss of substance must be made good by subsequent 
 plastic work. Necessarily, the cicatrization following this de- 
 structive 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 Treat- 
 ment is practically the same, except that here it may be possible 
 to immerse the patient in an antiseptic bath, thereby diluting the 
 toxic products, and possibly preventing the necessity for having 
 recourse to more serious surgical procedures. 
 
 (e) For Carbuncle and Boil, see Chapter XIV. 
 
GANGRENE 85 
 
 IV. Gangrene from Thermal Causes. 
 
 1. Frost-bite. — This condition is not very frequently seen in 
 this country, but is by no means uncommon in regions where the 
 winter is more severe. It occurs in those who are exposed to the 
 cold, and the symptoms are induced more readily if a high wind 
 is blowing, the heat of the body being thereby more quickly dis- 
 persed. It may originate 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 
 experienced in the freezing process, so that onlookers are more 
 likely to recognise the condition than the individual himself. 
 The extremities of the body, where the circulation is a little 
 sluggish, and exposed parts, are chiefly liable to be attacked, and 
 thus the nose, ears, fingers, and toes are most often involved. It 
 is more likely to occur in the young and in old people, whose 
 vita! powers are not very great. Gradually the part shrivels up, 
 turns black, and is either absorbed or separated by a process of 
 ulceration with or without suppuration. The most marked feature 
 of gangrene from frost-bite is the more extensive implication of 
 the superficial parts on account of their greater exposure. 
 
 (b) From the subsequent inflammation that arises in parts which, 
 though frozen, are not immediately killed. The thawing of such 
 structures is accompanied by the severest pain, and the prolonged 
 anaemia causes such a lowering of the vitality of the vessel walls 
 that the re-admission of the circulation is only too likely to be 
 followed by an acute inflammation, which terminates 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. — The 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. 
 
 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 solid bodies ; scalds, by 
 the action of boiling water, superheated steam, or other hot fluids 
 
86 A MANUAL OF SURGERY 
 
 or gases, the difference in the effects being comparable to the dis- 
 tinction between roasting and boiling. Naturally, fluids such as 
 oil, which boil at a higher temperature than water, produce 
 increasingly severe results. 
 
 The Effects of burns and scalds vary with the source of heat, its 
 intensity, and the duration of its application. 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 destruc- 
 tion of tissue ; the part may, however, remain red, painful, and 
 prone to ulceration for a time. Should the scorch be often 
 repeated, as by 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 blister results. When this bursts, and the 
 cuticle is removed, the cutis vera, red and painful, is exposed below. 
 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 is destroyed, but also from innumer- 
 able 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 
 fifth the muscles are also encroached upon, whilst in the sixth 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 subsequent 
 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, which follows the course described 
 elsewhere (p. 209). There are no special characteristics of these 
 processes which call for particular note, except that they are 
 usually of a septic nature, unless the burn is a small one. The 
 skin is usually dirty (from a surgical standpoint) at the time of 
 
GANGRENE 87 
 
 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 associated with it often 
 render complete sterilization impracticable. 
 
 The General or Constitutional Conditions which correspond to 
 these three stages require a little fuller notice. 
 
 1. As an immediate result of the burning and destruction of 
 tissue, the patient lies for a time in a state of shock, the intensity 
 of which depends not so much on the depth of the burn as on its 
 extent, so that total charring of a limb will probably cause less 
 depression of the system than an extensive superficial scorch, 
 especially if the latter involves the abdomen. It frequently passes 
 into a condition of collapse, due in measure to the absorption of 
 toxic products from the burnt tissues. During this stage the 
 internal viscera, especially those connected with the portal system, 
 become intensely congested. 
 
 2. Whilst the separation of the sloughs is being effected, a 
 period of inflammatory fever follows, usually of an asthenic type. 
 Any and every form of internal complication due to sepsis may 
 arise during this stage, which usually lasts from four to fourteen 
 days. Congestion of the brain or lungs is not uncommonly seen, 
 but the gastro-intestinal tract is that, perhaps, most generally 
 and seriously affected. The mucous membrane of the stomach 
 and intestines becomes engorged with blood, leading to vomiting 
 and diarrhoea, whilst ulceration, or even peritonitis, may super- 
 vene. 
 
 During the later days of this stage a peculiar form of Duodenal 
 Ulcer is liable to occur, although it is admittedly not at all 
 common. Its presence is suggested by pain in the epigastrium 
 after food, perhaps some vomiting, which may be blood-stained, 
 and possibly the passage of a motion containing a good deal of 
 altered blood ; but occasionally the first sign of such mischief is 
 the sudden collapse of the patient, followed by death, with or 
 without peritonitis, owing to perforation or excessive haemorrhage 
 (Chapter XXXII.). The bleeding generally arises from erosion of 
 the superior pancreatico-duodenal artery. The ulcers usually 
 occur in the second part of the duodenum, close to the entrance 
 of the common bile-duct. In appearance they present a cleanly 
 punched-out loss of substance with little or no surrounding 
 inflammation, and their distinct limitation suggests that they are 
 due to the auto-digestion of a distinct arterial area, the vitality of 
 which has been diminished by a preceding thrombosis of the 
 vessel. They probably result from the elimination by the liver 
 of some irritating substance derived from septic or other changes 
 in the burnt tissues which is capable of inducing thrombosis in 
 the structures in close contiguity to the entrance of the bile-duct, 
 or at any rate of producing ulceration. Thus, in a fatal case 
 recently under observation, the post-mortem examination revealed 
 
A MANUAL OF SURGERY 
 
 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. 
 
 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 
 anaemia. Where, however, the wounds are septic and suppurating 
 freely, this tendency will be much more marked, and the patient 
 may 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 sepsis, 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 the superficial scorches without vesication, all 
 that is required is the protection of the affected parts, e.g., by 
 dusting them over with boric acid powder mixed with starch. 
 Where blisters have formed, the cuticle should be washed 
 antiseptically and then punctured, so as to allow the contained 
 serum to escape, and then the area should be dusted with boric 
 acid powder, and covered with aseptic wool. Carron-oil (i.e., a 
 mixture of equal parts of linseed-oil and lime-water) is also much 
 used, applied on lint ; it is, however, not an antiseptic, although 
 by adding a small proportion of eucalyptus oil (1 to 10) this can 
 be corrected. Latterly some French authorities have commended 
 the use of picric acid as a dressing in cases of burns where the 
 cutis vera has not been entirely destroyed ; the vesicles are 
 punctured, and then a piece of lint, soaked in a solution of picric 
 acid (20 grains to 1 ounce of sterilized water), is applied to the 
 burnt surface, and over this, in turn, a pad of salicylic or sterilized 
 wool is bandaged. Thus a dry dressing is produced, which may 
 be left in situ for some days, when it is reapplied. We have used 
 this plan, and have been much pleased with the results. 
 
 Where the burn includes deeper structures, the clothes must be 
 removed with as little dragging as possible, being cut away if 
 necessary ; the damaged tissues are then well bathed with some 
 antiseptic, such as carbolic lotion (1 in 40), and covered up as 
 rapidly as possible with lint soaked in eucalyptus oil or weak 
 carbolised oil (1 in 40). In some cases, where the skin and surface 
 are exceedingly dirty, it is well to anaesthetize the patient, and 
 then to cut away parts which must obviously slough and 
 thoroughly purify the wound, which is covered with protective, 
 and dressed with cyanide gauze, or some such material. 
 
GANGRENE 
 
 At the same time, the general condition of the patient must not 
 be overlooked ; he is possibly in a state of considerable shock, 
 and therefore should be put to bed and covered with warm blankets 
 or rugs, whilst perhaps a little warm stimulating fluid is ad- 
 ministered ; in bad cases an intravenous injection of hot saline 
 solution is advisable, and it may often be repeated with advantage 
 more than once. 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, has been added ; the 
 clothes are then 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, if necessary, be replenished. The 
 wounds are then dressed, and the little patient removed to bed. 
 It may be desirable to repeat the immersion at every dressing. 
 
 When a limb has been hopelessly charred or burnt to the bone, 
 it is useless to retain it, and amputation through the nearest 
 healthy tissues should be undertaken at the first favourable 
 opportunity. 
 
 When the next stage, viz., that of inflammation and sloughing, 
 has been reached, the only requisite is to keep the parts as free 
 from sepsis as possible, assisting the natural processes of repair 
 by warm moist applications, and snipping away sloughs as they 
 loosen. Generally, attention to the ordinary rules of personal 
 hygiene, and a simple diet, are all the precautions that need be 
 taken. 
 
 When the stage of cicatrisation is reached, the granulating 
 wounds are treated on general principles. The granulations often 
 become prominent, and stimulating applications, such as touching 
 them with lunar caustic, may be necessary. In large wounds, 
 healing should be assisted by skin-grafting, according to Thiersch's 
 method ; unless some such proceeding is instituted, the wound is 
 likely to become chronic, and healing may be delayed perhaps 
 indefinitely. 
 
CHAPTER VI. 
 INFECTIVE DISEASES. 
 
 Cellulitis. 
 
 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 
 micro-organisms, and running on to suppuration, sloughing, or 
 even to extensive gangrene. 
 
 Causation. — The one essential is the infection of the cellular 
 tissues with some organism capable of multiplying locally, and 
 of developing toxic compounds, which not only act at the site of 
 inoculation, but are also carried along the lymphatics, and by 
 their absorption into the general circulation give rise to toxaemic 
 phenomena. The entrance of the organisms may result from an 
 operation wound which has been allowed to become septic, or 
 from an accidental breach of surface which has not been rendered 
 aseptic, or even from the slightest graze, prick, or scratch. Deep 
 septic 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, inflam- 
 matory phenomena readily supervene owing to the absorption of 
 septic material from neighbouring contaminated structures, e.g., 
 pelvic cellulitis arising from a septic uterus. 
 
 Bacteriology. — The less severe types are generally due to the Staphylococcus 
 pyogenes aureus or alius, whilst the more severe are caused by the Streptococcus 
 pyogenes, which, as will be stated hereafter, is probably identical with the 
 organism of erysipelas, and in these cases the cellulitis has more of an 
 erysipelatous character. In many instances various forms of non-pathogenic 
 organisms may accompany the above. The most acute manifestation of the 
 disease is usually described as acute emphysematous gangrene (see p. 81). 
 
 Clinical History. — The symptoms in any particular case 
 necessarily differ somewhat according to the site of inoculation 
 and the virulence of the causative 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 
 
INFECTIVE DISEASES 01 
 
 prick or abrasion which has become infected, there is often a 
 period of quiescence for a day or two, during which the virus is 
 incubating 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 condition. Fever will almost always be 
 present to a greater or less degree, and in the more severe types 
 one or more rigors occur. Occasionally, however, the tempera- 
 ture is subnormal, owing to the depressing effects of the toxic 
 substances absorbed. The affected part is found to be hot, 
 tender, and infiltrated ; if superficial, it looks red and angry, and 
 feels brawny. The course of the case depends to a very large 
 extent upon the treatment adopted ; if freely incised, the process 
 becomes limited, and although suppuration may occur, there is 
 but little sloughing, and hence repair is readily effected. If, how- 
 ever, it is left, or is merely poulticed, the process rapidly spreads, 
 and may even involve the whole limb, which becomes greatly 
 swollen, cedematous, red, and brawny. Intense pam and sleep- 
 lessness, accompanied perhaps with delirium, form the most 
 prominent symptoms, and these, together with the toxic fever, 
 rapidly exhaust the patient's strength. Finally, suppuration occurs 
 beneath the skin, whilst the cellular tissue sloughs, perhaps the 
 whole of the subcutaneous areolar tissue being thereby destroyed, 
 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 considerable 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. Occasionally the trouble spreads along the 
 deeper areolar planes, involving muscular bellies, which may be 
 infiltrated with pus or may actually slough. This is most likely 
 to occur when the disease is due to septic inflammation fol- 
 lowing a penetrating wound, such as a gunshot injury or a bad 
 compound fracture. In all these more severe forms the patient 
 runs a considerable risk of developing general septicaemia, or even 
 pyaemia. 
 
 Treatment. — With the exception of cases of emphysematous 
 gangrene, cellulitis results from the activity of organisms which 
 are readily destroyed, and over which the germicidal properties of 
 the body have considerable control. Hence careful attention to 
 the dicta of antiseptic surgery can prevent its occurrence to a 
 very large extent. Abrasions and small punctured wounds should 
 always be carefully protected, and all penetrating injuries dis- 
 infected, especially if the patient runs exceptional risk of infection 
 owing to his occupation or surroundings. Should inflammatory 
 phenomena supervene, the application of antiseptic fomentations, 
 such as the boracic poultice, may prevent their extension, whilst 
 
92 A MANUAL OF SURGERY 
 
 the bowels should be freely acted upon and the general health 
 attended to. Failing this, and if there is any tendency for the 
 inflammation to spread, incisions should be made into the brawny 
 tissues, so as to give exit to the serous and irritating discharges ; 
 the wounds thus made are dusted with iodoform and lightly 
 packed with gauze, over which the usual dressings are applied. 
 The object of this is to drain the fluids from the parts by capillary 
 action, and hence an effective junction must be maintained be- 
 tween the gauze drain and the surrounding dressing. It is often 
 wise to incorporate a piece of mackintosh in the outer folds of the 
 dressing, so as to keep the parts moist and encourage a free dis- 
 charge. Under such a regime sloughing may be entirely pre- 
 vented, or, at any rate, limited. At the same time the patient's 
 health and strength must be maintained by the administration 
 of suitable food and stimulants, whilst quinine is very useful 
 internally. 
 
 Another excellent plan of treatment is to immerse the wounds, 
 after freely incising the infiltrated parts, in a continuous warm 
 bath, by this means diluting the toxins to such an extent as to 
 render them innocuous. Warm water does perfectly well, although 
 it may be boiled before use with advantage. 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 fresh 
 infection of wounds or decomposition of discharges. 
 
 Antistreptococcic serum (p. 99) has also been employed as a 
 curative agent with a view to destroy the streptococci and 
 immunize the system to their further development, but the 
 results hitherto obtained have not been very encouraging. The 
 dose varies from 5 to 10 c.c. (1 c.c. = fl\_ i£), injected two or 
 three times a day beneath the skin of the back or abdominal wall. 
 
 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 a primary axillary lymphadenitis. The tissues of the armpit become 
 hard and brawny, the pain is severe, and the 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. Extensive incisions are required in order to 
 prevent such complications, but respect must be paid to the important vessels 
 and nerves contained in the cavity. 
 
 Submammary Cellulitis is usually due to an extension of inflammation from 
 the deeper parts of the breast, or perhaps from the cartilages or bones of the 
 chest wall. The areolar tissue beneath the breast becomes infiltrated and ' 
 brawny, and the gland itself is lifted up, and somewhat swollen and tender. 
 (See Submammary Abscess.) Free incisions must be made into the infected 
 area along the lower portion of the circumference of the organ. 
 
INFECTIVE DISEASES 93 
 
 Cellulitis of the Scalp results from a septic wound which has traversed the 
 occipito-frontalis aponeurosis, and opened up the subjacent layer of loose 
 areolar tissue. Suppuration extends to the limits of attachment of this 
 structure, and hence 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 ; in addition to the severe general disturbance, the patient runs 
 a risk of necrosis of the skull and of various intracranial complications. 
 
 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. The whole of the orbital tissues become infiltrated and swollen, the lids 
 are cedematous, and the eyeball is thrust forwards. There is a considerable 
 likelihood of the inflammation spreading to the meninges, owing to the dura 
 mater being continuous with the orbital periosteum through the foramina 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 panophthalmitis 
 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 slightly increase its size, so as to enable the deeper parts to be 
 cleansed. Drainage must always be provided for, and in many cases this is 
 best accomplished by stuffing it lightly with gauze. If cellulitis follows, the 
 original wound must be opened up, and possibly fresh incisions made either 
 through the lids or through the fornix conjunctivas. Antiseptic fomentations 
 or poultices are then applied. If panophthalmitis supervenes, the eyeball 
 must be incised crucially ; this is a safer proceeding than enucleation, which 
 is more liable to be followed by meningitis. 
 
 Submaxillary Cellulitis, or, as it is sometimes termed, Ludwig's Angina, 
 from the name of the surgeon who first called attention to it, is an infective 
 inflammation of the cellular tissue beneath the deep cervical fascia which 
 occurs in elderly and weakly individuals or in children, without, as a rule, 
 any apparent reason, although probably it spreads from some buccal focus. 
 It occasionally results from inflammation extending beyond the capsule of 
 glands, and may originate in disease of the middle ear, the mischief travelling 
 downwards along the digastric muscle. It commences as a brawny induration 
 in the submaxillary 'region, which is tender, painful, and hot; there is a 
 certain amount of fever, and this increases pari passu with the extent of the 
 area inflamed ; it tends to spread to the front of the neck and base of the 
 tongue, even causing the latter to protrude from the mouth. Dangerous 
 symptoms arise from pressure on important vessels and nerves, from extension 
 of the inflammation to the glottis, causing cedema 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 ; occasionally a large sublingual abscess may form, causing the 
 gravest constitutional and respiratory disturbance, whilst in rare instances the 
 mass may remain stationary and indurated for a considerable time. 
 
 The Treatment must be prompt and energetic; a free incision is made 
 through the median line into the midst of the brawny tissue, or along any line 
 of safety where pus is threatening to form. A sublingual abscess may be 
 opened from the mouth ; but it is better, if possible, to do so from below, so 
 as to exclude sepsis. Prior to suppuration, fomentations may be used, whilst 
 tonics, stimulants, quinine, and plenty of good food are needed. 
 
 Pelvic Cellulitis arises from extension of inflammation from the pelvic 
 viscera to the loose cellular tissue ensheathing them. It may be due to 
 lymphatic absorption from septic material contained in the uterus, or it may 
 
94 A MANUAL OF SURGERY 
 
 spread from the ovary, Fallopian tube, or prostate. Injuries to the bladder or 
 rectum may also light up the trouble. It is associated with all the "local and 
 general signs of deep inflammation, and often, indeed, with peritonitis, giving 
 rise to a tense, firm, painful swelling to be felt per vaginam or per rectum, and 
 sometimes to an indurated mass of inflammatory effusion, dull on percussion, 
 above the pubic arch. Abscesses may form in this effusion, bursting either 
 externally or into some of the viscera, or possibly in both directions, producing 
 very intractable forms of urinary or faecal fistulae, whilst venous obstruction 
 and pyaemia are very 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 
 vaginal or rectal 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 dis- 
 carded, and only blunt instruments or the fingers 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. 
 
 Erysipelas. 
 
 Erysipelas is a specific and contagious infective disease due to 
 the development of the Streptococcus erysipeloids (Fehleisen) in the 
 smaller lymphatics of the skin and occasionally of mucous mem- 
 branes, with a decided tendency to spread and to recovery without 
 loss of tissue, the constitutional symptoms being due to the 
 absorption of toxins developed locally. Occasionally the sub- 
 cutaneous connective tissue is also involved, constituting the 
 variety known as cellulo -cutaneous erysipelas. 
 
 There has been considerable discussion as to whether there is 
 any difference between the erysipelas microbe and the ordinary 
 Streptococcus pyogenes found in spreading suppuration. The 
 microscopical characters are indistinguishable, and the growth 
 in various reagents is very similar. Inoculation experiments, 
 "moreover, certainly seem to indicate that they are closely allied 
 species, and the majority of bacteriologists consider them to be 
 identical, the differing effects depending merely on the methods of 
 inoculation and the virulence of the particular organism. The 
 chief objection to this theory is the great difference which exists 
 between the ' infectiousness ' of erysipelas and cellulitis. No 
 surgeon can complain of the presence of the latter in his wards , 
 none permit the presence of the former, except on compulsion. 
 
 The Causes of erysipelas may be briefly stated as follows : 
 (i.) The existence of an abrasion or wound in most cases, and 
 particularly of an unprotected septic wound. Thus, it is not 
 uncommon to find it associated with neglected scalp wounds or 
 
INFECTIVE DISEASES 95 
 
 with those communicating with the mouth. (ii.) A weak, 
 depressed state of the constitution, as from alcoholism, vicious 
 living, diabetes, albuminuria, etc. Some people, moreover, seem 
 naturally predisposed to the disease, particularly plethoric and 
 gouty individuals, and one attack renders the subject more liable 
 to recurrence after a short period of immunity, (iii.) Bad hygienic 
 surroundings are a most important additional factor in its produc- 
 tion, especially overcrowding in hospitals and bad ventilation. 
 But these are all merely predisposing conditions ; the only ex- 
 citing and absolute cause is (iv.), the infection with the specific 
 micro-organism, which is very widely diffused in Nature. An 
 idiopathic form used to be described, in which the disease starts 
 without any apparent local origin; but when one considers that 
 infection may occur through the slightest abrasion, and even 
 through sound skin or mucous membrane, and that the cocci do 
 not exist, as a rule, in the blood, it is evident that the theory of 
 local infection is in all cases the more probable. When once an 
 entrance has been effected, the cocci develop in the superficial 
 lymph channels, producing a transient inflammatory condition of 
 the skin, and a concurrent pyrexial state of the individual from 
 the absorption of specific toxins. 
 
 The Symptoms of the disease are usually ushered in by a slight 
 chill, scarcely amounting to a rigor, and by a period of headache 
 and malaise for about twenty-four hours, with some degree of 
 pyrexia. These symptoms are followed by the development of a 
 bright, rosy-red 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. If the erysipelatous virus is unmixed with 
 other organisms, the healing process may continue until the rash 
 appears, about the fourth or fifth day, when the young cicatrix 
 will break open again, exposing a dry and sluggish surface, with 
 a thickened margin ; it may occur, however, at an earlier date. 
 The rash is generally of a characteristic vivid red colour, always 
 disappearing on pressure, and is 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 very severe. Swelling is not very marked, except in 
 lax areolar tissues, such as in the scrotum or eyelids ; the oedema 
 may then attain considerable proportions. The rash continues to 
 advance more or less rapidly, with a continuous margin, and as it 
 spreads to new regions it fades away from those already involved, 
 leaving a slight brownish stain and a fine branny desquamation. 
 In some cases it does not spread evenly, but appears to leap 
 over an interval, and then the intervening lymphatics are found 
 to be thickened. Vesicles and bullae form superficially, containing 
 serum, which speedily becomes turbid, but suppuration is un- 
 
96 A MANUAL OF SURGERY 
 
 common, except in lax oedematous tissues, such as the eyelids, 
 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 
 children. 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. The duration of the 
 attack is most variable, lasting, as a rule, from one to three weeks, 
 but relapses are not uncommon. 
 
 The so-called Idiopathic Erysipelas mainly affects the head, 
 and occurs in predisposed individuals ; it is characterized by 
 the great oedema of the subcutaneous tissues of the face, which 
 causes the features to become almost unrecognisable. Large 
 blebs form, and even abscesses about the eyelids. There is a 
 great tendency to recurrence about the same time of the year in 
 these cases, and pain and delirium are prominent symptoms. 
 
 Cellulo-cutaneous Erysipelas is due to an infection of the skin 
 and subcutaneous tissues with the specific virus, and results in 
 suppuration and sloughing both of the skin and subjacent cellular 
 tissue. The signs are those of a diffuse spreading inflammation, 
 e.g., heat, pain, redness, and swelling of a brawny type at first, 
 but which soon softens and becomes boggy, the skin giving way, 
 and allowing exit to the pus and sloughs. The general symptoms 
 are correspondingly severe, and pyaemia may also be present. As 
 distinguishing features from ordinary erysipelas, it is stated that 
 the margin of the redness is less defined, that the lymphatic 
 glands are less enlarged, and that it is doubtful whether or not 
 the disease is contagious ; the whole nature of this affection is 
 still more or less sub judice. 
 
 Erysipelas of the Fauces causes a diffuse inflammation of the 
 mucous membrane of the fauces, often spreading to the glottis 
 and larynx, and arising either by extension from without, or in 
 association with some external manifestation of the disease else- 
 where. The fauces and soft palate become of a dusky scarlet 
 colour, and are much swollen. The voice is either husky or 
 absolutely disappears, whilst severe spasmodic dyspnoea may 
 arise from the oedema extending to the glottis. The parts are 
 very prone to ulcerate or slough, and the glands at the angle of 
 
INFECTIVE DISEASES 97 
 
 the jaw are enlarged. Fever is usually, though not invariably, 
 present, and great depression of the vital powers. 
 
 Erysipelas of the Scrotum, or, as it is sometimes termed, acute 
 inflammatory oedema, is characterized by the part becoming 
 greatly distended by serum, but without any marked redness. 
 Suppuration and sloughing are not unlikely to follow. It thus 
 somewhat simulates the appearance produced by extravasation 
 of urine, but is distinguished from it by the facts that micturition 
 is usually not interfered with, and that the swelling is not limited 
 in the same way as in the latter affection. 
 
 Diagnosis. — There is not much difficulty in recognising a case 
 of erysipelas if we remember the distinguishing features of the 
 rash, viz., its method of extension by a broad, sharply-defined, 
 slightly raised and infiltrated red margin. Thus, the exanthemata 
 are never limited to one part of the body, and rarely form one 
 continuous red patch. Lymphangitis is characterized by streaks 
 or lines of redness, not by an area of uniform hyperaemia. In 
 phlebitis the skin is seldom red over the inflamed vein, which can 
 be felt as a hard knotted cord below. A septic wound with pent-up 
 discharge closely simulates erysipelas ; but the margin of the 
 redness is not so accurately defined, and lymphatic enlargement 
 does not so constantly occur. Diffuse erythema nodosum is recog- 
 nised from it by the slight degree of the febrile disturbance, and 
 the presence of outlying patches of redness, which, moreover, are 
 not so clearly limited. There is always considerable pain in this 
 affection, which often involves both legs, and usually occurs in 
 young women of a rheumatic temperament. The so-called 
 erythema solare follows exposure to the sun's rays, especially when 
 reflected from water, of parts of the body which are, as a rule, 
 protected ; though usually of slight importance, it may some- 
 times give rise to so much pain, cedema, and constitutional 
 disturbance as to simulate erysipelas. It is readily distinguished 
 by the facts that it is limited to the parts exposed and has no 
 tendency to spread. In acute eczema ruhum the presence of a 
 honey-like exudation is quite characteristic. 
 
 Pathological Anatomy. — If a person dies of erysipelas, one 
 merely finds the general signs common to all septic cases detailed 
 elsewhere (p. 7). The rash will have faded, but on microscopic 
 section of the skin colonies of cocci arranged in chains will be 
 found invading the lymphatics just beyond the spreading margin 
 (Fig. 10), whilst in the parts which the inflammation has recently 
 attacked there will be a considerable excess of leucocytes, pre- 
 sumably connected with the destruction and removal of the cocci. 
 The lymph glands will also be found enlarged and congested. 
 
 Prognosis. — Erysipelas is not peculiarly dangerous in itself 
 (Osier gives the death-rate as 7 per cent, in hospital patients), but 
 may become so from the complications which attend it. The 
 most important of these are inflammatory conditions of the brain, 
 
 7 
 
A MANUAL OF SURGERY 
 
 lungs, and other viscera, especially of the kidneys. Pyaemia and 
 general septic intoxication are also met with. Erysipelas is 
 usually attended with danger to life in old people, drunkards, and 
 infants, whose vital powers become rapidly exhausted. As a 
 local complication, erysipelas is not always an unfavourable 
 occurrence, since wounds which have become chronic and sluggish 
 will sometimes manifest marvellous reparative power after an 
 attack. Chronic lupoid and syphilitic ulcers may rapidly cicatrize, 
 and even malignant sores, especially sarcomata, have been known 
 to be cured. 
 
 The Treatment of erysipelas is mainly conducted on general 
 principles. Prophylaxis must be strictly attended to by observing 
 every antiseptic detail in the treatment of wounds, especially if 
 any erysipelas cases are under treatment at the time. When the 
 disease is prevalent, all operations that can be delayed should be 
 
 Fig. ii. — Section of the Spreading Edge of a Patch of Erysipelas, 
 showing the lymphatics occupied by chains of cocci, which as yet 
 have produced but little effect on the tissues. 
 
 postponed. Single cases should be isolated, and kept out of 
 surgical wards if practicable. If, unfortunately, a case develops 
 in the wards, and cannot be completely isolated, the bed should 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 sepsis. It is usual to surround 
 the bed with sheets kept moist with carbolic lotion, and the floor 
 around should be sprinkled with the same. Special nurses must 
 be told off to attend to the case, and house-surgeons and dressers 
 must take extra precautions to prevent the spread of the disease. 
 
 Local Treatment. — When one considers the bacterial origin of 
 the affection, it is evident that, except in the mildest cases, the 
 old-fashioned plan of merely protecting the part from the air, as 
 by painting it with collodion, or covering it with a thick layer of 
 starch or flour, mixed perhaps with boric acid, was very inefficient, 
 whilst it is equally obvious that the local application of cold is 
 
INFECTIVE DISEASES 99 
 
 absolutely harmful, as tending still further to depress the vitality 
 of the part. Where tension and pain are severe, fomentations 
 containing opium or belladonna (e.g., 1 ounce of laudanum to 
 1 pint of lotio plumbi) may be applied, or the parts should be 
 scarified and antiseptic compresses applied, e.g., gauze soaked in 
 carbolic acid (1 in 30) or in sublimate solution (1 in 1,000). Perhaps 
 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, possibly after scarification, as well 
 as over the neighbouring healthy skin several times a day until 
 the fever disappears; such treatment is stated to be usually 
 successful in checking the disease in two or three days, whilst the 
 stickiness of the preparation hinders the diffusion of the virus. 
 
 Pressure may be of some value in limiting the spread of the 
 mischief, probably by compressing the lymphatics. A wide band 
 of adhesive plaster wound around a limb beyond the margin of the 
 rash is often effectual, and it may be possible in this way to check 
 its advance from the scalp to the face or neck. 
 
 Anything that tends to produce a local accumulation of leuco- 
 cytes in the skin beyond the spreading edge should be beneficial 
 in checking its advance, and therefore good may be derived by 
 painting around the rash with strong solutions of nitrate of silver 
 or with lin. iodi, granting that it is done sufficiently far off to be 
 on healthy skin. The most efficient plan based on this idea is 
 Kraske's, in which the skin is scarified all round at a distance of 
 an inch or two, the knife going just deeply enough to draw blood ; 
 antiseptic compresses are then applied. 
 
 An antistreptococcic serum,* prepared by immunizing a horse with 
 the Streptococcus pyogenes, and then withdrawing its blood serum, 
 has been used a good deal, especially in France, where Marmorek 
 and others have elaborated this plan of treatment. Ten or 
 fifteen c.c. of this serum are given subcutaneously as a dose, and 
 repeated once or twice a day. In favourable cases the pain 
 rapidly diminishes, the rash ceases to spread, the temperature 
 falls, and in twenty-four to forty-eight hours the disease may be 
 at an end ; but this result is not always obtained, possibly owing 
 to some defect in the preparation of the serum. 
 
 Constitutional Treatment must be of a tonic and supporting 
 character. Good food, easy of assimilation, stimulants and 
 quinine should be freely administered, whilst the tincture of the 
 perchloride of iron in -^-drachm doses, repeated three or four 
 times a day, is still looked on by many as a specific. 
 
 In cellulo -cutaneous erysipelas early and free incisions must be 
 made to relieve tension, and, if possible, anticipate suppuration. 
 
 * Obtainable at a few hours' notice by telegraph from the Jenner Institute 
 of Preventive Medicine, and many large chemists. 
 
A MANUAL OF SURGERY 
 
 The tissues, when incised, look gelatinous from the oedema 
 present, and much fluid of a seropurulent type will escape. If 
 this is not undertaken, considerable portions of skin and sub- 
 cutaneous tissue may slough. Antiseptic poultices should be 
 employed after the incisions have been made, until granulations 
 have developed. 
 
 In erysipelas of the fauces the parts must be painted or freely 
 sprayed over several times a day with antiseptic lotions, such 
 as liquor argenti nitratis (10 grains to i ounce), liq. hydrarg. 
 perchlor. (i in 2,000), or liq. soda? chlorinatae (1 part to 15 parts 
 of water), whilst tracheotomy may be needed if the glottis is 
 involved. Diffusible stimulants and plenty of nourishment are 
 urgently necessary to combat the depressing effects of this disease. 
 
 Septicaemia. 
 
 Septicaemia is an acute general infective disorder, arising from 
 the development of some variety of pyogenic organism in the 
 blood. It differs from pyaemia in the absence of secondary 
 abscesses (although, as explained later, it may be associated 
 with it), and from sapraemia or septic intoxication by the fact 
 that the latter is merely a chemical toxaemia. In septicaemia, if 
 a comparatively minute trace of the blood taken at a distance 
 from the local focus of mischief is inoculated into another animal 
 or individual, the disease is almost certainly transmitted, and often 
 with increased virulence ; in sapraemia, injection of the blood, 
 except in large quantities, does no harm. 
 
 As to the ultimate cause of septicaemia in man, much discussion has arisen 
 owing to the divergence of the results obtained by experimental research. 
 Koch and Davaine succeeded in isolating bacilli which produce fatal septi- 
 caemia in rabbits and mice respectively ; but neither of these is necessarily 
 pathogenic to other animals, and neither is the same as the organisms usually 
 found in human septicaemia, although the symptoms are practically identical. 
 
 In man various bacteria seem capable of producing this disease under suit- 
 able conditions — viz., the ordinary Streptococcus pyogenes of acute spreading 
 suppuration ; the Streptococcus septicus of Fliigge, which is probably identical 
 with the above, though more active ; the Streptococcus septopy 'amicus, which is 
 more nearly allied to the erysipelas organism ; or even the Bacillus of malignant 
 oedema (Koch). 
 
 If a mouse is infected with its specific bacillus, it remains apparently un- 
 affected for a period of twenty-four hours (incubation stage), but then becomes 
 languid, its eye loses lustre, it refuses to eat or run about, the respirations 
 become slower, and in about another twenty-four hours it dies, all its functions 
 appearing to be more or less paralyzed. Anatomically, one discovers but few 
 naked-eye changes, except a little local inflammatory exudation at the point of 
 inoculation, and slight swelling of the spleen. Microscopically, many of the 
 red corpuscles are found to be invaded and broken up by bacilli which may 
 even be seen within them, and the capillaries, especially in the lungs, are more 
 or less blocked by aggregated masses of organisms. 
 
 The pathological processes in human septicaemia are inferred to be of a 
 
INFECTIVE DISEASES 
 
 similar character — viz., development of organisms in the blood, with dis- 
 integration of corpuscles, especially of the red ; obstruction to capillaries, 
 particularly in the lungs ; formation of toxins as a result of this development ; 
 and paralysis of the functions of the nerve centres thereby. 
 
 Clinical History. — Septicaemia occurs most commonly from 
 direct inoculation with suitable organisms through small lesions, 
 such as post-mortem wounds, or from scratches or punctures 
 with infected pins or instruments ; it also in rarer cases follows 
 operation wounds and severe lacerated injuries. It is the usual 
 accompaniment of acute spreading gangrene, and may be met 
 with in cellulitis and cancrum oris. As a rule, the individual 
 attacked is in a depressed and debilitated condition, often deterio- 
 rated by alcoholic or other excesses, so that the inherent germi- 
 cidal activity of the tissues is markedly insufficient to cope with 
 the inroads of the disease. 
 
 The point of inoculation may be the seat of any of the forms 
 of local trouble which we have already described under the title 
 of cellulitis, and this may vary from a mere slight inflammatory 
 blush to the acutest form of spreading gangrene. 
 
 The General Symptoms are those of fever, often ushered in by 
 a distinct and severe rigor ; the temperature reaches 104 or 
 105 F., and usually remains high, with but slight remissions and 
 no intermissions. Malaise is present, with loss of appetite ; the 
 tongue is brown and parched, the pulse quick and feeble, whilst 
 the skin has often a slight icteric tinge. Diarrhoea usually ensues, 
 and may be blood-stained, whilst the urine is albuminous, and 
 contains blood. Petechias appear under the skin, and the patient, 
 after a period of delirium, 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 temperature with a very rapid pulse is always of grave 
 import. 
 
 Illustrative Cases. — A servant-girl, aged about twenty-two, complained one 
 hot summer's day that she had been stung near the inner canthus by a fly ; 
 possibly the insect had come from some infected material, and thus poisoned 
 the wound. In twenty-four hours she was feeling ill and feverish, and had 
 some chills and flushes; a painful swelling developed at the inner canthus, 
 which rapidly increased in size and spread downwards. At the end of four 
 days, when we saw her, the eye was protruding and much congested, and a 
 definite band of inflammatory thickening could be felt reaching from the roof 
 of the nose across the face to the neck and jugular region, probably the throm- 
 bosed facial vein, the clot doubtless extending to the cavernous sinus. The 
 temperature was high, and the girl was delirious. An incision was made into 
 the orbit with the view of relieving tension and giving exit to any pus that 
 might be present, but with no result. She rapidly became unconscious, and 
 died within a week. 
 
 An elderly man, addicted to drink, fell in the street, and grazed the inner 
 side of his hand. Within twenty-four hours the whole arm was puffy and 
 swollen, and in two days gangrene had manifested itself, the infiltration reaching 
 beyond the shoulder. The patient was dead from acute septicaemia in five 
 days. 
 
A MANUAL OF SURGERY 
 
 The Post-mortem Signs are those found in all cases of acute 
 septic poisoning, described above (p. 7), with the addition that 
 on microscopical examination bacteria can be demonstrated in the 
 blood and internal organs. 
 
 The Diagnosis has to be made from the more virulent forms 
 of the acute exanthemata, in which the patient is destroyed before 
 the characteristic 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. Saprcemia is 
 always associated with some very obvious focus of putrefaction, 
 whilst septicaemia may occur with but slight local manifestations. 
 Septic traumatic fever, due to wound infection, may be so severe as 
 to cause grave anxiety for a time as to whether or not septicaemia 
 is present ; but if 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. From 
 pycemia it is known by the absence of repeated rigors and secondary 
 abscesses. 
 
 The Prognosis of septicaemia is always very grave, but it is to 
 be hoped that the modern plans of treatment mentioned below, 
 especially serotherapy, may prove beneficial in diminishing the 
 mortality. 
 
 The Treatment consists in dealing actively with any local focus 
 of inflammation, either by amputation, or by free incisions, purifi- 
 cation, and drainage ; but unfortunately this is seldom likely to be 
 successful, as blood infection has probably already occurred. In 
 addition to such means, tonics and stimulants, with plenty of 
 suitable nourishment, must be administered. 
 
 It is possible that even this grave disease may become amen- 
 able to some of the therapeutic measures which have been sug- 
 gested of recent years. Thus, the antistreptococcic serum (p. 89) 
 may be utilized, and cases have been already reported as cured by 
 its agency. Another plan which has been adopted is that of the 
 intravenous injection of considerable quantities of normal saline 
 solution, repeated two or three times a day ; by this means 
 diuresis and diarrhoea are induced, and it is hoped that thereby the 
 organisms and their products may be eliminated. This treatment 
 has, however, been introduced so lately that no dogmatic state- 
 ments can be made about it ; it will probably be of greater value 
 in cases of sapraemia than in those of true infective septicaemia. 
 
INFECTIVE DISEASES 
 
 >03 
 
 Fig. ii. — Disinte- 
 grating Clot 
 lying in a Vein in 
 
 Pyeemia. 
 
 Pyaemia (Greek ttvov, pus, and aifxa, blood) is a disease charac- 
 terized by fever of an intermittent type, associated with the 
 formation of multiple abscesses in different 
 parts of the body, arising from the diffusion 
 of pyogenic materials from some spot of local 
 infection. 
 
 It was supposed not long ago that pyaemia was due 
 to some specific micro-organism, but it has now been 
 definitely proved by Rosenbach that any of the pyo- 
 genic organisms can give rise to it ; in fact, theoretically, 
 pyaemia may arise as a complication following any 
 acute abscess, which, as we have already seen, is 
 always due to bacterial activity. As a rule, however, 
 there is a sufficiently rapid development of granula- 
 tion 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. The mere injection of 
 cocci into the circulation is not sufficient to give rise 
 to pysemia; if they are few in number, a transient 
 a'caskof'Pyamia Py rexia ma Y .supervene, and then the germicidal 
 fTii manns \ " P ower£ latent in the blood destroy them ; but if the 
 
 * ' dose is large, or the individual is not in a very re- 
 
 The apex of the clot sistant condition, septicaemia, and not pyaemia, results, 
 projects into a larger unless special conditions are present which determine 
 trunk, in which cir- the formation of embolic abscesses. If the cocci to 
 culating blood is be injected are mixed with such a material or aggre- 
 present, and from it gated into such masses that the organisms are carried 
 infected emboli on particles too large to pass through the terminal 
 would be detached, arterioles and capillaries, wherever they lodge abscesses 
 develop. In human pathology the infective emboli 
 consist of zoogloea masses of organisms, or of infected particles of disinte- 
 grating blood-clot (Fig. n). 
 
 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 
 infiltration and disintegration of a thrombus (infective phlebitis), 
 but occasionally in the heart (malignant endocarditis). The venous 
 contamination which was formerly so much dreaded after opera- 
 tions by surgeons has now been practically banished from surgery 
 by antisepsis ; but the disease is still occasionally met with in 
 casualty work, where efficient asepsis is difficult. Acute infective 
 inflammation of the cancellous tissue of bones, whether idiopathic 
 or traumatic, 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 also explains 
 
io4 A MANUAL OF SURGERY 
 
 the onset of the disease after parturition if septic material is 
 allowed to collect or remain 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 at first of a 
 plastic type, but later on becomes suppurative. In the lung 
 many such foci may 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 of blood (a hemorrhagic 
 infarct), but soon becomes greyish -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 primarily 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 development of 
 micro-organisms in the blood, producing pyosepticamia, the patient 
 perhaps dying before the secondary abscesses have fully developed. 
 In other cases the general symptoms are due rather to the absorp- 
 tion 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 Pyaemia 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. 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 earthy or dull yellow tint, together with 
 erythematous or petechial patches. A sweet, mawkish, hay-like 
 smell of the breath is very characteristic. Symptoms of grave 
 depression 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 
 consciousness. The presence of a bruit in the precordial region 
 may suggest the existence of an infective endocarditis, which is 
 
Infective diseases 105 
 
 not very uncommon. 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 unaccompanied by local pain or tenderness, and form 
 very rapidly ; thus, a knee-joint may fill with pus in the course of 
 a night of quiet sleep. They are, as a rule, small and numerous ; 
 if they occur in vital organs, death may result from their local 
 development. When situated in the subcutaneous tissues, they 
 are characterized by the almost total absence of a barrier 
 of granulation tissue, and hence, even when opened early and 
 aseptically, are likely to extend and continue secreting pus, 
 instead of following the usual course of rapid contraction and 
 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 hyperaemia, 
 which fades away after a few days ; such are probably due to the 
 impaction of small infective emboli, which the patient has sufficient 
 vitality 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 form- 
 ing 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 a septic sinus 
 leading to a kidney already disorganized. 
 
 The condition of the wound at the onset of pyaemia is always 
 very unsatisfactory. It gapes open and presents an inactive 
 surface, and any newly-formed scar tissue readily breaks down. 
 A layer of healthy granulations is an almost certain barrier against 
 the occurrence of pyaemia, on account of the germicidal power of 
 the cells constituting it. If the disease arises in connection with 
 bone, the latter structure is usually seen lying bare at the bottom 
 of the wound, denuded of its periosteum, and the cancelli filled 
 with sloughy foetid medulla, or pus. 
 
 The duration of a case of pyaemia is very variable. Acute cases 
 usually last a little over a week, whilst the subacute forms may 
 run on for three or four weeks, and chronic cases continue for 
 months, and not unfrequently end in complete recovery. 
 
 Post-mortem Appearances. — 1. The wound is unhealthy, the 
 surface being grey, dry, or sloughy ; if bone is implicated, as in 
 an amputation or excision, evidence of inflammatory mischief, 
 either of the periosteum or medulla, is present. 2. The veins 
 leading from the wound may be in a healthy condition, but are 
 more commonly in a state of septic phlebitis ; the coats are 
 thickened, and the lumen is filled with soft, disintegrating clot, 
 which extends for a considerable distance; the tissues surrounding 
 the vein are also involved in the suppurative process. 3. Secondary 
 
io6 A MANUAL OF SURGERY 
 
 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 contained 
 pus may be of the normal type, or thin and oily ; it is always, 
 however, swarming with cocci. 4. The general signs common to 
 all cases of septic poisoning (p. 7) 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, as in a deep-seated abscess, or if the importance of some 
 local lesion has not been appreciated, the initial symptoms may be 
 mistaken for those of acute rheumatism 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, whilst in the chronic type recovery is not only possible, but 
 probable, if the local abscesses are favourably situated. 
 
 In the Treatment of acute pyaemia the surgeon is acting at a 
 considerable disadvantage, in that the disease is only recognisable 
 when it has obtained some hold upon the patient, since the recur- 
 rent rigors, by which it is known, are usually the evidence of a 
 grave general infection of the blood. 
 
 Local Treatment is most important, and since the disease is in 
 the majority of cases due to the detachment of infected emboli 
 from a vein, the ideal surgical practice consists in preventing, if 
 possible, the further contamination of the general blood-stream. 
 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 with pure carbolic acid ; or if it is due to a wound in the 
 soft parts, it may be feasible to dissect out the implicated vein and 
 surrounding 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 septic thrombosis 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, opened, and all the 
 septic clot removed, partly from above, partly from below. Ad- 
 mirable results have been thereby obtained. The abscesses must be 
 dealt with, where practicable, by opening them early and washing 
 them out ; such wounds often heal well, and joints which have 
 been distended with pus may recover with free mobility. Occa- 
 sionally, 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 form in time, and repair be established. 
 
 Constitutional Treatment consists in supporting the patient's 
 strength by nourishing diet and stimulants, and in taking precau- 
 
INFECTIVE DISEASES io? 
 
 tions to avoid bedsores or any local injury. Salicylate of quinine 
 may be administered, though its value is doubtful. The antistrep- 
 tococcic serum may also be utilized, and it may do good in cases 
 which have not progressed too far. 
 
 Tetanus. 
 
 Tetanus is a local infective disease, due to the Bacillus tetani, 
 and the characteristic symptoms are of a toxaemic nature. 
 
 Predisposing Causes. — 1. Climatic Influences. — It is most com- 
 monly seen in the tropics, where it may be almost epidemic, 
 probably owing to the heat favouring the development and 
 virulence of the organisms in the soil ; hot seasons assist its 
 activity, and particularly when hot days are followed by cold 
 nights. 
 
 2. Personal Proclivity. — It was formerly considered that negroes, 
 horses, and stable attendants were specially liable to this disease, 
 owing to some peculiar idiosyncrasy ; but with the recent addi- 
 tions to our knowledge as to the habitat of the Bacillus tetani, it 
 is extremely doubtful whether such an idea can be maintained. 
 The organism is a facultative saprophyte — i.e., is capable of con- 
 tinuing its development apart from the body — and is almost 
 constantly found in garden soil, dust, or dirt of any kind. 
 Those, therefore, who are likely to be much brought in contact 
 with the ground, e.g., negroes, horses, and agricultural labourers, 
 are liable to develop the disease, owing to their more constant 
 exposure to infection. 
 
 3. Bad Hygiene is a most important predisposing condition. 
 Every hygienic error favours its appearance, but especially the 
 overcrowding of sick and wounded people into a limited space, 
 and especially if full antisepsis is impossible. 
 
 Exciting Causes. — 1. The existence of a wound. It may follow 
 a lesion which causes no breach of surface, such as a blow with 
 the fist, or a bruise, but in the great majority of cases there is a 
 definite solution of continuity of the skin. Any region of the body 
 may be thus affected, and it is rare for tetanus to occur in any but 
 septic wounds ; where asepsis has been fully maintained the 
 development of tetanus is almost unknown. Punctured or 
 lacerated wounds of the sole of the foot, perhaps due to a dirty or 
 rusty nail, are as likely to be associated with tetanus as any. 
 
 2. Infection with the Bacillus tetani. The first clue to the 
 infective nature of this disease was obtained from the observation 
 that, if portions of soil or garden mould were placed under the 
 skin of animals, they died in a short time with tetanic symptoms, 
 and in the pus and walls of the resulting abscess characteristic 
 bacilli were observed. Experimenting in the same way, it has 
 been found that the bacilli or their spores are very widely dis- 
 seminated, and, indeed, are present in almost every sample of 
 
[o8 A MANUAL OF SURGERY 
 
 garden or field soil ; they have been found in the grime on a 
 working man's hand, and on dirty surgical instruments. Great 
 difficulty was experienced in isolating and getting pure cultures 
 of the bacillus, but at last Nicolaier 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 and septic 
 microbes. It develops in the body as long, delicate threads consist- 
 ing of and breaking up into separate bacilli ; in artificial cultures 
 spores form, but only at one end, causing such an appearance 
 that the microbe is known as the 'drumstick' bacillus (Fig. 12). 
 These organisms are anaerobic, i.e., flourish apart from oxygen, 
 and, indeed, are best cultivated on nutrient gelatine at blood-heat 
 in an atmosphere of hydrogen. They are not endowed with high 
 vitality, and hence do not invade living tissues unless these have 
 been previously bruised or damaged by the presence of septic 
 inflammation. They grow in the neighbourhood and near the 
 surface of septic wounds, the septic organisms absorbing all the 
 oxygen present, and so originating the anaerobic conditions 
 
 ta 
 
 *4f* 
 
 C\ 
 
 Fig. 12. — Bacilli of Tetanus from Artificial Culture, showing the 
 Spores located at the Ends of the Rods ('Drumstick' Bacilli). 
 
 (TlLLMANNS.) 
 
 necessary for their development. The mode of action of the 
 bacillus consists in a local infection with general toxaemia ; that is 
 to say, by its local development in a wound certain substances 
 are produced which, when absorbed, act on the spinal marrow 
 and brain, producing toxic effects very similar to those of 
 strychnine. The actual tetano-toxin appears to have the nature 
 of a ferment, its virulence being readily destroyed by exposure 
 to a somewhat low temperature, e.g., one of 68° C., for about five 
 minutes. It is not influenced by drying, and its activity is such 
 that it is stated to be nearly 400 times as poisonous as strychnine. 
 As to the post-mortem Anatomical Changes, but little need- be 
 said, since they are not specially characteristic. The muscles 
 are often pale, or show evidences of rupture and extravasation 
 of blood. The peripheral nerves extending from the wound are 
 red and congested for some distance, but this is probably only due 
 to septic inflammation. The nerve centres frequently present 
 
INFECTIVE DISEASES ion 
 
 areas of softening, and perivascular cellular exudation, with some 
 hyperaemia. 
 
 A few observations are on record in which the bacilli have been 
 noticed on the pia mater and arachnoid of the human spinal cord, 
 and others claim to have transmitted the disease experimentally 
 by inoculation of the subdural space with an emulsion of the spinal 
 cord or medulla. If these facts be true, they indicate that we 
 have still much to learn as to the nature of the disease. 
 
 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) by a difficulty 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 administration 
 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 sardonicus), whilst dysphagia soon follows 
 from spasm of the pharyngeal muscles. A considerable 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 painful and violent, and 
 the remissions between them but partial. Fortunately the disease 
 usually involves the respiratory muscles late in the attack. The 
 spasms can be excited by any form of stimulus, such as the 
 slamming of a door, a draught of cold air, or some voluntary 
 movement, and are always of a tonic {i.e., continuous) character. 
 The body is contorted in various directions, and respiration much 
 impeded by the fixation of the thorax. Occasionally the body is 
 arched backwards {opisthotonos) by the contraction 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 {pleurosthotonos). The muscles may 
 contract so violently as to be ruptured, whilst teeth have been 
 broken and the tongue has ' been almost bitten off. The in- 
 tellectual faculties usually remain clear to the end, which is 
 generally 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 108 , or even, in one case, to 112 F., and it often 
 continues to rise for a degree or two after death ; such hyper- 
 pyrexia is mainly due to the continuous muscular contractions. 
 The surface of the body is bathed in sweat, and the urine occasion- 
 ally albuminous. Death may occur in twenty-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. 
 
A MANUAL OF SURGERY 
 
 The course is usually afebrile, and the spasmodic contractions 
 may be limited to the wounded part of the body whence the 
 infection has arisen, or may be general. A special variety of this 
 is known as cephalo -tetanus, or T. paralyticus (German, kopf -tetanus). 
 It follows injuries within the area of distribution of the cranial 
 nerves, and especially those about the supra-orbital margin, and 
 is characterized by the association of trismus with facial paralysis, 
 although spasms, both tonic and clonic, occur in other parts of 
 the body. Spasm of the muscles of deglutition and attacks of 
 maniacal frenzy are sometimes present, and hence the name 
 T. hydrophobicus which has been applied to it. The paralysis is 
 supposed to be due to an ascending neuritis of the facial nerve, 
 which becomes compressed in the aqueductus Fallopii. The 
 condition is uncommon, and the prognosis not quite so grave as 
 in the acute cases. 
 
 The Diagnosis of tetanus is rarely difficult. In the early stages 
 it must be distinguished from simple trismus arising from dental 
 irritation, or from inflammatory ankylosis of the temporo-maxillary 
 joint. This may be readily accomplished by noting that there is 
 also present in tetanus rigidity of the neck muscles. In the later 
 stages strychnine poisoning leads to a very similar group of symptoms, 
 but is recognised from it by the contractions 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 con- 
 vulsions 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. 
 
 The Prognosis is unfavourable in any case, but the so-called 
 idiopathic variety is less fatal than the traumatic. The longer 
 the case lasts, and the lower the temperature, the more likely is 
 the patient to recover, whilst an acute onset, hyperpyrexia, sleep- 
 lessness, delirium, and strabismus are bad signs. The length of 
 the incubation period is also a most important factor, since it has 
 been shown tha.t if it is under ten days, only 4 per cent, recover ; 
 whilst if it lasts for eleven to fifteen days, 27 per cent, of cures 
 may be expected, and if the outbreak is delayed for fifteen to 
 twenty days, 45 per cent, of the patients live. 
 
 Treatment. — Careful antisepsis applied to wounds is the surest 
 means of preventing its occurrence, and the worse the sanitary 
 conditions in which patients are found, and the more ragged the 
 wound, the stricter should be the measures employed. 
 
 If the originating sore is accessible, it should be freely excised 
 and the wound cauterized, or the limb may be amputated ; but 
 
INFECTIVE DISEASES 
 
 even then the tetanic convulsions may remain for a time, or even 
 prove fatal, from the amount of poison already in the system. 
 
 In addition to these local measures, the specific tetanus anti- 
 toxin (prepared by drying the blood serum of an immunized 
 animal) should be injected. At present the results of this 
 treatment have proved disappointing, since few cases of acute 
 tetanus have been saved by it, and the effect even in the more 
 chronic cases is not at all certain. The explanation of this lies 
 probably in the fact that the serum is in reality an immunizing 
 agent (i.e., one which prevents the development of the organisms), 
 and is not capable of dealing with the toxic bodies already acting 
 on the nerve centres ; so that if a certain dose of the tetano-toxin 
 has once been absorbed, it will produce its normal effects, even 
 though the antitoxin prevents any further development of the 
 organisms. 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. If the 
 fluid antitoxic serum is used, 20 to 30 c.c. may be given as the 
 initial injection, followed by doses of 10 to 15 c.c. twice a day. 
 This is introduced into the subcutaneous tissues of the abdomen 
 and back, or in somewhat smaller doses into the veins, and causes 
 but little inconvenience. If Tizzoni's dried antitoxic serum is 
 employed, 2 to 4 grammes, dissolved in distilled water, may be 
 given to start with, and 1 to 2 grammes for subsequent doses. 
 
 During the last few years it has been shown by Roux and 
 Borrel that the toxins are so closely attached to the nerve-cells 
 that it is almost hopeless to expect even an intravenous injection 
 of antitoxin to do much good, and hence it has been proposed to 
 introduce it into the substance of the brain, enabling it thus to 
 reach and act on the nerve centres more rapidly. The object to 
 be gained is to immunize the medullary centres and prevent any 
 further development of the toxin in the body ; what is there 
 already must be allowed to work itself off. The injection is made 
 through the dura mater into the posterior portion of the second 
 frontal convolution on each side ; 2*5 c.c. of the dried serum 
 dissolved in 5 c.c. of sterilized water are injected very slowly, and 
 this may be repeated several times, if an interval of a few days be 
 allowed to elapse between each injection. The point selected is 
 placed midway between the external angular process of the frontal 
 bone and the centre point of the line between the root of the 
 nose and the external occipital protuberance. A small trephine 
 may be applied here, or simply a hole drilled through the skull 
 sufficient to allow of the introduction of a syringe, which is pushed 
 about two inches deep into the brain. Of course, the strictest 
 asepsis is essential. Probably it will be found wise to restrict this 
 plan to the treatment of the worst cases, and it must be augmented 
 by subcutaneous injections and the other subsidiary measures to 
 be now noted, 
 
A MANUAL OF SURGERY 
 
 The patient should be kept absolutely quiet in a darkened 
 room, and free from all sources of irritation. Food should be 
 nutritious, fluid, and unstimulating ; it has been suggested to feed 
 the patient twice a day by a stomach-pump under chloroform. 
 When the trismus is very marked, he may be fed through a soft 
 rubber catheter passed into the pharynx through the^nose, unless 
 there is a sufficient gap between the teeth to admit of its entrance. 
 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 
 without. Chloroform should be administered to control the 
 spasms. 
 
 Hydrophobia. 
 
 Hydrophobia is an acute general infective disease, transmitted from animals 
 to men, especially from rabid dogs, wolves, etc. It consists in an affection of 
 the central nervous system, and one of its most marked features is the long and 
 variable incubation period. It never originates idiopathically either in animals 
 or man, and although the actual virus has not yet been isolated, there can be 
 no doubt that it is a micro-organism. Infection usually follows 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. Two chief varieties 
 have been described — the raging or maniacal, and the quiet or dumb. Rabies 
 with frenzy commences with a stage of depression, which is manifested by 
 snappishness and irritability, 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 followed by a period of frenzy and 
 maniacal fury, and this in turn is succeeded 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 paralyzed ; finally, 
 after partial or general convulsions, the animal dies five or six days from the 
 onset. In the melancholic or dumb form the animal succumbs more rapidly, 
 passing through the same stages as the above, with the exception of the 
 maniacal period. The disease lasts then but two or three days. 
 
 In Man the incubation period is most variable, lasting from days to months 
 or years, but as a rule 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 dis- 
 turbance of the mind, lasting for about twenty-four hours. Restlessness, 
 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. These 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 
 
Infective diseases 113 
 
 mouth is usually filled with ropy mucus, which is very difficult to remove. 
 The respirations became catchy, and a hiccoughing noise may be produced by 
 the 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, 
 10th, 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. 
 
 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 limb should be arrested by a string or bandage, bleeding encouraged, and 
 some powerful caustic, e.g., pure carbolic acid, applied as soon as possible. A 
 free excision of the part is, however, preferable. 
 
 Pasteur's Preventive Treatment. — A few years back M. Pasteur discovered 
 the fact that the injection of an attenuated virus in increasing doses, and 
 in gradually increasing strength, protects an animal or individual from the 
 disease, and mirabile dictu ! will even catch up the poison already inoculated, 
 and save the patient from its subsequent development, 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 disease appears with regularity on the 
 seventh day, all parts of the cord being then equally virulent. The material 
 inoculated is obtained by mashing up a portion of the spinal cord or medulla 
 of the diseased dog in sterilized broth, and injecting it with a hypodermic 
 syringe beneath the arachnoid after trephining. 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. Individuals are inoculated with portions of such cords, 
 pounded up in sterilized broth, beginning with the weakest, and gradually 
 increasing the strength of the injection, until a preparation of a cord which has 
 merely hung one day is used. This method of treatment was introduced in 
 1885, and the results hitherto obtained have been such as to indicate that we 
 have here a most potent preventive agent against hydrophobia, granted that 
 the disease has not been allowed too long a start. When the disease has 
 attacked an individual, only palliative treatment can be adopted. Every 
 source of irritation and disturbance 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, with the addition of stimulants. 
 
 Anthrax. 
 
 This disease results from infection with the Bacillus anthracis, which produces 
 in sheep and cattle the so-called 'splenic fever.' In man, if the microbe is 
 inoculated through the skin, it produces a form of carbuncle known as a 
 ' malignant pustule,' although occasionally a more diffuse condition termed 
 ' anthrax oedema ' arises from local infection ; whilst if the virus is absorbed by 
 the lungs or intestinal canal, it originates a general inflammatory disorder, 
 known as ' woolsorters' disease,' or anthracsemia 
 
 The Bacillus anthracis (Fig. 13) is one of the largest of the pathogenic 
 
H4 
 
 A MANUAL OF SURGERY 
 
 organisms, measuring 5 t0 20 /< in length, and 1 to 150^ in breadth. It is 
 found in the blood of diseased animals in the form of rods or threads, composed 
 of a variable number of individual elements (from two to ten). It is aerobic, 
 immobile, grows best at about blood-heat, and liquefies gelatine. 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 carcase in which they are present causes their death in 
 about a week. The spores, however, are very resistant ; for whilst a 1 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. 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 dog 
 and rat ; and one of Pasteur's most useful discoveries was that of artificially 
 providing immunity for cattle and sheep by inoculating them with an at- 
 
 FlG 
 
 13. — Bacillus Anthracis, from 
 Splenic Pulp of Infected 
 Animal, x 1,200. (Crookshank's 
 ' Textbook of Bacteriology.') 
 
 Fig. 14. — l;acillus Anthracis in 
 the Substance of the Kidney, 
 to show how the Tissues 
 become Infiltrated by it. 
 x 600. (Crookshank's ' Text- 
 book of Bacteriology.'} 
 
 tenuated virus, obtained by exposing a cultivation for some time to a high 
 temperature. 
 
 Symptoms. — Infection with this organism usually occurs an;ongst graziers 
 who tend the living animal, or butchers who deal with the carcase ; it is also 
 met with amongst workers in hides or wool. 
 
 Malignant Pustule commences as an angry red pimple at the site of inocula- 
 tion, which rapidly spreads, with much infiltration of the base, whilst the 
 centre becomes covered with vesicles, the serum within which contains the 
 typical bacilli. _ This stage is associated with no pain, but only with great 
 itching and irritation. As the pustule extends, the central part becomes grey, 
 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 pronounced 
 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, vomit- 
 ing, flatulence, more marked. Should the disease progress unchecked, the 
 
INFECTIVE DISEASES n 5 
 
 respirations become shallow and embarrassed, whilst signs of grave con- 
 stitutional 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 oedema 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. 
 
 Woolsorters' Disease (or anthracaemia) 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 either by swallowing 
 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 the 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, ciamps, vomiting, and blood-stained 
 diarrhoea are the most marked features in such a case. The intestinal type 
 appears to be not quite so virulent and 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, are usually recommended, though some who have 
 had experience of the affection think such treatment of little value. Large 
 doses of quinine may be given, but for the general disease merely symptomatic 
 treatment can be adopted. De-emetised ipecacuanha has been much recom- 
 mended, both as a local application after excision, and also internally in wool- /. 
 sorters' disease. 
 
 Gonorrhoea. 
 
 Gonorrhoea is an infective process due to the action of a specific 
 micro-organism, the Gonococcus (Plate I., Fig. 6), and charac- 
 terized by a discharge of pus from the urethra. The organism 
 was first isolated by Neisser in 1879, and is found with or without 
 other pyogenic cocci in the discharge, most commonly in the 
 epithelial cells or pus corpuscles, but sometimes apart from them. 
 They are readily demonstrated by staining a film of pus, dried on 
 a cover-slip, with methylene blue or gentian violet, and are almost 
 always found in the diplococcus condition, i.e., they occur in pairs, 
 held together possibly by some slight capsule; but often a con- 
 siderable number, even up to twenty, are massed in a clump. 
 The gonococcus is not easily cultivated, except in acid media ; 
 the addition of an alkali checks the growth and renders the 
 organisms less virulent. The disease has been transmitted both 
 to animals and to the human subject by inoculation experiments 
 with a pure and active culture. The organisms find their way 
 into the male urethra, and invade the epithelial cells of the mucous 
 membrane, within which they may often be seen ; they determine 
 
 8—2 
 
n6 A MANUAL OF SURGERY 
 
 an acute catarrhal inflammation, which quickly runs on to sup- 
 puration. One great characteristic of gonorrhoea consists in the 
 readiness with which it extends from one part to another, and the 
 ease with which even a healthy urethral or vulval mucous mem- 
 brane becomes affected by it, simple contact sufficing to determine 
 an attack. Hence, although the symptoms are often very slight 
 and insignificant, severe complications may arise, which may per- 
 manently cripple the individual, or even destroy life, especially if 
 other pyogenic organisms are present. 
 
 The Symptoms of Acute Gonorrhoea usually commence 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 constitu- 
 tional disturbance and fever. The bowels are usually constipated, 
 and the appetite impaired. Occasionally the swelling and conges- 
 tion 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 subsequent ones, although it is more 
 amenable to proper treatment. Gouty and rheumatic people are 
 especially difficult to treat, and often suffer from relapses after the 
 discharge has apparently ceased, and 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 sometimes termed a Posterior Urethritis, since it 
 involves that portion of the canal which lies behind the deep 
 constrictor. It usually becomes evident about the end of the 
 second week, and is characterized by frequent and painful mic- 
 turition, a sense of pain and heaviness in the perineum, possibly a 
 little blood in the urine, and a general feeling of depression. This 
 extension backwards is always serious, since it is likely to precede 
 complications involving the prostate, testis, or seminal vesicles, 
 whilst it is an extremely common cause of Chronic Gonorrhoea or 
 Gleet. A more or less abundant discharge continues for some 
 time without any other troublesome symptom than occasional 
 scalding on passing urine. The discharge varies in consistency, 
 but is often thin and muco-purulent, whilst sometimes, if due to 
 chronic prostatitis, it may be so clear and transparent that it 
 resembles uncooked white of egg. The causes of gleet vary in 
 different cases; it is sometimes due to an ulcerated or granular con- 
 dition of the mucous membrane, the discharge then being yellow, 
 whilst in others it arises from chronic prostatitis, a condition not 
 
INFECTIVE DISEASES 
 
 117 
 
 uncommonly associated with chronic enlargement of the vesiculae 
 seminales. The latter condition may be recognised on rectal 
 examination, whilst, when the prostrate is involved, flocculi of 
 mucus in the shape of worm-like threads may be detected in the 
 urine. A patch of granular urethritis should be suspected when 
 one portion of the urethra is especially tender on the passage of a 
 sound, but its presence can only be recognised with certainty by 
 the use of the urethroscope. 
 
 Every purulent discharge is not necessarily gonorrhceal, since 
 a simple urethritis may follow connection with a woman who is 
 simply suffering from leucorrhcea, 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 Bac. coli communis, which is known to be not an 
 unfrequent cause of vulvo-vaginitis. A diagnosis of simple 
 urethritis may be suggested by the history, but only a micro- 
 scopical examination of the pus, and a demonstration of the 
 absence of gonococci, can establish it with certainty. At the 
 same time it must be remembered that gonococci are capable of 
 remaining in a latent or passive state for a very long time in the 
 folds or crypts of a mucous membrane, and hence it is quite 
 possible for a person who has once suffered from it to be capable 
 of transmitting the disease, although there may be no evidence of 
 its existence at the time. 
 
 In the Treatment of the early stages of acute gonorrhoea it is 
 essential to keep the urine free from acidity by the use of alkalies, 
 to maintain a free action of the bowels, and to allay the irritability 
 of the parts by sedatives, such as tincture of henbane. The diet 
 should be light and unstimulating, and all alcoholic drinks pro- 
 hibited, as also strong tea and coffee, whilst the patient should be 
 recommended to take plenty of bland fluids, such as barley water, 
 or milk and soda-water. The scrotum should be supported in a 
 suspender, and the patient advised against taking severe or pro- 
 longed exercise. No local treatment is necessary, although the 
 use of hot hip-baths may relieve the pain and irritation ; indeed, 
 at this period injections are harmful. The same treatment must 
 be adopted as long as the discharge is copious, and the scalding 
 continues. As soon as these symptoms moderate, oleo-balsams in 
 the shape of oil of sandal- wood (10 minims, in capsules, three to 
 six times a day), copaiba (10 minims, in capsules or mixture, thrice 
 daily), or cubebs (^ to 1 drachm doses, wrapped in wafer-paper), 
 may be advantageously employed. Both cubebs and copaiba, 
 especially the latter, are capable of producing a bright-red erythe- 
 matous rash which causes much irritation, and may be extensively 
 diffused over the body. 
 
 The value of injections in the treatment of the disease has 
 been much discussed, and is a point on which difference of 
 opinion exists. Qn the whole, we are inclined fo think that many 
 
US A MANUAL OF SURGERY 
 
 of the less severe cases of acute gonorrhoea can be successfully 
 treated without them, and that they should never be employed when 
 any local irritation or scalding is present ; but where the discharge 
 tends to persist, or the urethra has been 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 normal act of micturition 
 answers admirably, so that the injection should be used immedi- 
 ately 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 com- 
 pressing the orifice with the finger 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 unquestionably the 
 cleanest. Of the many different injections employed, perhaps the 
 best consists of a mixture of tincture of catechu (10 minims to 
 i ounce of water) and sulphate of zinc (2 grains to 1 ounce), or of 
 permanganate of zinc (\ grain to 1 ounce), or nitrate of silver 
 (\ grain to 1 ounce). The great secret consists in using the injec- 
 tion 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 warmed prior to use, and care taken 
 not to use too strong a solution. 
 
 One is bound to admit, however, that many genito-urinary 
 surgeons hold views very different to these, and, indeed, main- 
 tain 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 suffi- 
 cient force to distend the urethra in all its parts and enter the 
 bladder ; all the crypts and lacunae are thus reached by the anti- 
 septic. 
 
 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 prevent 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 an excellent effect. Methodical dila- 
 tation of the urethra is also advised, with the object of compressing 
 all the crypts and lacunas, and removing pent-up secretion. If 
 granular urethritis is present, the topical application of nitrate of 
 silver may be undertaken through a urethroscope, but requires the 
 greatest care, for fear of the subsequent formation of a stricture ; 
 
INFECTIVE DISEASES U g 
 
 chronic prostatitis and vesiculitis are dealt with by counter-irrita- 
 tion applied to the perineum, or possibly by sedatives, such as 
 belladonna, administered in the form of suppositories. 
 
 Complications of Gonorrhoea. — These may be conveniently 
 arranged under the following headings : 
 
 I. Complications due to Direct Extension. — In the male, the 
 following may be described : 
 
 Balanitis is of frequent occurrence in patients with long fore- 
 skins. It 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. 
 
 Lacunar Abscess arises from infection of one or more of the 
 lacuna? 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 to treat. If a fistula forms within a quarter of 
 an inch or so 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, how- 
 ever, 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 when the 
 penis becomes erect, it is bent downwards or to one side, owing 
 to incomplete distension of the infiltrated tissue. This condition 
 is exceedingly painful, and most marked at night when the patient 
 becomes warm in bed. It is best dealt with by applying cold to 
 the part, and by administering bromide of potassium or opium at 
 bedtime. 
 
 Inflammation of Cowper's Glands may in some cases give rise to 
 deep suppuration in the perineum, with symptoms very similar to 
 those of acute prostatitis. It is dealt with in the same way as the 
 latter complaint. 
 
 Acute and Chronic Prostatitis (Chapter XXXVII.). 
 
 Acute and Chronic Vesiculitis (Chapter XXXIX.). 
 
 Epididymitis arises by distension along the vas, and will be fully 
 described at Chapter XXXIX. It rarely commences before the 
 third week, and often not until the fifth or sixth, being perhaps 
 caused by the injudicious use of injections, or by a blow or 
 squeeze, especially if the scrotum is lax and pendulous. 
 
 Acute Cystitis (Chapter XXXVII.). 
 
 In the female many complications arise by direct extension of 
 
A MANUAL OF SURGERY 
 
 the gonorrhoeal inflammation along the urinary and genital tracts. 
 The primary affection is most commonly a vulvovaginitis, and this 
 may spread to the lining membrane of the uterus, or even to that 
 of the Fallopian tubes (salpingitis), whilst ovaritis and pelvic 
 peritonitis also occur. 
 
 II. Complications arising from Direct Transmission of the Virus. 
 — Gonorrhoeal Proctitis sometimes results in the female from infec- 
 tion by the discharge which escapes from the vulva, whilst in both 
 sexes it may be due to unnatural practices. Considerable tenesmus 
 is produced, accompanied by a thick muco-purulent discharge. 
 It 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 
 unilateral 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, there- 
 fore, that not only must there be direct contact with the gonorrhoeal 
 poison, but in addition the mucous membrane must be in a recep- 
 tive condition. 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 eyelids are red 
 and swollen, the conjunctiva is thickened and spongy (chemosis), 
 and the discharge liable to accumulate within the conjunctival 
 sac. If allowed to progress unchecked, the cornea may be injured 
 by the inflammatory process, ulceration, or even necrosis, ensuing, 
 and possibly general panophthalmitis. 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 fre- 
 quently irrigated with warm boric acid lotion, and every four 
 hours the membrane is carefully washed, dried, and swabbed over 
 with a solution of nitrate of silver (5 grains to 1 ounce). Between 
 the applications lint wrung out of iced boric acid lotion is kept 
 over the eye. This plan of treatment is continued until the sup- 
 puration ceases, and then the silver salt is omitted, and simple 
 astringents, such as chloride or sulphate of zinc, 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 
 complication not uncommonly followed by escape of the lens 
 and blindness. Crede's preventive treatment should always be 
 adopted for new-born children, viz., washing out the conjunctival 
 
INFECTIVE DISEASES 
 
 sac with a weak solution of nitrate of silver or corrosive subli- 
 mate soon after birth. When suppuration occurs, the treat- 
 ment 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!. Sclerotitis, or inflammation of the deep subconjunctival 
 fibrous tissue, is a rare affection, arising quite independently of 
 the disease just described. 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. 
 
 Gonorrheal Affections of Joints are not uncommon sequelae, 
 arising usually in the subacute stage of the disease. They occur 
 either in the form of a synovitis with effusion, or as an arthritis, 
 which may or may not suppurate, but usually ends in ankylosis. 
 The former is probably due to the embolic transmission of gono- 
 cocci alone, whilst in the latter pyogenic organisms are also con- 
 veyed to the articulation. For symptoms and treatment, see 
 Chapter XX. 
 
 Any muscular, tendinous, ligamentous, or aponeurotic tissues 
 may become inflamed and painful during the course of an attack 
 of gonorrhoea. Special mention must be made of the involvement 
 of the ligaments supporting the arch of the foot, since, if the 
 cause is not recognised and the patient is still allowed to walk, 
 the arch of the foot may be lost, and a permanent flat foot 
 result. 
 
 Secondary abscesses, similar to those of pyaemia, are sometimes 
 developed in cases of gonorrhoea, probably resulting from the 
 diffusion of pyogenic organisms, and even general infection of a 
 septicaemic nature has been described, leading to a fatal issue. 
 
 YVe now come to a group of diseases which have been classified 
 by Virchow under the term Infective Granulomata. They are all 
 characterized by the formation of growths more or less resembling 
 granulation tissue, which either persist or undergo various de- 
 generative changes. They are all infective in nature, and most 
 of them chronic in their progress, although acute manifestations 
 are occasionally met with. Five conditions are included under 
 this heading, viz. : Syphilis, Tuberculosis, Glanders, Leprosy, 
 and Actinomycosis. 
 
 Syphilis. 
 
 Syphilis is an infective disease, resulting from inoculation 
 with some specific virus, which has not yet been identified with 
 certainty. Ltistgarten demonstrated an organism in the initial 
 lesion which was supposed to be the bacillus of syphilis, but it 
 
A MANUAL OF SURGERY 
 
 was probably nothing more than the bacillus always present in 
 smegma. The inability to transmit the disease to animals is one 
 of the great difficulties in the way of a complete bacteriological 
 examination. 
 
 Syphilis is characterized by the appearance of a primary sore, 
 usually known as a hard chancre, which is followed in the course 
 of a few weeks by evidences of general infection, referred mainly 
 to the skin and mucous membranes, comprising the secondary 
 stage. After a variable time, known as the intermediate period, 
 during which symptoms may be absent, tertiary manifestations 
 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 transmitted 
 by other means (syphilis insontium), and then the primary lesion 
 is often located on some other part of the body (extragenital 
 chancres) ; thus, a hard chancre may be found on the lips, as a 
 result of drinking out of the same glass or smoking the same pipe 
 as a syphilitic patient, or may even be acquired by kissing. The 
 disease is not always equally infectious ; in the primary stage the 
 discharge derived from the chancre will alone convey the con- 
 tagion ; in the secondary period the virus is found in the blood 
 of the individual, and hence all pathological exudations, as also 
 the blood itself, may transmit the disease. Pure secretions, 
 e.g., milk or urine, are free from infection, although if mixed with 
 a serous exudation from abraded surfaces, as so frequently occurs 
 in the case of the saliva, they at once become infective. The 
 semen is probably an exception to the above rule, since, although 
 the maternal passages may entirely escape, the ovum becomes 
 diseased. It is usually held that in the tertiary stage the patient 
 is no longer capable of transmitting the affection. 
 
 The syphilitic virus is exceedingly resistant to the action of 
 antiseptics, and hence the risk of infection is very great, even 
 though prompt measures are taken to destroy it. Thus, many 
 cases are on record in which an abraded surface was brought into 
 contact with a syphilitic poison, and, although cauterized with 
 fuming nitric acid within a few hours, the disease ran its ordinary 
 course. In one case, however, under our observation, in which 
 a student's finger was accidentally pricked with a bent broad 
 needle, which a moment before had been inserted into the anterior 
 chamber of a syphilitic patient suffering from a secondary sup- 
 purative iritis, nitric acid was applied within a quarter of an hour, 
 and although a suspicious indurated spot formed six weeks later 
 at the site of injury, no other evidences of syphilis have been 
 observed, in spite of the fact that the individual had not previously 
 suffered from the disease, and took no mercury. 
 
 One attack of syphilis usually confers immunity on the patient 
 from further outbreaks of the disease, even if exposed to infection. 
 
INFECTIVE DISEASES 
 
 This protection is, however, not always permanent, since well- 
 authenticated cases have been observed of second attacks of 
 syphilis, in which the primary lesion was followed by distinct 
 signs of general infection. 
 
 Course of the Case. — The stage of Incubation lasts for a variable 
 period, extending from two to six weeks ; as a rule, however, 
 evidences of induration of the sore can be detected about the 
 third week. It is probable that long ere this the virus has 
 entered the circulation, and hence removal or destruction of the 
 local lesion has not the slightest influence upon the progress of 
 the case, unless it can be undertaken immediately after infection. 
 During this period nothing unusual is noted at the site of inocula- 
 tion, if the infection is purely syphilitic, and the local sore merely 
 a slight abrasion ; it may even heal completely in the course of 
 a few days, and nothing further is noticed until the typical in- 
 duration manifests itself. Not unfrequently, however, pyogenic 
 infection occurs or a soft chancre is also present ; in the latter 
 case the lesion does not heal in a typical manner, and the base of 
 the ulcerated surface becomes indurated after a time. 
 
 I. The Primary Stage of syphilis is characterized by the develop- 
 ment of a typical primary sore, associated with enlargement of 
 the neighbouring lymphatic glands. It is usually situated on the 
 base of the prepuce, close to the corona glandis, or on the fraenum ; 
 in the female the inner aspects of the labia majorae or nymphae 
 are the most common sites. 
 
 The primary sore does not invariably present the same 
 appearance, although it is always characterized by a certain 
 amount of infiltration and induration. Should the superficial 
 abrasion have healed, a localized growth of 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, though the base becomes 
 indurated. The following are the chief forms in which the 
 chancre manifests itself, (a) The desquamating papule is a slightly 
 elevated spot, which is extremely irritable, of a dusky colour, 
 and free from ulceration. It is usually small, but hard, and its 
 surface covered with epithelial 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, (b) The indurated, hard, or Hunterian chancre 
 is that most commonly seen ; it results from the irritation of a 
 papule, or is developed in association with a soft sore. It consists 
 of a distinctly localized infiltration and induration of the sub- 
 mucous or subcutaneous tissues, giving rise to a lump which feels 
 like a pellet of cartilage ; or the induration may be more exten- 
 sively diffused through the surrounding structures. In some 
 
124 
 
 A MANUAL OF SURGERY 
 
 cases there may be but little elevation of the growth, and the sur- 
 face is free from ulceration, constituting the variety known as the 
 ' parchment induration ' of Ricord, and not unfrequently seen on 
 the glans penis. Where, however, the prepuce or body of the penis 
 is involved, greater induration takes place, owing to the laxity of 
 the connective tissue. When affecting the base of the prepuce, 
 the induration tends to spread transversely, producing a collar- 
 like mass, which on retraction of the part rolls back en bloc in a 
 very characteristic manner. Examined microscopically, the new 
 formation consists merely of a mass of round and spindle cells 
 packed closely together, with a certain amount of intercellular 
 fibrous tissue ; giant cells are sometimes seen. The blood-supply 
 of the part is scanty, a fact which explains the readiness with 
 which ulceration occurs. Several chancres may be seen on the 
 same individual if the infection occurs at one time, and it is 
 possible that a patient could 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 Urethral Chancre is usually situated just within the lips of 
 the meatus, constituting a sore with an indurated base. It may 
 be felt as a hard nodule on grasping the urethra between the 
 fingers, and gives rise to a thin serous discharge, often blood- 
 stained. The orifice itself is sometimes the site of a chancre, and 
 the induration may completely encircle it. This condition is 
 very apt to be followed by a stricture. 
 
 Extragenital Chancres are often observed, perhaps most com- 
 monly on the lips, finger, and nipple ; but, of course, any part 
 of the body may become affected. They are usually characterized 
 by a greater amount of infiltration 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 ulcera- 
 tion occurs there is a greater amount of discharge, which forms a 
 thick scab over the surface. The neighbouring lymphatic glands 
 are enlarged, and sometimes surrounded by infiltrated tissue. 
 This condition has often been mistaken for epithelioma, from 
 which, however, it can be distinguished by the age of the patient, 
 the character of the sore, its rapid development, and the simul- 
 taneous enlargement of the glands. The course of the case is 
 generally more severe than when the primary lesion is in the 
 usual situation, a fact possibly explained by the disease remaining 
 unrecognised till secondary symptoms appear. 
 
 In surgeons or accoucheurs infection may occur on the fingers, 
 usually starting by the side of the nail. It gives rise to an 
 indolent sore, which becomes infiltrated and ulcerates, tending to 
 
INFECTIVE DISEASES 
 
 spread 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 malignant disease. 
 
 Phagedena is a form of spreading ulceration, rarely met with at the present 
 time, except in connection with venereal disease, and, according to most 
 authorities, seldom apart from syphilis. It always attacks unhealthy and 
 debilitated individuals, especially men with phimosis. The discharge, which 
 is abundant and sometimes offensive, is retained under the long foreskin, and 
 this, together with the end of the organ, becomes 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. 
 A similar condition is occasionally seen in connection with an inguinal bubo, 
 and then the integrity of the femoral vessels is threatened. 
 
 The Treatment consists in the relief of all tension by division of the foreskin 
 if that structure has not been already destroyed, followed by prolonged im- 
 mersion of the patient in a hot hip-bath, in order that the toxins may be so 
 diluted as to prevent any extension of the ulceration, and thus facilitate the 
 natural processes of repair. If the patient cannot be kept for twelve or twenty- 
 four hours in a warm bath, it will suffice to immerse him in warm water 
 for two or three hours every day. In the intervals the wound should be 
 dressed with iodoform, and covered with lint dipped in lotio nigra. Under such 
 circumstances, the surface of the sore quickly cleans, and becomes covered 
 with healthy granulations. 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 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. 
 They move freely under the skin and feel hard, like bullets, 
 pellets of cartilage, or almonds (hence the term ' amygdaloid ' 
 which has often been applied to them) ; they are usually quite 
 painless, and there is no tendency for them to suppurate if the 
 infection is purely syphilitic ; but if the original sore is septic, or 
 also inoculated with the virus of a soft chancre, an abscess often 
 follows, one or more of the inguinal glands breaking down, and 
 causing a painful, red, and brawny infiltration of the superjacent 
 integument. After a time the skin gives way, and is often found 
 extensively undermined. 
 
 Occasionally the lymphatic vessels extending from the sore to 
 the glands become the seat of a chronic lymphangitis, and may 
 be felt as hard cords beneath the skin. The dorsal lymphatic of 
 the penis is frequently blocked in this way, and gives rise to solid 
 or lymphatic oedema of the prepuce and glans. Should the 
 chancre suppurate, an abscess may form in the course of the 
 lymphatics. 
 
 The Diagnosis of a syphilitic from a soft sore is not always easy. 
 
12b A MANUAL OF SURGERY 
 
 Of course, where there is no ulceration, .and the typical induration 
 of the base can be felt, no doubt need arise. But when the 
 primary sore is septic, and an excavated ulcer is present, sur- 
 rounded by infiltrated and hyperaemic 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 syphilis. (See also on ' Soft 
 Chancre,' Chapter XXXVIII. ). In such cases it is often neces- 
 sary to wait for the development of secondary symptoms before a 
 decided opinion can be given. 
 
 The Duration of the primary sore varies in different cases, and 
 depends in great measure on whether treatment is commenced 
 early or late. If the case comes under observation during the first 
 six weeks, and a mercurial course is at once started, the chancre 
 heals, and the induration usually disappears in from six to eight 
 weeks. The glands in the groin, however, remain enlarged for 
 some time. The longer the case is left untreated, the more slowly 
 does the hardness disappear. If no mercury is administered at 
 all, 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 little scar results, 
 although a well-marked cicatrix may follow a soft or septic 
 chancre. 
 
 Re-induration of the cicatrix sometimes occurs from too early 
 a cessation of the mercurial course, or from some localized irrita- 
 tion, or from a fresh exposure to infection. It is occasionally due 
 to a tertiary or gummatous development, and will then be free 
 from lymphatic complications. 
 
 II. Secondary Syphilis. — In the secondary stage, the virus is 
 diffused generally throughout the body by means of the blood, 
 which is itself infective. A certain amount of constitutional 
 disturbance may exist, the patient feeling ' seedy ' and out of 
 sorts, whilst in some cases distinct febrile phenomena and head- 
 ache 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. The chief secondary manifestations consist in the 
 appearance of various forms of rash on the skin and mucous 
 membranes, associated with a general enlargement of the lym- 
 phatic glands, sore throat, mucous tubercles and condylomata, 
 loss of hair, and other less common phenomena, and these usually 
 show themselves in from seven to nine weeks from the time of 
 inoculation, although they may be delayed to a much later date. 
 Their intensity also varies considerably, the phenomena being 
 sometimes scarcely evident, and at others very marked. They 
 are also influenced greatly by the period at which the administra- 
 
INFECTIVE DISEASES 127 
 
 tion of mercury commences ; the earlier the drug is given, the 
 less obvious are the secondary phenomena. 
 
 The Cutaneous Eruptions of secondary syphilis are chiefly 
 characterized by the fact that, although any form of rash may be 
 simulated, no specially distinctive variety is originated. More- 
 over, in the same individual the eruption is not always of the 
 same character throughout, several distinct types developing in 
 separate parts of the body (polymorphism). The rash is usually 
 more or less symmetrical, the colour in the early stages being a 
 dusky red, resembling that of raw ham, whilst later on it becomes 
 of a more coppery hue ; occasionally, however, it may be a bright 
 rosy red. Syphilitic rashes do not completely fade on pressure, 
 but leave a brown stain, and give rise to but little irritation or 
 itching ; they always tend to progress from the simpler types, 
 due to hyperaemia, to the more serious, in which infiltration and 
 overgrowth are evident. 
 
 In the simplest form, merely a hyperaemia is present, some- 
 times appearing as a dusky mottling of the skin (roseolous 
 syphilide), which quickly fades, or may persist whilst other 
 types are developing. If distinct papillae become infiltrated and 
 hyperaemic, a papular syphilide is said to be present ; such may 
 become either vesicular or pustular, constituting the vesicular or 
 pustular syphilides ; the latter change is uncommon, and only 
 appears in bad cases or in debilitated patients. Another form of 
 eruption is the squamous syphilide, characterized by patches of 
 hyperaemia and infiltration, combined with superficial desquama- 
 tion. 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 (tubercular syphilide). 
 
 As to the situation of the rash, the roseola is usually limited to 
 the abdomen, whilst the other forms are often widely scattered 
 over the trunk and extremities, involving, however, the flexor 
 more than the extensor surfaces of the limbs. A somewhat 
 characteristic phenomenon 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 hyper- 
 aemic area being abruptly limited, and semicircular in outline ; 
 symmetrical ulceration usually follows, originating near the 
 anterior pillars of the fauces, and spreading thence to the tonsils 
 and along the soft palate to the uvula. These ulcers are shallow, 
 have sharply-cut edges, and often present a characteristic greyish 
 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 common at this 
 period of the disease. Smoking undoubtedly aggravates these 
 conditions. Concurrently with these manifestations in the fauces 
 
128 A MANUAL OF SURGERY 
 
 a number of bare patches from loss of epithelium 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. 
 
 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. Mucous Tubercles consist of slightly- 
 raised patches of enlarged and infiltrated papillae, white in appear- 
 ance from the superficial epithelium becoming sodden, and often 
 progressing to actual ulceration. Examined microscopically, the 
 papillae are found to be definitely enlarged, and the epithelium 
 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 (often due there to the irritation of rough teeth), 
 or the margin of the anus ; in the last-named situation they are 
 usually symmetrical, one side being infected from the other. They 
 are also not at all uncommon between the toes, and the ulcers 
 caused thereby become exceedingly offensive from septic con- 
 tamination. Condylomata are similarly the result of overgrowth 
 of the papillae, 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 cauli- 
 flower-like growth. They are most commonly seen about the 
 anus or vulva, in the former situation being often mistaken by 
 the patient for piles ; they give rise to an abundant, highly infec- 
 tive 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. The extent of the glandular com- 
 plication is possibly a measure of the degree of virulence of the 
 affection. The condition of the nuchal and epicondyloid glands 
 should always be ascertained in suspicious cases, since, if no 
 obvious local cause exists for their enlargement, syphilis is very 
 probably present. 
 
 Syphilitic 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 mem- 
 brane 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. 
 
INFECTIVE DISEASES 129 
 
 On examination a bright-red circular zone immediately surrounds 
 the cornea, resulting from hyperaemia 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 sometimes 
 entirely prevented by the formation of adhesions either to the 
 back of the cornea (anterior synechiae) or to the lens capsule 
 (posterior synechiae). Occasionally small yellowish nodules are 
 seen on its surface, consisting of plastic lymph. 
 
 The Duration of the secondary stage varies considerably in 
 different cases, and is largely influenced by the character of the 
 treatment and the period at which it is commenced. The sooner 
 the patient is brought judiciously under the influence of mercury, 
 the less severe the secondary phenomena, whilst cases in which 
 treatment has been delayed are likely to be much more trouble- 
 some. 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 and untreated. When 
 treatment is commenced within- four or five weeks of infection, 
 the secondary stage is slight, and all traces of its existence may 
 pass off in two months or less ; if mercury is not administered until 
 the cutaneous eruption has appeared, this stage is likely to last 
 longer. The condition of the patient's health is an important 
 factor, as also the previous habits, particularly as to temperance, 
 since syphilis always follows a more aggravated course in the 
 weakly and the dissipated. Even under the best circumstances, 
 the patient is liable to outbreaks of the affection within the first 
 twelve months. Relapses are by no means uncommon, being 
 usually due to intermissions in the treatment. The rash which 
 appears under these circumstances is often of a more charac- 
 teristic type, the papules being grouped into rounded or corymbose 
 figures. 
 
 III. The Intermediate or late Secondary Stage comprises a 
 group of symptoms which form a link between those already 
 described and the tertiary phenomena; and indeed 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 treatment has been 
 carried out regularly. Some of the secondary manifestations, 
 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. Deep lesions of the eye 
 (choroido-retinitis), and of the central nervous system (syphilitic 
 monoplegia), are not uncommon, the latter usually arising from 
 anaemia of the cerebral centres due to a syphilitic endarteritis 
 (p. 254). The principal cutaneous affection is the so-called 
 syphilitic psoriasis, most frequently seen on the palms and soles. 
 
 9 
 
»3° 
 
 A MANUAL OF SURGERY 
 
 A squamous syphilide is often observed in the secondary stage, 
 but is then symmetrical and readily influenced by mercury. In 
 this intermediate period, the lesion may be bilateral or limited to 
 one side, according to whether it appears early or late. In the 
 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 dis- 
 tinctly serpiginous in outline, and there is an infiltrated border. 
 
 Rupia and Ecthyma are both met with in this stage of the 
 disease. They are characterized by an infiltration of the skin, 
 which progresses to ulceration. In rupia the discharge forms a 
 distinct scab on the surface, which increases in thickness by the 
 
 Fig 15. 
 
 -Rupia of Face. (From Wax Model in Museum of Royal 
 College of Surgeons.) 
 
 deposit of successive layers one under the other, each being 
 somewhat larger than the one which precedes it ; hence a scab 
 shaped like a limpet-shell is produced, resting on an inflamed and 
 hyperaemic base (Fig. 15) ; 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, surrounded by an area of vivid congestion. 
 Under appropriate treatment these conditions disappear, but leave 
 depressed, whitish cicatrices, often surrounded by pigmentation. 
 
 A somewhat unusual intermediate manifestation is a subacute 
 symmetrical epididymitis, in which the cord also becomes 
 thickened, enlarged, and tender. 
 
INFECTIVE DISEASES 131 
 
 IV. Tertiary Syphilis. — -The phenomena occurring in this stage 
 may appear within six months of infection, or not for twenty 
 or thirty years. They are mainly characterized by infiltration 
 and overgrowth of the connective tissues of the body. Such 
 may occur in one or many places, and may be diffuse or localized. 
 In the former case the organ or part affected becomes enlarged, 
 hard, and sclerosed, and unless the condition is treated promptly, 
 the normal tissue of the part may entirely disappear, being 
 replaced by fibro-cicatricial tissue. If, however, 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 involved area becomes occupied by a round-celled infiltra- 
 tion, the cells being derived partly from proliferation of the 
 connective tissue, and partly from leucocytes. This gradually 
 increases in amount, the normal tissue of the part disappear- 
 ing before it. Very few vessels penetrate into the mass thus 
 formed, which otherwise somewhat resembles granulation tissue. 
 As the process extends peripherally, the older portion is trans- 
 formed into cicatricial tissue, and, finally, owing mainly to the 
 compression of the vessels by its contraction, and partly to a 
 concurrent syphilitic affection of the tunica intima of the nutrient 
 arteries (p. 254), the blood-supply of the centre of the gumma 
 fails, and the tissue dies. In this stage a gumma consists of 
 a central, whitish-yellow slough, devoid of vessels, formed by 
 the oldest portions of the growth in a condition of fatty degenera- 
 tion and necrosis ; surrounding this is a zone of loose vascular 
 fibro-cicatricial tissue, whilst the periphery of the tumour is con- 
 stituted by a round-celled hyperaemic infiltration of the normal 
 tissues of the part. Under appropriate treatment, the whole of 
 this new formation may disappear, being replaced by a fibrous 
 cicatrix ; but not unfrequently the central portion breaks down 
 into a gummy, semi-purulent fluid, which 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. Under exceptional circumstances the central 
 slough may become encysted by the formation of a fibrous capsule, 
 and calcification of the centre may even occur ; this is stated to 
 be most frequently found in the brain, testis, and liver. 
 
 Clinically, the appearances vary according to whether the 
 gumma is cutaneous or subcutaneous. 
 
 Cutaneous gummata (Fig. 16) are very frequently observed in 
 tertiary syphilis, especially in the earlier stages. They occur as 
 dusky-red nodules of firm consistency, and but slightly painful. 
 Many such growths are often grouped together in one region, and 
 when ulceration has occurred, they produce by their confluence 
 
 9—2 
 
'32 
 
 A MANUAL OF SURGERY 
 
 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. 
 
 Occasionally a diffuse infiltration of the skin is met with in this 
 stage, appearing as a red hyperaemic area with a rounded or 
 serpiginous border, and not at all unlike lupus in appearance. It 
 is readily amenable to treatment, and runs a much more rapid 
 course than lupus ; the edge is usually thickened to the same 
 extent all round, and there is but little tendency to the formation 
 of outlying nodules. The apple-jelly-like granulations, so typical 
 
 
 
 ^ 
 
 
 
 
 
 *»Mt~ - 
 
 
 JjKM 
 
 1 ■ 
 
 ■ .i^r- " ijLi-c^. 
 
 
 
 
 
 
 
 
 
 
 
 
 v, S(*f 
 
 
 d^ 
 
 
 ^^B 
 
 w 
 
 
 
 
 Fig. 16. — Cutaneous Gummata. 
 
 of lupus, are of course not present. A cicatrix is usually pro- 
 duced, even if ulceration has not taken place. 
 
 A subcutaneous gumma develops as a firm nodule, which gradually 
 increases in size, and sooner or later travels towards the surface ; 
 the centre of the tumour becomes elastic and fluctuating ; a 
 certain amount of pain and tenderness is noticed, and when 
 the skin is affected, it becomes dusky and even oedematous. 
 Ulceration follows, and the contents of the gumma thus escape. 
 The sore produced is deep, the edges being sharply cut, and 
 perhaps undermined ; the base of the ulcer consists of granu- 
 lation tissue, although it is sometimes covered by the charac- 
 teristic slough. 
 
 The peculiar features of tertiary syphilis, as it affects special 
 regions, will be described under the appropriate headings : vide 
 syphilitic diseases of arteries, of lymphatic glands, of muscles, 
 
INFECTIVE DISEASES 
 
 of bones, of joints, of the lips, of the pharynx, of the tongue, 
 of the larynx, of the rectum, of the testis. The symptoms arising 
 from gumma of the brain will be alluded to at Chapter XXIV 
 but the general relation of syphilis to the nervous system has 
 been purposely omitted, since it belongs rather to the physician 
 than to the surgeon. 
 
 The Prognosis of syphilis is good if the patient comes under 
 treatment at a sufficiently early stage, and if he has no idiosyn- 
 crasy which prevents the administration of mercury or iodide of 
 potassium. In persons suffering from extragenital chancres, which 
 are not recognised till late, the disease often runs a more than 
 usually severe course. The general health of the patient, and 
 perhaps a peculiar predisposition, may influence the evolution of 
 the case considerably, whilst the co-existence of tuberculous disease 
 may render the prognosis peculiarly unfavourable, especially when 
 the disease is inherited. The character of the rash, and the extent 
 of the general glandular enlargement in the secondary stage, may 
 perhaps give some indication of the gravity of the case ; where the 
 eruption is but slightly marked, the other symptoms are usually 
 mild, whilst a pustular eruption is almost always of grave import. 
 Death is rarely produced by any of the secondary manifestations, 
 but may occur in the tertiary stage, when important viscera, such 
 as the brain, spinal cord, liver, etc., are involved. 
 
 As to the Curability of syphilis, the general opinion held at 
 present is that, if the disease is seen early, and treated satis- 
 factorily, the patient will in all probability never suffer from any 
 further manifestations after the secondary symptoms have dis- 
 appeared. A cure can, however, never be definitely promised, 
 since, should the general health of the patient become impaired, 
 characteristic syphilitic phenomena may make themselves evident 
 even thirty or forty years after the primary lesion. There is also 
 no doubt that certain cases are to be looked on as absolutely 
 incurable, owing probably to the fact that they were not brought 
 under treatment until tertiary phenomena were present ; such are 
 usually seen amongst females. 
 
 The Treatment of syphilis consists in the administration of 
 mercury during the primary and secondary stages, and of iodide 
 of potassium, with or without mercury, in the late secondary and 
 tertiary periods. 
 
 Many different methods have been suggested for the administra- 
 tion of mercury, in order that the patient may derive the greatest 
 amount of benefit from the drug with the minimum of incon- 
 venience, (a) It is usually given by the mouth, either in the form 
 of pills composed of grey powder (grs. i. — iii., t.d.s.), or of the 
 green iodide (gr. ^ — i, t.d.s.), or as a mixture containing a 
 solution of corrosive sublimate. The last method is distinctly 
 objectionable, inasmuch as its prolonged use in sufficient doses 
 disturbs the digestion. Grey powder is perhaps the best means 
 
i 3 4 A MANUAL OF SURGERY 
 
 of giving the drug ; the patient should commence with 2 grains, 
 given three times a day, or in some cases ij grains four times a 
 day, combined with a little extract of opium or pulv. ipecac, co. 
 if there is any tendency to diarrhoea ; but this addition is not 
 always needed. This should be cautiously continued until all 
 prominent signs of the disease have disappeared, and then the 
 dose is gradually reduced, (b) Inunction of the mercurial ointment 
 is also frequently adopted, and with great success, inasmuch as it 
 is less likely to cause digestive derangements. 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 some- 
 what smaller amount is required. Possibly this is one of the best 
 ways of bringing a patient rapidly under the influence of the drug. 
 (c) Mercurial vapour baths may be advantageously employed 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 containing about 1 ounce of 
 water. The water is boiled, and the calomel sublimed, by means 
 of a spirit-lamp placed under the chair. In about twenty minutes 
 all the calomel will be volatilized, and deposited in part upon the 
 skin of the patient, who perspires freely during the process. He 
 then gets into bed between warm blankets, without wiping the 
 skin. This treatment may be combined with medication by the 
 mouth, (d) Mercury is sometimes administered by subcutaneous 
 injections, in the form of the perchloride, | grain or less being 
 injected once or twice a week into the substance of the gluteus 
 maximus. A little thickening of the site of injection results, but 
 quickly passes away, and suppuration scarcely ever follows. 
 
 During the course of mercury, the patient's general health and 
 habits must be carefully regulated, all excesses in drink and diet 
 being forbidden, and strict instructions given as to keeping the 
 teeth and gums clean. To minimize the risk of throat and mouth 
 trouble, it is wise to stop all smoking for at least six months. 
 The dose required varies in different individuals, being increased 
 in robust people, and diminished in those who are weak or un- 
 healthy. It should always be pushed until mild physiological 
 effects are produced in the shape of slight 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. 
 
 Although symptoms of excessive mercurialism are generally 
 induced by overdoses of the drug, yet in some people a very 
 small dose suffices to produce severe effects ; the existence of 
 this idiosyncrasy must not be forgotten, and large doses should 
 
INFECTIVE DISEASES 
 
 J 35 
 
 never be administered without first ascertaining whether or not 
 the patient can tolerate them. When mercury is producing 
 toxic effects, the gums become soft and spongy, and bleed readily 
 on pressure. Salivation follows, and even acute glossitis may be 
 produced, whilst the breath is always exceedingly offensive. In 
 worse cases the teeth become loose, and even necrosis of the 
 alveoli has been known. Derangements of the digestion, in the 
 shape of colicky pain and diarrhoea, are also observed. The 
 treatment of this condition consists in suspending the administra- 
 tion of the drug, 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 
 is the removal of gummatous tissue, but that it has no other 
 influence upon the course of the disease ; in order to prevent 
 recurrence of the trouble, mercury is still required. The dose of 
 iodide should not exceed 5 grains to start with, and is gradually 
 increased until in some cases 1 drachm four times a day has been 
 reached. A feeling of depression and sinking at the epigastrium 
 is often produced, but may be alleviated by the addition to the 
 mixture of sal volatile (11\_. xv.) or carbonate of ammonia, as 
 suggested by Sir James Paget. Symptoms of coryza may follow, 
 and an acneiform eruption over the shoulders and face, which, 
 however, often disappears on increasing the dose. Sometimes 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, and plenty of water should always be taken im- 
 mediately afterwards to assist in its dilution and facilitate its 
 absorption. The iodides of sodium and ammonium are some- 
 times substituted for the potassium salt, on the plea that they 
 give rise to less depression. 
 
 Other drugs, such as sarsaparilla 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 is usually treated with lotio nigra on lint, iodoform being 
 sometimes employed if septic ulceration is present. Mucous 
 tubercles in the neighbourhood of the anus or vulva, or between 
 the toes, are best dealt with by keeping them scrupulously clean 
 and dusting them over with powdered calomel, or by the applica- 
 tion 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 
 
l 3 G A MANUAL OF SURGERY 
 
 bad cases calomel may be placed on a hot copper coin, and its 
 vapour inhaled. Superficial gummatous ulcers are treated by re- 
 moving the scabs, and applying some form of mercurial oint- 
 ment. A determined attempt should be made to keep deep gum- 
 matous ulcers in an aseptic condition, 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 even 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 antisepti- 
 cally, or their cavity stuffed with lint or gauze soaked in lotio 
 nigra. 
 
 Inherited or Congenital Syphilis. 
 
 Syphilis may be conveyed to the ovum either by direct trans- 
 mission from the father or mother alone, or both parents may 
 be tainted with the disease. Occasionally the mother acquires 
 syphilis during pregnancy, and in such cases the foetus also 
 becomes affected. In those instances where the ovum is infected 
 from the father, whilst the mother has escaped, the latter becomes 
 in measure protected, so that, if the child is put to her breast, she 
 does not contract the disease, even though there are ulcerating 
 lesions on the child's gum and lips ; healthy wet-nurses are 
 invariably infected {Colics' s Law). Whether the immunity is 
 permanent or not is still a matter of uncertainty, and even the 
 inviolability of this law has recently been called in question. 
 
 The length of time during which the patients retain 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 it is safe 
 for a syphilitic patient to marry. The rule of practice generally 
 followed is that no one suffering from syphilis should be allowed 
 to marry until he or she has been free from all symptoms for at 
 least twelve months, and even then it is advisable that a mild 
 course of mercury should be given for about three months shortly 
 before marriage. 
 
 A syphilitic foetus often fails to arrive at maturity, the mother 
 miscarrying at the end of six or seven months. This is probably 
 due to a specific affection of the endometrium, especially involv- 
 ing that portion of the decidua which enters into the formation 
 of the placenta. The circulation and nutrition of the foetus are 
 thereby impaired, so that it is usually born not only dead, but 
 in many cases macerated, and partially decomposing. This may 
 be repeated for several pregnancies, and then a living child is 
 produced. In many cases, however, a living child is born at 
 
INFECTIVE DISEASES 
 
 '37 
 
 full time at the end of the first pregnancy, in spite of the 
 syphilitic infection of the parents. 
 
 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 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 tends to persist for a con- 
 siderable time. Speaking generally, the symptoms of inherited 
 syphilis are similar to those of the acquired disease, except that 
 
 Fig. 17. — Child with Inherited Syphilis, showing Radiating Scars 
 round the Mouth. (From a Photograph kindly lent by Dr. 
 G. F. Still.) 
 
 the primary lesion is absent. Thus, during the first year of life 
 the child develops various cutaneous eruptions, mucous tubercles, 
 and superficial ulcerations 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 surfaces, which, 
 by their subsequent cicatrization, leave radiating scars (or 
 rhagades), especially about the angles of the mouth (Fig. 17). 
 Other cutaneous affections, such as squamous syphilides of the 
 
138 
 
 A MANUAL OF SURGERY 
 
 soles of the feet, together with papular syphilides of the body, and 
 a bullous eruption becoming pustular (pemphigus), are also 
 observed, the last mentioned, however, only occurring in de- 
 bilitated infants. A catarrhal rhinitis is a very early and constant 
 manifestation, giving rise to obstructed nasal respiration, or 
 snuffles. This affection is often protracted, going on to ulceration 
 and destruction 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 
 
 Fig. 18. — Head and Face of a Patient with Inherited Syphilis, showing 
 Depressed Bridge of Nose and Frontal Bosses. (From a Photo- 
 graph.) 
 
 reached (Fig. 18). 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 manifesta- 
 tions described above disappearing, although their scars may 
 remain. The child's subsequent development is frequently im- 
 paired, and it often retains an almost pathognomonic facies. 
 
 After the first year, any of the tertiary phenomena which appear 
 in acquired syphilis may develop, but, in addition to these, peculiar 
 manifestations may be produced, especially affecting the teeth, 
 bones, and cornea. 
 
INFECTIVE DISEASES 
 
 »39 
 
 The Teeth in inherited syphilis are sometimes very char- 
 acteristic. The temporary teeth usually appear early, are 
 discoloured, and crumble away. The permanent teeth are often 
 sound 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. The enamel is 
 often imperfectly developed, and hence they decay early. Occa- 
 sionally 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 
 1 Hutchinson's teeth,' but they are not very commonly seen at the 
 present day. 
 
 The Bone affections observed in inherited syphilis will be de- 
 scribed at Chapter XVIII. 
 
 Interstitial Keratitis, or diffuse inflammation of the cornea, 
 usually occurs about the age of puberty, or earlier. 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 something 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 ulcera- 
 tion, but in protracted cases the anterior part of the eye may bulge 
 forwards, constituting a condition known as ' anterior staphyloma.' 
 The inflammation may spread to the iris and ciliary body. With 
 suitable precautions the cases usually do well, although treatment 
 for several years may be necessary. 
 
 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 must 
 it be given to a wet-nurse. Mercury is best administered by 
 anointing the under surface of the flannel belly-band with mer- 
 curial ointment, or the same preparation may 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. Cod-liver oil may also be ordered with 
 advantage in some cases. When tertiary symptoms appear, 
 iodide of potassium and mercury may be given in a mixture, in 
 suitable doses. 
 
 The local treatment of external lesions is conducted according 
 to the rules laid down for the acquired type of the disease. 
 
i 4 o A MANUAL OF SURGERY 
 
 Tuberculosis. 
 
 By tuberculosis is meant a condition resulting from the develop- 
 ment within the tissues of the body of certain definite anatomical 
 structures, known as tubercles, and caused by the growth and 
 activity of the Bacillus tuberculosis. Before the fact was established 
 that such lesions were due to a micro-organism, they were usually 
 termed strumous or scrofulous, and even at the present day these 
 two names are occasionally employed to indicate that condition 
 of constitutional weakness which predisposes to the appearance of 
 tuberculous disease. It is better, however, to avoid the use of 
 such misleading terms. 
 
 .^Etiology. — i. The individual is often predisposed to the develop- 
 ment of this disease by some inherited weakness, as indicated by 
 the fact that parents, relations, or ancestors have suffered from 
 some similar affection, or that it has occurred in other branches 
 of the same family. It is becoming doubtful, however, whether 
 heredity plays such an important part as was formerly attributed 
 to it, and whether the disease is not much more commonly due to 
 direct infection. Considerable ingenuity has been exercised in 
 describing various types of physiognomy supposed to be charac- 
 teristic of a tuberculous inheritance, and although not always 
 present, these appearances are not unfrequently observed. Two 
 chief varieties are described, viz., the sanguine and the phlegmatic. 
 In the former, the individual is slight and well proportioned, 
 possessing a thin, delicate skin, often freckled, and so transparent 
 that the subcutaneous veins are readily seen. The hair is fine 
 and auburn-coloured, or even reddish, the conjunctivae are thin 
 and pearly, the eyelashes well developed, and the fingers long 
 and tapering. Such children are usually excitable and precocious 
 in their habits, and possess taking manners. The phlegmatic type 
 is characterized by a short, stunted stature, with somewhat coarse 
 features, and strong though somewhat short limbs. The skin is 
 coarse and muddy-looking, the lips thick, the hair rough and 
 brown. In children of either type there is a considerable tendency 
 to the development of eczema, inflammation of the mucous mem- 
 branes, and a subacute enlargement of the lymphatic glands, all 
 of which are simple in nature, but may constitute a suitable nidus 
 for the development of tubercle, especially if the child is run down 
 by some preceding illness, such as measles or scarlet fever. They 
 also suffer frequently from cracked lips, and as a result of the 
 irritation caused thereby considerable infiltration and thickening 
 may follow. Although tuberculous disease is most frequently 
 seen in young people or children, no age is exempt from its 
 attacks, even elderly persons being affected by what is known 
 as ' senile tuberculosis.' These senile manifestations differ in no 
 way from those met with in the young. 
 
INFECTIVE DISEASES 
 
 141 
 
 2. Unhealthy surroundings and bad hygiene certainly predispose to 
 its development ; hence it is seen, perhaps, in its severest forms 
 amongst the poor, although it is only too common amongst the 
 rich, arising usually from improper feeding and want of fresh air 
 in the case of children, and not unfrequently from faulty hygiene 
 or carelessness, especially as to judicious clothing, in adults. 
 
 3. A local nidus suitable for the development of the micro- 
 organism usually exists, although tuberculous infection occasion- 
 ally follows wounds and punctures in previously healthy parts. 
 Thus, as already mentioned, lymphatic glands in a condition 
 of chronic enlargement and hyperemia form a suitable breeding- 
 ground for the bacillus, as also bones and joints which are in a 
 state of congestion as a result of slight and often overlooked 
 injuries. 
 
 4. The ultimate exciting cause of tuberculosis is the develop- 
 
 Fig. 19. 
 
 -Bacillus Tuberculosis in and around Giant Cell. 
 shank's 'Textbook of Bacteriology.') 
 
 (Crook- 
 
 ment within the tissues of the Bacillus tuberculosis (Fig. 19). This 
 organism, which was originally isolated by Koch, is always present, 
 though not always recognisable, in the products of the disease. 
 It exists in the form of fine straight rods, the individual bacilli 
 being 2 [x to 5 \i in length, and "i /x to 3 //. in breadth. They are 
 always cultivated artificially with difficulty, growing best on 
 glycerine agar-agar, and only slowly on coagulated blood serum 
 at the temperature of the body. The colonies produced consist 
 of yellowish -white or greyish scales, more or less cheesy in 
 appearance. The organism gains admission to the system either 
 through some abrasion of the skin, or by the digestive tract with 
 some article of food, especially milk, or by inhalation, its presence 
 in the dust of rooms occupied by phthisical individuals having 
 been frequently demonstrated, and being due to the dessication of 
 the sputum. 
 
 The infective nature of the disease has been abundantly 
 
i 4 2 A MANUAL OF SURGERY 
 
 demonstrated by clinical and experimental work during the last 
 few years. Thus, it can be readily transmitted by inoculation to 
 animals, especially to rabbits and guinea-pigs, the anterior chamber 
 of the eye of the rabbit being a very favourite spot, owing to the 
 fact that the growth of the characteristic neoplasm can be readily 
 watched, and that spontaneous tuberculosis never occurs in this 
 region. Transmission of the disease to the human subject has 
 frequently occurred from direct inoculation through a puncture or 
 abrasion of the skin, as in the case of surgeons whose fingers have 
 been wounded whilst operating on tuberculous cases. The risk 
 of living with phthisical patients, or of occupying their rooms 
 without previous thorough disinfection, is also fully admitted at 
 the present day. 
 
 Pathological Anatomy. — The tuberculous process consists in the 
 development of the so-called grey or miliary tubercles, which run 
 together, and produce larger masses, and these undergo secondary 
 changes, whilst the tissues invaded become inflamed and gradually 
 disappear, being replaced by pulpy granulation tissue, in the midst 
 of which the tuberculous foci can be seen. 
 
 Miliary tubercles can be recognised by the naked eye as greyish, 
 semi-translucent nodules, rarely exceeding a millet-seed in size. 
 The process which leads to their formation almost always com- 
 mences in or around the small vessels, and can perhaps be best 
 studied in the pia mater. The bacilli are presumably brought to 
 some area of lowered vitality, settling in the tunica intima. This 
 leads to an overgrowth of the endothelial elements — i.e., to an 
 endarteritis, which may spread for some distance — and this in 
 turn is followed by a proliferation and infiltration of the surround- 
 ing connective tissues, resulting in the obliteration of the affected 
 vessel, and the formation of the characteristic tuberculous nodule. 
 In the earlier stages all that is seen is an ill-defined mass of con- 
 nective-tissue cells, distinctly nucleated, and aggregated around a 
 bloodvessel, thus giving rise to no very characteristic appearances. 
 The structure of a fully-developed tubercle (Plate III., Fig. i) is as 
 follows : In the centre lies a giant cell, containing a large number 
 of nuclei, which are often arranged around its periphery, or grouped 
 together at one or other pole. Delicate processes extend from the 
 giant cell, and form a fine network, in the meshes of which are 
 situated the cells of the surrounding zone. These are rather 
 larger than ordinary leucocytes, with a granular protoplasm and a 
 clearly-defined oval nucleus. They are known as epithelioid cells, 
 although they are derived from the neighbouring connective 
 tissues, and are, in fact, identical with fibroblasts. Around them 
 are collected a large number of smaller cells, probably leucocytes, 
 and these merge into the surrounding structures, which are 
 gradually changed into granulation or fibro-cicatricial tissue. • In 
 many cases the giant cell is absent, and, indeed, it must in no way 
 be looked upon as a characteristic feature of tubercle, since such 
 

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INFECTIVE DISEASES 143 
 
 cells are often met with in syphilis and other conditions where 
 active tissue changes are taking place. Its origin is a little 
 doubtful, but it is probably derived from an enlargement of one 
 connective-tissue corpuscle, or by the union of several such cells. 
 No vessels are present in the tuberculous neoplasm, and as a result 
 degenerative changes are certain to follow. Not unfrequently a 
 number of these tubercles develop close together, and under these 
 circumstances the intervening structures disappear, being re- 
 placed by granulation tissue, which may in part become further 
 transformed into cicatricial tissue. By the use of appropriate 
 staining reagents it can be demonstrated that bacilli are present 
 in the giant cell, and sometimes in the zone of epithelioid cells 
 surrounding it (Fig. 19), but as soon as degenerative changes 
 commence, the organisms can no longer be recognised. 
 
 If the disease progresses, caseation always ensues, owing 
 partly to the defective nutrition of the neoplasm, partly to the 
 specific action of the bacillus or its products. Not only does 
 the centre of the miliary tubercle undergo this change, but also 
 the granulation tissue around or between the separate nodules. 
 A caseating focus of yellow or crude tubercle, as it used to be 
 termed, consists of a degenerating centre surrounded by a zone of 
 granulation or fibro-cicatricial tissue, in which are scattered 
 miliary tubercles, and which in turn gradually runs into normal 
 tissue (Plate III., Fig. 2). 
 
 The ultimate result of this process depends to a large extent on 
 the general health of the individual and the treatment which is 
 adopted. 
 
 1. If the parts are kept at rest, and free from external irrita- 
 tion, and if the constitutional weakness is combated by suitable 
 measures, the destructive process may come to an end. In 
 such a case the peripheral layer of granulations is converted into 
 dense fibro-cicatricial tissue, which forms a sort of capsule, and 
 checks the advance of the disease. The caseous material is either 
 removed by an invasion of leucocytes, or becomes calcified, usually 
 leaving a firm fibrous nodule, perhaps interspersed with calcareous 
 particles. Possibly some of the tuberculous material persists in a 
 latent state in this mass, like an ' extinct volcano,' ready to be 
 lighted up into activity if the opportunity is given. In less 
 advanced cases the diseased tissue may be so completely removed 
 as to leave scarcely any trace of its existence behind. 
 
 2. The caseous material is often transformed into a yellowish 
 fluid, usually known as pus, by a process of emulsification, due to 
 the absorption of fluid from the hyperaemic tissues around, and 
 resulting either from mechanical causes, or more probably from 
 the activity of the tuberculous organisms, or possibly from infec- 
 tion with ordinary pyogenic or septic bacteria. In such cases a 
 chronic or subacute tuberculous abscess results, the structure and 
 characters of which have been already described (p. 50). 
 
i 44 A MANUAL OF SURGERY 
 
 One of the chief features of tuberculous disease is its great 
 tendency to diffusion. This may occur (a) locally, by direct con- 
 tinuity of tissue, or by extension along neighbouring lymphatics or 
 bloodvessels ; or (b) distant viscera or organs may become infected, 
 probably through dissemination by the bloodvessels. Thus 
 phthisis is a not uncommon sequence of a similar affection of 
 bones, joints, or lymphatic glands, whilst meningeal tuberculosis 
 is more frequently associated with tuberculous affections of the 
 genital organs, (c) Moreover, any tuberculous lesion may lead to 
 acute general tuberculosis, in which the disease is scattered 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 few weeks. 
 
 Treatment. — It must be fully recognised that tuberculosis is an 
 infectious, and therefore, to a large extent, a preventable disease, 
 and it is the duty of all medical practitioners to do everything in 
 their power to limit its ravages. We cannot here enter into this 
 subject, but would merely mention the dangers to the general 
 public arising from the distribution of milk obtained from tuber- 
 culous cows, and from the indiscriminate expectoration of tuber- 
 culous sputum. 
 
 Curative treatment is based on the assumption that natural 
 processes of repair have a considerable influence upon the course 
 of the disease. When Koch first discovered the bacillus, a great 
 impetus was given to surgical treatment, and some authorities 
 went so far as to maintain that it was as necessary to extirpate 
 every particle of diseased tissue as in a case of cancer. The 
 pendulum has now slowly swung back, and we are more and 
 more endeavouring to promote healthy repair of the lesions by 
 constitutional measures. The value of an abundance of fresh air 
 is fully admitted, and many sanatoria for the open-air treatment of 
 phthisis and other tuberculous lesions are being built or planned. 
 In this country residence by the seaside, especially in such bracing 
 places as Margate, or, if that be too cold, Ramsgate, Bournemouth, 
 or Ventnor, is usually recommended. At the same time, plenty 
 of good food, such as milk and eggs, must be taken. Local foci 
 should be kept at rest, and, if the disease is external, elevation 
 and steady pressure (as by Scott's dressing) are desirable acces- 
 sories. On the other hand, if a tuberculous lesion is sufficiently 
 localized and suitably situated, as when it occurs in the lymphatic 
 glands of the neck, total excision is the ideal treatment, although 
 one has sometimes to be satisfied with scraping. In this process 
 the possibility of disseminating the disease by too vigorous 
 manipulations must not be overlooked. Any open tuberculous 
 sores should be well scraped, and the surface then swabbed over 
 with liquefied carbolic acid, and dressed with gauze soaked in an 
 iodoform emulsion. 
 
INFECTIVE DISEASES 145 
 
 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.). 
 
 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. It is charac- 
 terized by the development of inflammatory swellings under the mucous 
 membrane of the respiratory tract, which break down and ulcerate, and by 
 the formation of similar growths, embolic in origin, in the lungs and other 
 viscera, which go on to abscess formation. 
 
 There is now no doubt that the disease is due to a definite micro-organism, 
 the Bacillus mallei, which was isolated about 1882 by Schutz and Loffler, and 
 has since been cultivated outside the body ; the experimental evidence as to its 
 being the cause of the malady is quite 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 destruction of the bones and cartilages. The lymphatic glands, 
 especially those under the jaw, early become enlarged, constituting the ' farcy 
 buds' of farriers, and by their ulceration may leave ragged, foul 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, usually ending in suppuration. 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 inflamed. An eruption of papules, 
 which somewhat resemble 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 ecthy- 
 matous-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 sub- 
 jacent bone. Similar changes occur in the viscera, muscles, and joints, and 
 these being associated with high fever of an asthenic type, may suggest the 
 existence of pyaemia. In such cases death may ensue in seven to ten days. 
 
 In Chronic Glanders simikr symptoms are met with, but the course is 
 slower ; there is little or no fever ; the disease is less extensive, and inter- 
 missions 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 commonly 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 
 undertake 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 more extensively involve the subcutaneous tissues, and by the 
 absence of umbilication. Chronic cases resemble syphilis and tuberculosis, but 
 the history of exposure to infection from animals suffering from the disease is 
 most important, as also the result of cultivations made from the discharge. 
 
 10 
 
146 
 
 A MANUAL OF SURGERY 
 
 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 also be used 
 for diagnostic purposes, an injection of a minute dose causing a sharp febrile 
 reaction if glanders is present. 
 
 Treatment in acute cases can be of use only when undertaken early, and 
 before general infection has ensued. The local foci should be thoroughly 
 extirpated, either by the knife, or by scraping and applying some active 
 cauterizing agent. The same treatment must be adopted in chronic cases, 
 and may then need frequent repetition. 
 
 Leprosy. 
 
 Leprosy (syn. : lepra, or elephantiasis Gracomm) is a general infective disease 
 due to the Bacillus lepra;, characterized by the formation of granulation-like 
 neoplasms, which arise primarily in connection with the skin and nerves. 
 
 The bacilli of leprosy closely 
 resemble those of tubercle, being 
 4 to 6 /( long and 1 n broad (Fig. 20). 
 They are stained by most of the 
 ordinary methods of demonstrating 
 bacteria, and are found in abund- 
 ance in the tissues ; but the disease 
 has not yet been transmitted to 
 animals. 
 
 Leprosy, though formerly common 
 in this country, is now but rarely 
 seen, and has then been imported. 
 In Iceland, Norway, Russia, and the 
 East it is still frequently met with, 
 although the compulsory separation 
 of lepers enforced in Norway is 
 much diminishing the number in 
 that country. It is apparently con- 
 tagious, though with ordinary care 
 infection may be avoided ; but in 
 the exhalations and secretions bacilli 
 are abundant, at any rate in the 
 later stages. Opinions differ as to whether or not it is transmitted by 
 heredity, but probably this is not the case. 
 
 Symptoms. — Two cnief 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 in 
 Europe. Nothing may be noticed for months or years after exposure to the 
 contagion, and then, after a period of malaise, associated with dyspepsia, 
 diarrhoea, and drowsiness, a distinct febrile attack is noted, lasting for days 
 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, hyperaemic spots, which are from the first infiltrated, slightly 
 raised, and hyperaesthetic ; they are usually situated on the forehead or 
 cheeks, on the outer side of the thighs, or on the front of the forearms. They 
 may 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 little pink nodules form 
 over the site of one or more of the erythematous patches, and these gradually 
 
 Fig. 20. — Leprosy Bacilli contained 
 within Epithelial Cells. 
 
INFECTIVE DISEASES 147 
 
 increase in size and coalesce, until possibly they 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. 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 de- 
 pressed and pigmented cicatrices, or ulceration may ensue. Visceral com- 
 plications and enlargement of the lymphatic glands follow, any fresh deposit 
 being associated with febrile phenomena. The testes atrophy, and sexual 
 power is lost in both sexes. Death is usually due to septic phenomena, 
 laryngeal 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 through 
 them are numbers of large cells, containing multitudes of bacilli (Fig. 20). 
 Considerable difficulty exists in cultivating these organisms, but Ducrey has 
 succeeded by using an alkaline medium, and excluding air 
 
 Fig. 21 — Leprous Hand. (From Wax Model in Museum of Royal 
 College of Surgeons.) 
 
 Anaesthetic, or Non-tuberculated, Leprosy is the most common form met 
 with in hot climates. The earliest phenomena consist in a certain amount of 
 malaise without appreciable fever, 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 finally to paralysis, various 
 modifications of sensation, and trophic phenomena, involving at first only the 
 skin, but later on attacking bones, joints and muscles. Circular yellowish- 
 white patches are observed in the skin, spreading peripherally, and tending to 
 run together, forming large irregular ovals; the border is often 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 becoming 
 markedly ' clawed,' as in ulnar paralysis (Fig. 21). 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 ankylosis of the 
 joints. The affected nerves can usually be felt distinctly enlarged and tender. 
 Visceral lesions are 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, 
 whilst 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. 
 
 IO — 2 
 
148 A MANUAL OF SURGERY 
 
 The Treatment is still very unsatisfactory. Chaulmoogra oil, administered 
 both internally and externally, is the drug most frequently depended on, but 
 latterly intra-muscular injections of corrosive sublimate have been employed 
 with some success. 
 
 Actinomycosis. 
 
 Actinomycosis is a disease mainly of cattle, but occasionally seen in man, 
 due to the growth of the ray fungus (streptothrix actinomyces) . 
 
 The fungus is transmitted to animals with their food, having been found 
 most often within the husk, or sheath, of barley. It usually attacks the tongue 
 or jaw, turning these into hard infiltrated masses (the ' wooden tongue ' or 
 ' big jaw ' of cattle), in which, after a time, suppuration appears at many foci, 
 producing multiple abscesses, which discharge externally, and leave a diffuse 
 inflammatory mass riddled with sinuses. The pus from such abscesses is of 
 
 Fig. 22. — Actinomyces in Tissues. (From Crookshank's ' Textbook of 
 Bacteriology.') 
 
 the usual type, but in addition contains firm yellowish gritty bodies, which 
 can be isolated by the fingers, and consist of masses of the fungus, perhaps 
 undergoing calcareous changes. On microscopic examination of these collec- 
 tions one finds in the interior an abundant mycelial development, in the 
 centre of which are observed numerous small rounded bodies, probably 
 conidia. The fibres, which are arranged more or less in a concentric fashion, 
 terminate peripherally in a layer of radiating, club-shaped bulbous processes, 
 arranged in a more or less symmetrical fashion ; these enlargements are not 
 spores, as was originally taught, but are merely due to a hyaline degeneration 
 of the sheaths of the filaments (Fig. 22). 
 
 In Man the disease occurs much more commonly than was expected when 
 attention was first drawn to it, and is probably due to direct inoculation with 
 the fungus from chewing or eating fresh corn, or by inhaling the spores with 
 dust during the process of grinding corn. It has been found in the tongue 
 and maxilla, causing diffuse induration and suppuration ; in the lungs, giving 
 rise to destructive lesions very similar to those of tuberculosis, and perhaps 
 ending in localized empyemata; in various parts of the intestinal canal, 
 
INFECTIVE DISEASES 
 
 149 
 
 especially about the caecum ; in the liver, giving rise to a very characteristic 
 reticulated swelling, in which diffuse suppuration occurs ; and in the skin. 
 Wherever situated, the same pathological phenomena manifest themselves, 
 viz., either the formation of a localized tumour, in the jaw possibly simulating 
 an epulis, or of a diffuse infiltrating mass, in which abscesses form ; great 
 destruction of tissue is likely to result. The bones are affected equally with 
 the soft parts, and may become carious. In itself the process is not dangerous, 
 but may become so by involving important organs, or by septic contamina- 
 tion. The commonest site for it is close to the angle of the jaw (Fig. 23), 
 constituting a cervico-facial tumour, the appearance of which is tolerably 
 characteristic. 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 yel- 
 lowish 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 actinomy- 
 cotic nodules can be 
 demonstrated. "When 
 all the fungus has 
 been discharged, the 
 abscess contracts, and 
 the wound closes. 
 The cicatrization in- 
 duced by the constant 
 repetition of this pro- 
 cess makes the surface 
 of the mass curiously 
 nodular and puckered, 
 and this condition, when present, is almost pathognomonic. Trismus is an 
 exceedingly 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 nerves. 
 
 The Treatment most recently advised consists in the administration of large 
 doses of iodide of potassium (grs. 20 or 30 three times a day), which seems 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 seres are present, 
 surgical measures must also be employed. Extirpation of all the infiltrated 
 tissue, either by the knife or by vigorous scraping, should be undertaken, and 
 the part freely cauterized ; in fact, it must be treated in exactly the same 
 way as a diffuse tubercular mass. This can, however, only be very partially 
 carried out in the visceral affections. 
 
 Fig. 23. — Cervico-Facial Actinomycosis. (By kind 
 Permission of Mr. Malcolm Morris.) 
 
CHAPTER VII. 
 
 TUMOURS AND CYSTS. 
 
 Although the term 'tumour' is often used for any abnormal 
 swelling which may be met with in the body, yet for 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 it 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, may dis- 
 appear completely, and often diminish in size temporarily. Pure 
 hypertrophies 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 tissues, 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. 
 
 As to the Causes of tumours, but little is known. Probably 
 they are all in the first instance local developments, and may be 
 lighted up by some form of injury or irritation, which determines 
 abnormal development of some of the tissues of the part. Thus, 
 a blow on the breast is often responsible for an adenoma ; the 
 irritation caused by smoking a clay pipe may produce epithelioma 
 of the lip, and many other illustrations readily suggest themselves. 
 Moreover, even if, as supposed by some pathologists, the carcino- 
 mata and sarcomata result from infection, it is probable that some 
 local irritation or breach of surface is needed to allow entrance 
 to, or determine the activity of, the organisms. The hereditary 
 nature of some malignant tumours is sometimes thought to be 
 evidence of a constitutional origin ; but although it may indicate 
 a predisposition of the patient to their development, some local 
 condition is usually found to determine it. Cohnheim has sug- 
 gested that tumours may be due to excessive growth in small 
 portions of undeveloped and undifferentiated embryonic material, 
 
TUMOURS AND CYSTS 151 
 
 or, as he terms them, foetal residues, left among the normal tissues. 
 These remain in a condition of suspended activity, until some 
 local lesion excites their development. As an illustration may be 
 mentioned the fact that many branchial cysts do not appear till 
 adult life ; evidently the embryonic cells were present from birth, 
 but required some special stimulus to call them into activity. It 
 is also probable that the presence of cartilage in many tumours of 
 the parotid and testis may be explained in a similar way ; in the 
 former case it is due to the inclusion of a portion of Meckel's 
 cartilage; in the latter, to the fact that the testis develops in 
 the posterior abdominal wall not far from the notochord, and 
 evidently cartilaginous cells from the protoyertebrse developed 
 around this structure become included within it. 
 
 Tumours may be divided into two great classes from a clinical 
 standpoint, viz., the benign and the malignant. 
 
 Benign or Simple Tumours are characterized by the develop- 
 ment being strictly local, by their more or less exact limitation, 
 being frequently encapsuled, and by their method of growth, 
 which results from a proliferation of all the cells constituting their 
 structure. There is no tendency to infiltrate or invade surround- 
 ing tissues, which are merely pushed aside and compressed ; 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 and development of the mass ; hence enucleation 
 is easy, and recurrence uncommon. They are not unfrequently 
 multiple, and may be hereditary : but these characters are no 
 evidence of a constitutional taint. 
 
 Malignant Tumours, unless removed by operation, are almost 
 invariably fatal. The following are the chief characteristics of 
 malignancy : (1) The primary growth is usually single, rarely 
 multiple. (2) It progresses steadily and constantly, but with 
 varying rapidity in different cases. (3) The local development is 
 characterized by an infiltration of the surrounding tissues, which 
 are gradually 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 
 removed, recurrences are very common, owing to the non-removal 
 of these prolongations (or, as they are termed by the lay public, 
 ' roots ') of the disease into apparently normal tissue. If a 
 malignant tumour, with all its ramifications, is completely 
 removed, it does not recur. The impossibility of knowing 
 whether all the growth has been removed, or how far it has 
 extended into the surrounding tissues, is responsible for the 
 frequent recurrences. (4) When a malignant tumour invades the 
 skin, it usually leads to ulceration, and then not uncommonly a 
 
i 5 2 A MANUAL OF SURGERY 
 
 foul fungating mass results (the fungus hamatodes of the older 
 pathologists). (5) Secondary deposits are often found in neigh- 
 bouring lymphatic glands or distant viscera. (6) An apyrexial 
 cachexia develops in the 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 
 is 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. (7) Finally, death ends the scene, after a longer 
 or shorter period of suffering. 
 
 The degree of malignancy varies with different tumours. In 
 some the local phenomena predominate, whilst in others the 
 constitutional 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 vital parts. Melanotic 
 sarcoma, on the other hand, may produce only a small primary 
 growth, but the most extensively diffused secondary deposits may 
 form in the viscera. The sarcomata are very frequently dissemi- 
 nated by the blood-stream, and hence secondary growths are not 
 common in the lymphatic glands, whilst the carcinomata spread 
 by means of the lymphatics. Even among the latter consider- 
 able differences are met with ; 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 generally escape. The term semi-malignant is some- 
 times applied to those growths which are on the borderland 
 between the malignant and benign. 
 
 The Classification of Tumours is conducted along lines partly 
 anatomical, partly embryological, and on these grounds the 
 following groups are described : 
 
 I. Tumours derived from mesoblastic tissue, constituting what 
 is known as the Connective Tissue Group : 
 
 (1) Embryonic connective tissue tumours : 
 
 (a) Myxoma (mucoid tumour). 
 
 (b) Sarcoma. 
 
 (2) Fully-developed connective tissue tumours : 
 
 (a) Lipoma (fatty tumour). 
 
 (b) Fibroma (fibrous tumour). 
 
 (c) Chondroma (cartilaginous tumour). 
 id) Osteoma (bony tumour). 
 
 (e) Myoma (muscle tumour). 
 
 (/ Neuroma (tumour in connection with nerves). 
 (g) Angioma (tumour composed of bloodvessels). 
 (h) Odontoma (tumour connected with the teeth). 
 (i) Lymphadenoma, or lymphangioma (tumours of 
 lymphatic origin). 
 
TUMOURS A±JD CYSTS 153 
 
 II. Tumours derived from epiblastic or hypobiastic structures, 
 or Epithelial Tumours : 
 
 (ij Innocent varieties : 
 
 (a) Papilloma (wart-like growth). 
 
 (b) Adenoma (glandular new formation). 
 (2) Malignant growths, or the carcinomata : 
 
 (a) Epithelioma (cancer of skin or mucous mem- 
 
 brane). 
 
 (b) Rodent ulcer (cancer of sebaceous glands). 
 
 (c) Columnar carcinoma (cancer arising from tubular 
 
 glands, e.g., Lieberkiihn's follicles, or from 
 ducts lined with columnar epithelium). 
 
 (d) Acinous carcinoma (cancer arising in glands 
 
 with spheroidal epithelium). 
 
 L The Connective Tissue Group of Tumours : (r) Tumours 
 composed of Embryonic Connective Tissue. 
 
 Myxoma. — A myxoma is a tumour consisting of connective 
 tissue cells, surrounded and separated from each other by an 
 
 Fig. 24. — Myxomatous Tissue, showing the Stellate Cells with their 
 Branching Processes separated by Translucent Intercellular 
 Substance. (Tillmanns.) 
 
 intercellular substance of a mucoid character ; a similar type of 
 material occurs normally in the substance of the umbilical cord. 
 The cells are usually polygonal in shape, and present long branched 
 processes which interlace with those from adjacent cells (Fig. 24). 
 The intercellular substance is homogeneous and translucent, con- 
 taining wandering connective tissue corpuscles, and traversed by 
 bloodvessels ; the density of the tumour varies inversely with the 
 amount of intercellular substance. It is not uncommon for this 
 form of growth to be associated with sarcoma, and hence a 
 thorough and early removal of the mass is always advisable. 
 
154 A MANUAL OF SURGERY 
 
 Myxomata occur as rounded tumours, perhaps tabulated, in the 
 neighbourhood of mucous membranes — e.g., the face, intestine, 
 and bladder ; they also grow in the sheaths of nerves, and are the 
 commonest form of simple tumour of the spinal cord. Mucous 
 polypi of the nose were formerly considered of this nature, but at 
 the present time rhinologists look on them as merely consisting of 
 cedematous granulation tissue. 
 
 Sarcoma (Greek, <rap£, flesh = a flesh-like tumour). — By a sar- 
 coma is meant a tumour formed from some kind of immature or 
 embryonic connective tissue ; that is to say, it consists of cells of 
 varying size and shape, held together by a delicate reticulum, 
 which penetrates between each of the cellular elements. The 
 structure is, thus, not unlike that of inflammatory new formations, 
 but differs from it in that there is a considerable tendency to 
 develop into higher types of tissue, such as bone, cartilage, etc., 
 although the embryonic character of the growth still persists at 
 the periphery. From carcinoma it is recognised by the fact that 
 in all except the alveolar sarcomata the structure is more or less 
 uniform, and the cells are not grouped in alveoli separated from 
 one another by stroma ; moreover, there is no intercellular tissue 
 between the epithelial cells of a cancer, whereas, with suitable 
 preparation, it can always be demonstrated between the cells of a 
 sarcoma. 
 
 A sarcoma always arises from pre-existing connective tissue, 
 and hence is of mesoblastic origin ; occasionally it starts from the 
 deeper parts of the skin, but even here it is probably derived from 
 the same embryological basis. It may be at first well defined, 
 and even in some cases encapsuled ; 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. Dissemina- 
 tion 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 intra- 
 vascular growth projects into the lumen of a vessel in which the 
 blood is freely circulating. It may be detached by some slight 
 mechanical injury, and is then carried away as a malignant 
 embolus ; if a large portion is set free, 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 
 
TUMOURS AND CYSTS 
 
 l 55 
 
 general circulation, giving rise to secondary growths wherever 
 they are arrested ; it is quite usual for general visceral implication 
 to be secondary to the pulmonary growths. Nothing is known as 
 to the existence of nerves or lymphatics in sarcomata ; occasionally, 
 however, dissemination by way of the lymphatic glands is met 
 with, especially in melanotic sarcoma, lympho-sarcoma, and 
 sarcoma of the tonsil, testis, and thyroid body. Various secondary 
 changes are apt to occur, e.g., fatty degeneration, mucoid softening, 
 and haemorrhage, whilst calcification is not uncommon. 
 
 On naked-eye examination, a sarcoma presents a more or less 
 homogeneous appearance, the colour varying with the amount of 
 the blood-supply, from a greyish-white in the fibro-sarcomata to 
 a deep maroon colour in the myeloid. On scraping the cut 
 
 surface, juice, like that from a 
 cancer, is never obtained, even 
 when the tumour has been re- 
 moved from the body for some 
 time, and thus the cohesion of 
 the cells impaired ; a milky sub- 
 stance then sometimes appears, 
 whilst in myeloid sarcoma a slimy 
 fluid escapes, but it in no way 
 resembles that obtained from a 
 
 
 v%- 
 
 Fig. 25. — Small Round -celled 
 Sarcoma infiltrating Muscular 
 Tissue. (Tillmanns.) 
 
 cancer. 
 
 This form of malignant disease 
 occurs most commonly in young 
 and middle-aged people, especially 
 affecting the first and fourth de- 
 cades of life ; it may also be con- 
 genital. The degree of malignancy varies considerably, some 
 forms being almost benign, or, at any rate, only locally malignant, 
 whilst others are exceedingly virulent in nature. 
 
 Sarcomata are divided artificially into the following groups, 
 depending on the size, shape, arrangement, and character of the 
 constituent cells : (a) The round-celled ; (b) the spindle-celled ; 
 (c) the myeloid ; (d) the alveolar ; and (e) the melanotic. 
 
 (a) Round-celled Sarcomata (Fig. 25) consist of a mass of round 
 cells containing a very definite circular or oval nucleus ; the inter- 
 cellular substance is slight in amount, and often homogeneous in 
 character. The mass is very vascular, and may even pulsate ; 
 it is soft, like granulation tissue, and usually grows rapidly. 
 Several subdivisions are described : (i.) The small round-celled 
 sarcoma is extremely malignant, infiltrating surrounding parts, 
 and early giving rise to secondary deposits ; lymphatic glands 
 are not unfrequently affected in this variety. Any part of the 
 body may be involved, and it may be met with at any age. 
 (ii.) The large round-celled sarcoma is made up of larger cells, which 
 contain one or two large oval nuclei with an abundant protoplasm 
 
'5* 
 
 A MANUAL OF SURGERY 
 
 around. A well-marked stroma is interspersed between the cells, 
 and an alveolar arrangement is sometimes present ; it occurs in 
 the same position as the former, but is rather less malignant, 
 (iii.) Lymphosarcoma is very similar in structure ; the cells, how- 
 ever, are small, and the intercellular substance is of a delicate 
 reticular nature, corresponding to the retiform tissue commonly 
 met with in lymphatic glands. Such tumours grow rapidly, and 
 are exceedingly malignant ; they usually start in lymphatic glands, 
 or in the lymphoid tissue of mucous membranes, and are dissemi- 
 nated by means of the lymphatics. For the clinical characters of 
 these tumours, see Chapter XII. (iv.) Glioma or glio-sarcoma is 
 probably a variety of round-celled sarcoma which develops in 
 connection with the nervous system ; but there is some doubt as 
 
 Fig. 26. — Spindle-celled Sarcoma. 
 The individual cells have been separated, and the characteristic nuclei can be 
 
 to whether it should be considered a sarcoma at all. It consists 
 of round cells from which a number of delicate filamentous pro- 
 cesses are furnished ; they probably originate from the neuroglia, 
 the cells of which they much resemble. Gliomata are found grow- 
 ing from the retina in children, forming tumours which, situated 
 at first within the eye, sooner or later invade the lymph spaces 
 surrounding the bloodvessels in the orbit, and also spread back- 
 wards along the optic nerve to the chiasma, and thence downwards 
 to the opposite eye, or upwards to the brain. They are also 
 found as primary growths in the cerebral substance, and some- 
 times in the spinal cord. They have no general malignancy, but 
 may destroy life as a result of their local development. 
 
 (b) Spindle-celled Sarcomata (Fig. 26) consist of large or small 
 spindle cells, which are often arranged in a somewhat fasciculated 
 manner with a greater or less amount of intercellular substance. 
 When consisting of small cells, the tumour grows rapidly, and is 
 firmer and less succulent than the round-celled variety. In 
 some cases the intercellular substance is very abundant, and 
 so fibrillated in character as to cause the tumour to be known as 
 
TUMOURS AND CYSTS 
 
 157 
 
 a fibrosarcoma (the ' recurrent fibroid ' of Paget). They may 
 originate in any part of the body, but more especially from 
 aponeuroses, fasciae, tendons, etc., constituting localized growths, 
 which are at first tolerably well defined, but later on invade and 
 infiltrate surrounding parts. When growing rapidly, the cells 
 become less fusiform in shape, and may even approach to the 
 round cell in character, after passing through a stage known as 
 the oval- or oat-shaped sarcoma. These tumours, consisting of 
 small spindle cells, are usually very malignant in character, except 
 when of the fibro-sarcomatous character, and then the tendency 
 to become disseminated is less marked, although there is usually 
 
 w^ty 
 
 Fig. 27.— Myeloid Sarcoma, showing the Multi-nucleated Myeloid 
 Cells (Myeloplaxes) lying amongst the more abundant Spindle 
 Cells. (Green's 'Pathology.') 
 
 a considerable risk of local recurrence. The large spindle-celled 
 sarcomata are softer and of a deeper colour than the former. They 
 grow from the fibrous tissues, and not uncommonly from the 
 viscera. The congenital sarcoma of the kidney is of this nature, 
 though some of the cells become transversely striated, looking 
 like muscle fibres ; such tumours are sometimes called ' myo- 
 sarcomata.' 
 
 (c) Myeloid Sarcomata (Fig. 27) are characterized by the pres- 
 
158 A MANUAL OF SURGERY 
 
 ence of large numbers of multi-nucleated giant cells {myeloplaxes), 
 imbedded in a considerable quantity of round or spindle cells, the 
 intercellular substance being usually of a gelatinous nature. The 
 myeloid cells vary a good deal in size, but always contain a large 
 number of distinct nuclei, which are not distributed regularly in 
 the periphery of the cell, as in the case of the giant cells of 
 tubercle ; they may be regular in outline, or prolonged into 
 numerous interlacing processes, 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 exceedingly vascular, and may pulsate. 
 Haemorrhage into their substance is common, giving rise to cysts, 
 filled with serum and a yellowish fibrinous clot stained with the 
 colouring matter of the blood. When fresh, the growing edge is 
 of a dark maroon colour on section, and has been 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 are the least malignant of all the 
 sarcomata, but rarely or never giving rise to secondary deposits, 
 either in the lymphatic glands or viscera. Their growth is 
 tolerably rapid, and they may attain enormous dimensions. Myeloid 
 sarcoma is almost invariably found growing from bones ; for the 
 particular sites, symptoms and treatment, see Chapter XVIII. A 
 certain amount of doubt exists as to whether these tumours should 
 be included amongst the sarco- ^_ 
 
 mata, since their clinical history fjg ,/#*'§ 
 
 and progress are of a benign ^ . ^ % /;* U%? ' .§> U \ 
 
 type, and the term 'myeloma' -^ S^.-.i'V'V/-- ;V "l>> ■ % J/ 
 
 has been suggested for them, <§> * ».^ J*^ ^vC*? -* .1 -«% ? -** 
 as indicating in measure their '; % ! -."V ^\^ '- jf 1'i f 
 
 nature and structure. &^i i. •, ., " AA 
 
 (d) Alveolar Sarcoma (Fig. 28) , * i ";-- & | ' i; /^^%^ y %^'"^\ » 
 is a variety in which the cells % . %s ••'?/•> ' .-s'.VjVJ^"}* 
 are grouped together in alveoli, 
 separated by a distinct fibrous 
 stroma. On microscopic ex- •<-,'»'?; * ^Z"~k^*3^'S® 
 amination they closely resemble ^ f ® < &"%f'f(" ! &*'' K 
 cancer ; but on carefully pen- " ? 
 
 cilling a section with a camel's- Fig. 28. — Alveolar Sarcoma. 
 
 hair brush, it will be found (Tillmanns.) 
 
 that the stroma sends delicate The individual cells in the alveoli are 
 
 prolongations between each of here apparently lying in close con- 
 
 fY 11 t-u- <- tact, but in reality there is a certain 
 
 the cells. I his variety of amount of intercellular substance 
 
 tumour is most commonly found placed between each of them. 
 
 growing from the skin, and is 
 
 occasionally of a melanotic nature, and always very malignant. 
 
 (e) Melanotic Sarcoma is perhaps the most virulent of all this 
 
TUMOURS AND CYSTS 159 
 
 group of tumours. It almost invariably originates from pigmented 
 structures, e.g., the deeper layers of the skin or the retina. It is, 
 however, sometimes met with growing from the mucous mem- 
 brane of the lips and gums. It consists of round or spindle cells, 
 often arranged in alveoli, whilst in other cases club-shaped pro- 
 cesses of epithelium may penetrate into the subjacent tissues, thus 
 causing it to resemble epithelioma. The most prominent feature 
 is the brown colour, owing to a deposit within the cells of granules 
 of melanin. The amount of this pigmentation varies consider- 
 ably, some tumours being of a deep brown or brownish-black 
 colour, and then consisting of flattened plaques, whilst others 
 are of a papillomatous nature, and show but slight discoloration, 
 especially if growing rapidly. The tumour soon spreads to the 
 nearest lymphatic glands, and secondary deposits in the viscera 
 follow. So great is the malignancy, that, according to Erichsen, 
 if the primary growth has attained the size of a filbert, local 
 treatment is of but little value. The original tumour is often not 
 very large, and the secondary deposits are similarly characterized 
 by their number rather than by their size, scarcely an organ in 
 the body being free. 
 
 Of late years a more benign type of melanosis has been described, and is 
 now well recognised by dermatologists. It usually spreads from a congenital 
 mole as a deeply pigmented patch, which may extend over an area of several 
 square inches, and presents at first no sign of induration or infiltration ; in this 
 stage microscopic examination reveals no change in texture except pigmenta- 
 tion of the deeper layers of the cutis vera. Sooner or later, a tumour develops 
 in the centre of this patch, and may be either a sarcoma or a cancer, but more 
 frequently the former. It is not very rapid in its course, but if left alone will 
 finally become disseminated. In treating this type of melanosis, it is essential 
 to remove every portion of pigmented tissue as well as the tumour. 
 
 Some degree of uncertainty exists as to the position which should be 
 assigned to the tumour known as an endothelioma ; it originates in mesoblastic 
 tissues, but is somewhat similar in nature to the cancers, for which, indeed, 
 it has often been mistaken. It arises from the endothelial cells of serous 
 membranes, lymphatics or bloodvessels, and usually consists of columns of 
 cells supported by a fibro-cellular stroma. It sometimes originates from the 
 pleura or cerebral membranes, but may also be observed in glandular organs, 
 such as the breast, parotid, testis, or ovary. On serous membranes it may 
 give rise to large tumours, from which secondary deposits in glands or viscera 
 are after a time developed, but the rate of dissemination is not great. In 
 glands the tumour often starts as a more or less cylindrical proliferation of 
 the endothelial cells of the arterioles or lymphatics ; this gradually extends 
 along the vessel and usually leads to its obliteration, whilst either the cells or 
 the surrounding tissues undergo a mucoid or hyaline change; this arrange- 
 ment in cylinders or columns led to the name cylindroma, which was often 
 applied to it. The tumour runs a slowly malignant course, comparable to 
 that of some of the less virulent sarcomata, and its nearest homologue is 
 probably an angio-sarcoma. 
 
 The Treatment of sarcoma consists in its removal as early and 
 completely as possible. This may be a simple matter in cases 
 where the tumour is encapsuled, but even then recurrence is very 
 
i6o 
 
 A MANUAL OF SURGERY 
 
 likely to follow unless the capsule is also taken away, and a 
 considerable margin of tissue beyond it. Where, however, the 
 growth is more diffuse, the only hope lies in cutting widely, so as 
 to get beyond its furthest limits ; the prognosis of such cases is 
 very bad. 
 
 In hopelessly inoperable cases somewhat similar measures have 
 been employed as for the similar stage of cancer (vide p. 145). 
 Several cures have now been recorded from the use of Coley's 
 fluid, which consists of a sterilized culture of the Streptococcus 
 erysipelatis and Micrococcus prodigiosus in bouillon. This fluid is 
 intensely toxic, and the injections, commencing with doses of half 
 a minim, are gradually increased up to 7 or 8 minims ; severe 
 reaction usually follows, and the surgeon should aim at obtaining 
 two or three such effects each week. The fluid is introduced partly 
 into the abdominal wall, and partly into, or around, the tumour. 
 In favourable cases the growth gradually dwindles. The spindle- 
 celled sarcomata are apparently the most suitable for this treat- 
 ment, whilst ossifying and melano- sarcomata are but little, if at 
 all, affected. 
 
 (2) Tumours consisting of Fully-developed Connective Tissue. 
 
 Lipoma. — A fatty tumour is an overgrowth of fibro-cellular 
 
 On microscopical examination it 
 
 -- 
 
 tissue, infiltrated with fat. 
 differs in no respect from 
 ordinary adipose tissue, 
 and is not very freely sup- 
 plied with bloodvessels. 
 
 When localized (Fig. 
 29) it forms a tumour, 
 soft and semi-fluctuating 
 in consistence, rounded 
 and lobulated in outline, 
 and if occurring in the 
 subcutaneous tissues, the 
 skin becomes dimpled on 
 moving it from side to 
 side, owing to the fact 
 that fibrous trabeculae 
 pass from the capsule to 
 the skin. The growth is 
 usually encapsuled and 
 freely movable ; but if 
 exposed to pressure or 
 friction, as when situated 
 on a man's shoulder and 
 
 rubbed by the braces, it becomes firmly adherent to surrounding 
 structures. Such growths are either single or multiple, in the 
 
 Fig. 29. — Lipoma, showing Characteristic 
 
 Lobulated Outline. (From King's 
 
 College Museum.) 
 
TUMOURS AND CYSTS 
 
 161 
 
 latter case perhaps occurring in hundreds, and are most com- 
 monly found about the trunk or the upper extremities. It has 
 been stated that lipomata travel from one point of the body to 
 another by the action of gravity, but it is somewhat doubtful 
 whether this ever occurs. Occasionally subcutaneous tumours 
 become pedunculated and pendulous. 
 
 Deep inter-muscular lipomata are sometimes met with, and the 
 diagnosis may then be uncertain, since their mobility and lobulated 
 outline are masked by the superjacent tissues ; they have even 
 been mistaken for sarcomatous growths. Still more difficult of 
 recognition are those 
 known as parosteal lipo- 
 mata, growing from the 
 outer surface of the peri- 
 osteum. They are often 
 congenital, and appear 
 as soft swellings, lying 
 beneath the muscles in 
 close proximity to a bone 
 and suggesting the 
 presence of a chronic 
 abscess. We observed 
 one a little time back- 
 growing just above the 
 angle of the jaw beneath 
 the masseter. 
 
 Pericranial lipoma is 
 of a somewhat similar 
 nature. It is usually 
 congenital in origin, and 
 often the cranium is per- 
 forated and a connec- 
 tion established with the 
 meninges. An angioma- 
 tous element is some- 
 times present in these 
 growths. 
 
 By the term Diffuse Lipoma (Fig. 30) is meant a fatty infiltra- 
 tion of the subcutaneous tissues of some region of the body, 
 particularly beneath the chin and at the back of the neck, and 
 more rarely in the pubic region. These growths are often 
 multiple and almost always symmetrical. They usually occur in 
 individuals who drink freely and take but little exercise. Their 
 size diminishes on limiting the amount of alcohol and making the 
 patient do physical work. 
 
 Occasionally the connective-tissue basis of a lipoma undergoes 
 modifications ; e.g., it may become increased in amount, con- 
 stituting a Fibro-lipoma, or be transformed into mucoid tissue, 
 
 11 
 
 Fig. 30. — Diffuse Lipoma. 
 
162 A MANUAL OF SURGERY 
 
 giving rise to a Myxo-lipoma ; or, again, the vessels may become 
 dilated, originating a Nsevo-lipoma ; and even a Sarco-lipoma may 
 develop. 
 
 Localized or diffuse overgrowths are often met with in the 
 sub -peritoneal fatty tissue, constituting Subserous Lipomata. 
 They occur not unfrequently in the lower part of the abdomen, 
 and may extend into the inguinal and crural canals, forming 
 the so-called fatty tumour in these parts. By their traction a 
 process of peritoneum may eventually be drawn down, and a true 
 hernia produced. A similar condition occurs in the anterior 
 abdominal wall, small pedunculated masses of fat projecting 
 through congenital or acquired openings in the linea alba or 
 linea semilunaris ; these are sometimes known as Fatty Hernia 
 of the Linea Alba, and are often painful. 
 
 Lipoma Arborescens is the term applied to a villous outgrowth 
 of fatty tissue, met with in the interior of joints, and usually 
 associated with osteo-arthritis. There is often a considerable 
 increase in the amount of intra-articular fluid, and the condition 
 has then been designated ' synovitis lipomatosus.' 
 
 The Treatment of lipomata consists in their removal. When 
 they are loosely encapsuled, this is a very simple matter, all that 
 is required in many cases being to squeeze the mass forwards 
 between the thumb and finger, making the skin tense over it, and 
 then to incise the capsule freely, when the tumour almost jumps 
 out ; but if there are many adhesions it may not be so easy. In 
 the diffuse forms dietetic and hygienic measures should first be 
 tried. Should an operation be required, it is well to cut through 
 the whole thickness of the tumour at once, and deal with each 
 half separately, dissecting it away from its deep attachments. 
 
 Fibromata consist of overgrowths of fibrous tissue ; they were 
 formerly divided into two groups, the hard and the soft, and 
 although there is no essential difference between them, it is a 
 useful clinical distinction. 
 
 The Hard Fibroma is composed of firm dense tissue, which 
 creaks on section with the knife, the exposed surface showing 
 numerous trabecular of glistening fibres, similar in character to 
 those met with in a tendon (Fig. 31). Microscopically, interlacing 
 fibrillae are seen, which are sometimes arranged concentrically 
 around the bloodvessels ; there are but few nucleated cells in the 
 more slowly growing tumours. The vascular supply is somewhat 
 defective, although dilated veins are often present, especially in 
 the capsule, and sometimes in the substance of the mass ; these, 
 if opened by ulceration, may lead to profuse haemorrhage. Hard 
 fibromata are met with in the form of epulis, fibrous polypus of the 
 nose, keloid, and not uncommonly in connection with the sheaths 
 of nerves. 
 
 Soft Fibromata develop as localized overgrowths of the sub- 
 
TUMOURS AND CYSTS 
 
 163 
 
 cutaneous fibro-cellular tissue, or as the so-called Molluscum 
 fibrosum of the skin. In the latter case many different forms of 
 the growth are met with ; sometimes a development of small 
 nodules occurs, scattered widely over the surface, usually pinkish, 
 and with the skin over them somewhat corrugated ; these may be 
 associated with changes in the underlying nerves (p. 168). It also 
 exists in the form of pendulous folds, perhaps involving a large 
 area of the trunk ; the so-called pachydermatocele of the scalp is 
 of this nature. 
 
 Chondroma. — Cartilaginous tumours are met with growing 
 either in connection with bones or in certain soft tissues. They 
 
 
 Fig. 31. — Section of Hard Fibroma. (Royal College of Surgeons' 
 
 Museum.) 
 
 consist of hyaline cartilage, which, instead of being uniform in 
 texture and devoid of vessels as at the articular ends of bones, 
 occurs in the form of pellets or nodules of varying size, held 
 together by vascular connective tissue, which may even penetrate 
 into the substance of the cartilage. The cells are also less regular 
 in shape than is the case with normal cartilage, and are not 
 arranged according to any definite plan. 
 
 Chondromata are liable to become calcified, and even ossified. 
 When large, the central parts may undergo a mucoid change, 
 giving rise to a cavity which, if sepsis is admitted, becomes 
 
 11 — 2 
 
164 
 
 A MANUAL OF SURGERY 
 
 exceedingly foul. They are not uncommonly accompanied in 
 their growth by sarcomatous and other elements. 
 
 When growing from the long bones, chondromata usually start 
 from beneath the periosteum, and are independent of the epiphy- 
 seal cartilage, although it has been suggested by Virchow that 
 they may originate from a nodule of cartilage which has been dis- 
 placed from its usual situation during an attack of rickets. They 
 constitute firm lobulated encapsuled tumours, and give rise to no 
 pain, except when they encroach on neighbouring nerves. They 
 often attain a great size. The growth may extend secondarily 
 into the medullary canal, and thus cause expansion of the bone ; or 
 it may erode the compact tissue, and lead to spontaneous fracture. 
 Amputation of the limb will probably be necessary, unless the 
 case comes under observation in the early stages, when the tumour 
 can be gouged or scraped away. 
 
 Chondromata also originate from the smaller bones, usually from 
 those of the hand (Fig. 32). In such cases 
 the growth commences in the interior, 
 close to the epiphyseal cartilage ; several 
 tumours may be present in the same indi- 
 vidual. The bone is expanded by the 
 growth, and the parts become much de- 
 formed. Treatment consists in incising 
 the capsule, and scooping out the carti- 
 laginous tissue, a proceeding which may 
 result in defective growth and subsequent 
 deformity. In the later stages, however, 
 amputation is inevitable. 
 
 Chondromata are also found in the soft 
 parts, especially affecting the parotid and 
 submaxillary glands, and the testes. In 
 the parotid gland they are usually asso- 
 ciated with mucous and fibrous tissue, a 
 few glandular elements being also embedded in the mass. They 
 develop from the capsule of the gland, or immediately beneath it, 
 and are usually simple in nature, though occasionally they become 
 sarcomatous. Submaxillary chondroma is frequently an almost 
 unmixed cartilaginous tumour. 
 
 Overgrowths of cartilage, known as Ecchondroses, occur around 
 the articular cartilages in connection with osteo-arthritis ; they 
 also arise from the cartilages and septum of the nose, and from 
 the laryngeal cartilages. Some of the loose bodies which form in 
 joints are of a similar nature. 
 
 Osteoma. — Bony tumours are of two chief forms : the cancellous 
 and the ivory. 
 
 Cancellous Osteomata are usually met with growing near the 
 articular end of a bone, being derived originally from some iso- 
 lated portion of the epiphyseal cartilage, which has perhaps been 
 
 Fig. 32. — Multim-e 
 
 Chondromata of 
 
 the Fingers. 
 
PLATE IV 
 
 Exostosis of the Radius. 
 
 This growth occurred in a young man aged twenty-three years. It will be noticed 
 that it has caused great deformity of the ulna, and, indeed, apart from the skia- 
 gram, one might have supposed that it had originated from that bone. 
 
 To face •/>. 165.] 
 
TUMOURS AND CYSTS 165 
 
 separated from its original connection after an attack of rickets. 
 It is well known that in this affection irregular outgrowths from 
 the epiphyseal cartilage occur, and if one of these near the peri- 
 phery of the bone becomes shut off from its epiphyseal attachment, 
 it is easy to understand its development into a tumour, which 
 consists of cancellous bone, capped by a layer of hyaline cartilage, 
 from which it grows (Fig. 33). It is pedunculated or sessile, and 
 may attain to a large size, leading to considerable deformity 
 (Plate IV.). It necessarily develops in young people, and may 
 be congenital. As the individual grows, the basis of attachment 
 may become separated from the epiphysis to an extent corre- 
 sponding to the amount of growth which has taken place at that 
 spot, or it may still remain attached to the epiphyseal line. As a 
 
 Fig. 33. — Diagrammatic Represen- 
 tation of Cancellous Exostosis 
 growing from the lower end 
 of the Femur. Fig. 34. — Subungual Exostosis. 
 
 _. . .,', '. . , . (Bland Sutton.) 
 
 Its proximity to the epiphyseal car- 
 
 tilage is indicated, as also its carti- 
 laginous covering and the bursa 
 which occasionally lies over its 
 summit. 
 
 rule its growth and development cease at maturity, when the 
 cartilage covering it, as well as the epiphyseal cartilage, ossifies. 
 A bursa occasionally forms over the most prominent part of these 
 tumours as a result of friction or pressure, giving rise to the con- 
 dition known as Exostosis Bursata ; this cavity may communicate 
 with the joint. An effusion of blood or serum into the bursa may 
 be the first evidence of the existence of such a growth. Multiple 
 exostoses are not unfrequently met with, and are then often 
 hereditary. The most common situation for such a tumour is 
 the inner condyle of the femur, close to the adductor tubercle, 
 but they are not rare on the inner aspect of the mandible. The 
 Subungual Exostosis (Fig. 34) develops as a rounded, cherry-like 
 swelling under the nail of the great toe. It is very painful, and 
 should be treated by removing the nail, incising the tissues over 
 
1 66 
 
 A MANUAL OF SURGERY 
 
 it down to the bone, and clipping it away with cutting pliers. 
 
 Fig. 35 represents a skiagram of an exostosis growing from the 
 
 proximal phalanx of the thumb. 
 
 Ivory Exostoses develop most frequently on the inner or outer 
 
 aspect of the cranial bones, especially affecting the orbit, external 
 
 auditory meatus, antrum, and frontal sinus (Fig. 36). They 
 
 consist of masses of very dense compact tissue, covered by 
 periosteum, from which they grow. They 
 are usually lobulated, and when situated 
 in the frontal sinus, or growing from the 
 under surface of the skull, may give rise 
 to serious symptoms from irritation or 
 compression of the brain or its membranes. 
 In a few cases necrosis has resulted, and 
 they have sloughed out, thus bringing 
 about a spontaneous cure. 
 
 Occasionally diffuse overgrowth of the 
 bones of the skull (Hyperostoses) are met 
 with, affecting either the calvarium alone, 
 being then probably syphilitic in nature, or 
 the facial and cranial bones, as in leontiasis 
 ossea. New formation of bone sometimes 
 occurs in the substance of tendons which 
 are exposed to irritation or excessive 
 action, e.g., the tendon of the adductor 
 longus in riders, producing what is known 
 as ' the rider's bone,' but this is inflam- 
 matory in origin. 
 
 The Treatment of osteomata consists in 
 their removal where possible. This may 
 be tolerably simple in the case of the 
 cancellous osteomata of the limbs, but is 
 
 sometimes a most formidable proceeding when dealing with sessile 
 
 compact exostoses of the calvarium. 
 
 Myoma.— Myomata almost always consist of unstriped muscle 
 fibres (Leiomyoma or fibromyoma), forming rounded and often en- 
 capsuled 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 
 considerable size are found in the capsule. It is often difficult to 
 distinguish 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 fibrillae ; 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 
 
 Fig. 35. — Skiagram of 
 Exostosis growing 
 from the Base of 
 Proximal Phalanx 
 of Thumb, showing 
 Open Cancellous 
 Texture and Origin 
 near the Epiphy- 
 seal Cartilage. 
 
TUMOURS AND CYSTS 
 
 167 
 
 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 and prostate, and occasion- 
 ally in the walls of the alimentary canal and in the ovary. 
 Secondary changes sometimes occur, e.g., mucoid softening, as in 
 fibro-cystic disease of the uterus, calcification, ulceration with 
 
 Fig. 36 — Ivory Exostosis growing from Frontal Sinus, and encroach- 
 ing both on the Orbit and the Cranial Cavity. (Bland Sutton.) 
 
 (From specimen in the College of Surgeons' Museum.) 
 
 profuse haemorrhage, and possibly consequent septic inflammation, 
 whilst malignant disease may supervene. For the characters of 
 the prostatic myomata, see Chapter XXXVII. 
 
 Tumours consisting of striped muscle fibres (Rhabdomyoma) 
 have been described, but are exceedingly rare. 
 
 Neuroma. — True Neuroma is seldom met with, only five un- 
 doubted cases being on record. It is formed by a mass of newly- 
 formed ganglion cells and nerve fibres, which may be medullated 
 or not. In all but one case it involved the sympathetic system, 
 and occurred in children or young people. The tumours may 
 attain considerable dimensions, are often multiple, and may be 
 quite soft, like a lipoma, or firm. They are insensitive and inno- 
 cent, and may be freely removed. 
 
 False Neuromata, or those developing in connection with the 
 sheaths of nerves, are more common, and may be described under 
 three headings : 
 
 1. Solitary Pseudo-Neuroma, which may be innocent or malig- 
 nant, the former being a fibroma or myxoma, the latter usually a 
 
1 68 
 
 A MANUAL OF SURGERY 
 
 Fig. 37. — Pseudo - Neuroma : 
 Fibrous Tumour growing 
 from Nerve Sheath, and 
 causing the Fibres to be 
 widely stretched over it. 
 
 sarcoma. It may project from one side of the nerve, or more 
 frequently causes the nerve fibres to be separated and spread out 
 over it (Fig. 37). It moves more freely in a direction at right 
 
 angles to the axis of the nerve 
 than along its course. When de- 
 veloping from a small nameless 
 subcutaneous twig, it is termed a 
 painful subcutaneous nodule, and then 
 gives rise to intense pain of a 
 neuralgic type, 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 relatively 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 nature to lead to complete 
 paralysis or anaesthesia, unless 
 they are of a malignant 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 fibrillae. If this cannot be accomplished, the nerve must be 
 divided, and the ends united by immediate suture. 
 
 2. Diffuse or Generalized Neuro- fibromatosis [Recklinghausen 's 
 disease). — 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 peri- 
 pheral nervous system may be affected, including the sympathetics, 
 but it is most common in connection with the cranial nerves and 
 the large plexuses of the trunk. The actual symptoms are some- 
 times very slight, but the tumours may be sensitive to pressure, 
 and some one of them, more exposed than the others, may be ex- 
 quisitely 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 ter- 
 mination. The disease may start at any time during life, and 
 although progressing slowly, sooner or later terminates fatally. 
 No known treatment is of any avail, but should any particular 
 tumour become large and tender, it may be removed. 
 
TUMOURS AND CYSTS 169 
 
 In connection with this disease one frequently finds a large 
 development of fibrous growths of the skin, similar to what we 
 have already described as molluscum fibrosum. On careful 
 microscopical examination of specimens stained by Weigert's 
 method, the presence of nerve fibrillae can be demonstrated in 
 these growths, showing that they are really neuro-fibromatous in 
 origin. So excessive does this overgrowth occasionally become 
 that a form of elephantiasis is produced, e.g., the irregular hyper- 
 plasia of the scalp tissues known as a pachydermatocele. 
 
 A Plexiform Neuroma is a special modification of this process, 
 occurring congenitally or in young people, and usually involving 
 the trigeminal or superficial cervical nerves ; it may be associated 
 with the former condition. The overgrowth is of a softer, more 
 gelatinous type (myxo-fibromatous), and the resulting tumour 
 consists of a plexus of thickened, tortuous, vermiform strands, of 
 soft consistence, held together by loose connective tissue, but 
 easily separable 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. 
 
 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, 
 coiled up within which are numbers of newly-formed axis cylinders 
 (p. 328). They are almost always present in amputation stumps, 
 but are not painful unless adherent to the periosteum of the 
 neighbouring bone, or to the cicatrix, when every movement of 
 the nearest joint causes traction upon them, and induces severe 
 neuralgia. 
 
 Angioma. — Several distinct varieties of tumour consisting of 
 dilated arteries or veins exist, but the term angioma is applied 
 only to those in which a new formation of bloodvessels occurs ; 
 hence aneurisms and varicose veins are not included in this 
 catagory. 
 
 Three main types of angioma may be described: (1) The simple 
 naevus ; (2) the cavernous naevus ; and (3) the plexiform angioma. 
 
 The Simple Naevus is exceedingly common, and consists of a 
 mass of dilated capillaries, bound together by a small amount 
 of connective tissue. It is usually congenital, and may increase 
 rapidly in size during the first few months of life. It is located 
 in the skin, or may also involve the subcutaneous tissues, but the 
 tubular form of the constituent vessels always remains. It may 
 
170 
 
 A MANUAL OF SURGERY 
 
 be of a bright red colour or of a dusky tint. For a fuller account, 
 see Chapter XI. If untreated, simple naevi may persist unchanged, 
 or may disappear ; in a few instances they increase rapidly in size, 
 either early or late in life, sometimes giving rise to a considerable 
 vascular growth, purplish in colour, and occasionally becoming 
 prominent and pendulous. Such a tumour is soft and easily 
 compressible, being in reality a cavernous 
 ulcerate, and profuse haemorrhage may result, 
 in electrolysis, if excision is impracticable. 
 
 The Cavernous Nsevus consists of dilated spaces, where the 
 tubular form of the constituent vessels is lost, the arteries usually 
 opening directly into thin-walled cavities lined with endothelium 
 without the intervention of capillaries (Fig. 38). The tumours 
 are thus more or less erectile in nature, somewhat resembling the 
 
 corpus cavernosum. They are 
 
 angioma ; it may 
 Treatment consists 
 
 met with in the skin and sub- 
 cutaneous tissues, constituting 
 diffuse or circumscribed tumours 
 of a reddish-blue colour, which 
 can be emptied on pressure, but 
 rapidly refill when such is re- 
 moved, and in which pulsation is 
 occasionally present. A similar 
 condition arises in the viscera, 
 especially the liver, and then is 
 always acquired, and it is not 
 difficult in suitable cases to 
 demonstrate that it has been 
 formed by a dilatation of the 
 capillaries between the lobules, 
 the liver substance meanwhile 
 disappearing by a process of 
 simple atrophy. Occasionally a 
 cavernous angioma undergoes a 
 process of spontaneous cure as the result of some inflammatory 
 affection similar in nature to phlebitis, a non-vascular fibro-cystic 
 mass remaining. 
 
 Under the term Plexiform Angioma may be included the cirsoid 
 aneurism, or aneurism by anastomosis, the former term being 
 applied by some authors to tumours consisting of large vessels, 
 and then most commonly seen about the scalp and face, and the 
 latter to a congeries of small vessels. The treatment is always a 
 matter of considerable difficulty (see Chapters XVIII. and XXIV.). 
 Odontoma. — Tumours originating from some abnormal condi- 
 tion of the teeth or teeth-germs are known as ' odontomes.' 
 Bland Sutton, in his work on tumours,* has described seven 
 different varieties, several of which are, however, rarely met with 
 * Bland Sutton, 'Tumours and Cysts.' Cassell and Co. 
 
 Fig. 38. 
 
 -Section of Cavernous 
 Angioma. 
 
TUMOURS AND CYSTS 171 
 
 in man. We can only deal here with the more important of 
 these, and must refer our readers to Chapter XXV. and to 
 Sutton's book for a fuller description. (1) Epithelial Odontome. 
 In this condition, formerly 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 enamel organ. 
 It occurs most frequently in young people, 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 
 development of a cavity around a misplaced or ill-developed tooth 
 of the permanent set, which often lies horizontally, so that its 
 eruption is impossible. (3) Fibrous Odontomes are the result 
 of a thickening and condensation 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 result in septic inflammation of the 
 surrounding bone. (5) Composite Odontomata consist of a con- 
 glomeration 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. 
 
 Lymphadenoma and Lymphangioma. — The primary tumours 
 developing in lymphatic glands are described in Chapter XII., as 
 also the conditions arising from the dilatation of lymphatics. 
 
 II. Tumours derived from Epiblastic or Hypoblastic Structures. 
 
 These are either innocent or malignant in nature, the innocent 
 tumours being the papillomata and adenomata, and the malignant 
 the carcinomata. 
 
 Papillomata consist in an outgrowth of the papillae of the skin 
 or mucous membrane, which may be simple in nature, or compo- 
 site from the development of lateral offshoots, giving rise to a 
 cauliflower-like mass ; they may be sessile or pedunculated. The 
 connective tissue of the papillae, with its vessels, also extends 
 into the growth, which is sometimes exceedingly vascular. The 
 epithelium never dips down into the subcutaneous or submucous 
 tissue, the growth being only centrifugal in development, and not 
 centripetal, as in the case of the epitheliomata. Not unfrequently, 
 however, a papilloma which has become irritated may take on 
 malignant action. Clinically, a papilloma is distinguished from 
 an epithelioma by the base being free from infiltration. 
 
 Papillomata of the skin are met with in the form of hard 
 excrescences, such as warts or corns ; but if growing from 
 
172 A MANUAL OF SURGERY 
 
 moist parts, as from the prepuce, they may be soft and vascular. 
 Occasionally warts may grow to such an extent as to constitute 
 horn-like projections or cauliflower-like growths. 
 
 Papillomata of the mucous membranes are usually villous in 
 character, constituting long, fimbriated tufts, covered with a thin 
 layer of epithelium, and containing delicate bloodvessels, which 
 readily give way, and may lead to considerable haemorrhage. 
 They are most commonly observed in the bladder, but occasion- 
 ally in the pelvis of the kidney, and on the intestinal mucous 
 membrane, especially in the rectum. They also occur on the 
 true vocal cords, and are then wart-like, and hard in consistency. 
 Growths of a very similar nature, but somewhat more solid in 
 texture, are found within the ducts or acini of glandular viscera, 
 such as the breast. Condylomata and mucous tubercles, develop- 
 ing in the course of syphilis, are also of a papillomatous nature. 
 
 Adenomata consist of new growths arising in connection with 
 secreting glands, and in structure simulating somewhat closely the 
 organs from which they rise. They differ from them, however, 
 in that they are incapable of producing the characteristic 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, 
 however, does not pass beyond the basement membrane into the 
 connective tissue, and hence they also are distinguished from can- 
 cerous tumours by the new formation being centrifugal, and not 
 centripetal, in its growth. A variable amount of connective tissue 
 is always present, and may be normal in texture, or may mani- 
 fest various modifications. Adenomata are usually encapsuled, 
 being merely connected with the original gland by a pedicle, 
 through which the vessels enter. When growing from mucous 
 membranes, they are sometimes 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. They are 
 absolutely free from malignancy, except when, as occasionally 
 happens, the connective tissue undergoes a sarcomatous change, 
 whilst sometimes carcinoma supervenes. When of large size, 
 they may cause trouble by compression of important structures. 
 Any glandular organ may become affected with adenoma, and 
 several varieties will be described hereafter in the chapters on 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. The growth is usually slow, but 
 occasionally becomes rapid. 
 
 Carcinoma. — The malignant forms of epithelial new growth are 
 known as cancers or carcinomata, of which the following varieties 
 are described, viz., epithelioma, rodent ulcer, columnar carcinoma, 
 and glandular or acinous cancer. The term 'colloid cancer' is 
 
TUMOURS AND CYSTS 173 
 
 also used to indicate a degenerative change occurring in some 
 forms. 
 
 The essential character of a cancerous growth consists in an 
 unlimited multiplication of the epithelial elements of the organ 
 attacked. In some cases this may result in the formation of a 
 superficial outgrowth of a papillomatous type, while deep pro- 
 cesses or columns of cells advance into the tissues along the 
 lymphatic channels, and even burst through the basement mem- 
 brane of glandular alveoli. The irritation of this development 
 leads to an infiltration of the surrounding structures with round 
 cells, which are presumably inflammatory in origin, by the agency 
 of which the normal tissues are disintegrated and removed, and 
 a stroma of variable density develops around the epithelial 
 outgrowths. Hence all cancerous tumours may be said to consist 
 of a fibro-cellular or fibro-cicatricial stroma (Plate V., Fig. 1), 
 within the alveoli of which are collections of epithelial cells, 
 sometimes arranged in a methodical manner, but more often 
 packed irregularly together, and with no intercellular tissue 
 between them. The alveolar spaces are in reality dilated 
 lymphatics, and hence it is easy to understand that carcinomata 
 are disseminated along these vessels ; the cancer cells are 
 epithelial in origin, and of very variable size and shape ; but they 
 always retain more or less the characters of the epithelium from 
 which they are originally developed, so that, e.g., a squamous 
 epithelioma is never derived from a part covered with columnar 
 epithelium, or vice versa. Bloodvessels ramify through the stroma, 
 and are more or less abundant according to its density. The 
 tumours are not necessarily tender to the touch, but a consider- 
 able degree of pain, usually of a neuralgic type, is often com- 
 plained of, especially in the harder forms, where tissues get 
 dragged upon by the contracting stroma. 
 
 iEtiology. — Formerly cancer was considered to be of constitu- 
 tional origin, resulting from some morbid condition of the blood, 
 and in favour of this view the immense difficulty of eradicating it 
 was educed, as also its hereditary nature in many cases. It is 
 now, however, generally admitted to be primarily local in origin, 
 and probably the result of the inoculation and development of 
 some specific organism. The chief arguments in favour of its 
 local origin are as follows : (1) That it often occurs in individuals 
 who, up to the time of its onset, have been in perfect health ; 
 
 (2) that cachectic symptoms only manifest themselves in the later 
 stages of the disease, being then readily explicable by excessive 
 pain, the absorption of septic discharges, loss of blood, or possibly 
 the toxic effect of some material absorbed from the growth ; 
 
 (3) that the original neoplasm is always single, multiple tumours 
 being the result of infection from the primary growth ; (4) that 
 some definite focus of local irritation may frequently be traced as 
 the cause of the tumour — e.g., the irritation of the lip by a short 
 
174 A MANUAL OF SURGERY 
 
 clay pipe, the presence of ulceration or cicatrices of the tongue, 
 resulting from ragged teeth, syphilitic affections, etc. It is also 
 interesting to note that cancer usually involves the intestinal 
 canal in situations where there is a sudden change of calibre, 
 giving rise to increased friction from the passage of the contents — 
 e.g., at the upper and lower ends of the oesophagus, at the pylorus, 
 the ileo-caecal valve, either end of the sigmoid flexure, the lower 
 part of the rectum, and the anus. (5) Moreover, if an early and 
 thorough operation is undertaken, the growth can be completely 
 eradicated from the system, whilst even if it recurs, it usually 
 attacks the cicatrix or the neighbouring glands, indicating that 
 the removal has been incomplete. 
 
 The infective nature of cancer is still sub judice. Clinical evidence 
 exists to indicate that cancer can be transmitted from one person 
 to another, but it is somewhat scanty in amount. Thus, cancer of 
 the cervix uteri has been known to be followed ■ by epithelioma of 
 the penis in the husband. Again, it has been shown by Shattock 
 that in certain houses (called by him ' cancer houses ') one set 
 of indwellers after another has been attacked by this disease. 
 Experimental research, as to the transmissibility of cancer from one 
 individual to another, is necessarily unobtainable, although it has 
 been proved that, in a person already suffering from cancer, a 
 portion of the growth transplanted to a distant part of the body 
 will grow, and lead to the formation of a similar tumour at the site 
 of inoculation. Attempts have also been made to transmit the 
 disease to animals, but with a very slight degree of success, even 
 in cases where the point of inoculation has been previously 
 irritated. Hence the view that cancer is due to infection depends 
 rather on the analogy of the disease to other chronic infective dis- 
 orders than on any well-ascertained facts. The relation of cancer 
 to Psorospermiae has been much discussed of recent years, and by 
 some authorities the disease is supposed to be due to these 
 organisms. Their opinions, which are not generally accepted, 
 are based on the following facts : (a) That in the majority of 
 cancerous growths certain abnormal bodies resembling the coccidia 
 of psorosperms have been demonstrated within the epithelial 
 cells ; but even if these ' cancer bodies ' are of this nature, it has 
 yet to be proved that they are causative, and not concurrent 
 manifestations, whilst it is probable that they are merely foci of 
 colloid degeneration, (b) In rabbits suffering from undoubted 
 psorospermosis, outgrowths somewhat similar in nature to epithe- 
 lioma have been detected in the biliary ducts and certain viscera, 
 and these growths have even been produced by artificial inocula- 
 tion with the organisms. Mention must be made here of Dr. 
 Lack's interesting experiment in which he caused an extensive 
 intraperitoneal development of cancer in a rabbit by scattering 
 broadcast throughout the cavity the scrapings of an ovary which 
 necessarily contained a vast number of living epithelial cells. His 
 
TUMOURS AND CYSTS 
 
 175 
 
 idea is that cancer is merely the outcome of the development of 
 epithelium placed in unusually favourable nutritive conditions, 
 e.g., in lymphatic spaces. 
 
 Epithelioma {syn. : Squamous Epithelioma, Epithelial Cancer). — 
 By this term is meant a cancerous tumour growing from skin or 
 from those portions of the mucous membranes which are covered 
 with squamous epithelium. The variety formerly known as 
 columnar epithelioma is really of glandular origin, and will be 
 described separately. 
 
 Epithelioma is usually met with in middle-aged or elderly 
 individuals, although occasion- 
 ally it is seen in young adult 
 life. Any portion of the skin 
 may be the site of this tumour, 
 as also the mucous membrane 
 of the mouth, pharynx and oeso- 
 phagus, and that lining the 
 genito- urinary tract. It com- 
 monly results from some long- 
 continued irritation, as in the lip 
 or tongue, whilst on the penis it 
 is always associated with a long 
 foreskin. Old scars, especially if 
 they become ulcerated, are likely 
 to be invaded, and the disease 
 may supervene on intractable 
 lupus. 
 
 Clinically, epithelioma may be 
 looked on as a malignant wart, 
 which not only grows outwards 
 from the surface, but also 
 burrows deeply into adjacent 
 tissues ; sooner or later ulcera- 
 tion follows. Several character- 
 istic 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. 39). (b) The destruc- 
 tive 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) Occasionally the superficial 
 outgrowth is excessive, and the destructive process limited, 
 giving rise to a projecting cauliflower-like mass, which is soft and 
 easily _ bleeds {malignant papilloma), (d) A chronic epithelioma is 
 sometimes seen, in which the fibrous stroma contracts and com- 
 
 
 \ 
 
 A 
 
 / A 
 1 
 
 7 
 
 Fig. 39. — Typical Epitheliomatous 
 Ulcer, showing Heaped-up Mar- 
 gins and Deep Central Crateri- 
 form Excavation. (College of 
 Surgeons' Museum.) 
 
I7 6 A MANUAL OF SURGERY 
 
 presses 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. 
 
 The disease, as a rule, early infects neighbouring lymphatic 
 glands, which become the seat of a similar growth, and, if super- 
 ficial, sooner or later involve the skin and give rise to charac- 
 teristic ulceration. As the disease progresses, more distant 
 groups of lymphatic glands are attacked ; it is unusual to find 
 this form of cancer disseminated through the internal viscera. 
 The glands sometimes become cystic, especially in the neck, and on 
 cutting into them a thin, turbid fluid like sero-pus escapes, mixed, 
 
 j* 
 
 
 .■oaooo 
 
 Fig. 40. — Section of Epithelioma. (Ziegler.) 
 
 a, Epidermis ; b, corium ; c, subcutaneous areolar tissue ; d, sebaceous gland ; 
 e, hair follicle ; /, cancerous ingrowths from the epidermis ; g, deeply-set 
 cancerous cell groups ; h, proliferating fibrous tissue ; i (above), cell nesl 
 or epidermic globe ; i (below), sweat gland. 
 
 perhaps, with 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 also follow, 
 and cause death from haemorrhage ; otherwise the fatal event is 
 due to cachexia and exhaustion. 
 
 Microscopically, an epithelioma consists of club-shaped columns 
 of epithelial cells, 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 
 growth (Fig. 40). The superficial cells in epithelioma are usually 
 
TUMOURS AND CYSTS 
 
 177 
 
 squamous in type, but in the deeper parts prickle cells are not 
 unfrequently observed, whilst the processes are bounded by a 
 tolerably definite layer of cuboidal epithelium, tending to become 
 columnar. Within the processes, concentrically arranged collec- 
 tions of squamous cells round one or more enlarged cells are often 
 seen, known as 'epithelial nests ' (Fig. 40, i). The stroma in the 
 neighbourhood of the advancing columns is always infiltrated 
 with an abundant exudation of leucocytes. 
 
 Rodent Ulcer is generally admitted to be a cancerous tumour of 
 an epitheliomatous type, commencing probably in the sebaceous 
 glands. It is usually 
 met with in elderly 
 patients, though 
 occasionally observed 
 in those under forty, 
 and is seen with 
 special frequency on 
 the upper two-thirds 
 of the face, the skin 
 below the inner and 
 outer canthi being 
 the chief seats of 
 election. It com- 
 mences as a papule 
 or flat-topped nodule 
 in the skin, sur- 
 rounded, perhaps, by 
 an area of hyperemia. 
 The infiltration ex- 
 tends gradually in all 
 directions, but the 
 ulceration usually 
 keeps pace with the 
 new growth. The 
 ulcer has a smooth 
 but somewhat de- 
 pressed surface, is 
 perhaps covered with 
 granulations, and 
 bounded by a 
 slightly-raised, indurated, rolled-over edge (Fig. 41). In the 
 later stages one can often detect evidences of the new forma- 
 tion beneath the skin beyond the edge. If kept aseptic, there is 
 but little discharge, and imperfect attempts at cicatrization are 
 often observed, the scar, however, readily breaking down; but 
 when septic, the surface is covered with sloughs, and an abundant 
 offensive discharge escapes. The condition is painless ; neigh- 
 
 12 
 
 -Rodent Ulcer. 
 Photograph. 
 
178 A MANUAL OF SURGERY 
 
 bouring lymphatics are not enlarged, and the general health does 
 not suffer, except in the later stages. The progress of the case is 
 slow, but continuous, and although it spreads superficially rather 
 than deeply, sooner or later underlying structures become in- 
 volved, and nothing hinders the destructive process, even the 
 bones of the skull being eroded, and the dura mater exposed. 
 
 Microscopically, the growth is very similar to an epithelioma, 
 consisting of interlacing columns of epithelial cells, interspersed 
 with fibro-cellular tissue. The chief differences consist in the 
 facts — (i.) that the constituent cells, although epithelial, are not 
 epidermic in character, being smaller, more globular, never of the 
 ' prickle-cell ' type, and rarely showing signs of keratinization ; 
 hence, ' cell nests ' are uncommon, although they are sometimes 
 observed, (ii.) The deep processes are not so distinctly columnar 
 or club-shaped, spreading laterally beneath the unaffected skin 
 rather than deeply ; their outline is also more clearly defined, and 
 frequently angular on section, (iii.) There is less cell infiltration 
 around the new formation. 
 
 The Treatment of rodent ulcer consists 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 such cannot be undertaken, the ulcer 
 may be 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 X rays have also 
 proved beneficial in these cases, the patient being submitted to 
 their influence for about ten minutes daily. The surrounding 
 parts are protected by plates of soft metal foil carefully fitted to 
 them, and with a suitable hole in the centre exposing the sore. 
 Sometimes a good deal of irritation results, but frequently the 
 ulcer rapidly cleans up and commences to heal. 
 
 Columnar Carcinoma. — This affection, which was formerly 
 termed ' columnar epithelioma,' is in the majority of cases a true 
 glandular cancer. It is met with most frequently in the alimentary 
 canal, arising from any portion of it in which columnar epithelium 
 occurs, and usually originating as an overgrowth of Lieberkiihn's 
 follicles (Fig. 42). These form a projecting growth from the 
 surface in the same way as a papilloma springs from the skin, but 
 also penetrate deeply into the submucous and muscular coats. 
 The deep processes retain an imperfect alveolar arrangement, and 
 between them is found a certain amount of fibro-cellular stroma, 
 upon the character of which the hardness of the tumour depends. 
 In the firmer types the stroma is abundant, and fibro-cicatricial 
 in quality, the growth of the tumour being slow ; in the softer and 
 more rapidly-growing forms the stroma is less abundant, and more 
 of a simple fibro-cellular nature. On section of a limited portion 
 of the growth, it would often be impossible to distinguish it from 
 a simple adenoma of Lieberkiihn's follicles ; but if a large section, 
 
TUMOURS AND CYSTS 179 
 
 including the whole thickness of the intestinal wall, is examined, 
 the extension of the glandular tissue into and between the mus- 
 cular fasciculi at once indicates the malignant nature of the case. 
 Ulceration usually occurs, giving rise to a typical sore, bounded 
 in the more chronic forms by indurated and everted edges. Neigh- 
 bouring lymphatics are implicated, as in the case of all cancers, 
 whilst later on the disease spreads to the viscera, and may be 
 
 02 
 
 
 i 
 
 I 
 
 1 
 
 Fig. 42. — Section through Advancing Margin of Columnar Cancer of 
 Stomach, x 25 (Ziegler.) 
 
 a, Mucosa; b, submucosal c, muscularis; (/.serosa; e, neoplasm which, starting 
 from the mucosa, has invaded the other layers. Small-celled infiltration 
 has accompanied here and there the formation of the neoplastic tubules. 
 
 generally disseminated. A similar type of growth occurs in the 
 cervical portion of the uterus, and occasionally in the ducts of 
 glands such as the liver and breast. It is also met with in the 
 superior maxilla, originating in the tubular glands of the mucous 
 membrane lining the antrum. 
 
 Glandular or Acinous Cancer. — Glandular cancer may be looked 
 on as a malignant form of adenoma, bearing the same relation to the 
 latter as does an epithelioma to a benign papilloma. The epi- 
 thelium of the glandular acini, from which it originates, is not 
 retained by the basement membrane, but travels beyond it along 
 
 12 — 2 
 
180 A MANUAL OF SURGERY 
 
 the lymphatics into surrounding parts, which are transformed 
 by a process already described into the tumour substance. 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 applied ; to the latter, Encephaloid. 
 
 Scirrhus is met with most frequently in the breast, but also 
 occurs in the prostate, pancreas, and pyloric end of the stomach. 
 The clinical features of the disease as seen in the breast are 
 described in Chapter XXXI. On naked-eye examination a 
 scirrhous tumour appears as a hard nodular mass, the limits 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 fibrous 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 scraping the cut surface with 
 the blade of a knife, a typical cancer juice is obtained, consisting 
 of epithelial cells and debris. 
 
 On microscopical examination, the tumour is found to consist 
 of an abundant and well-marked stroma, the acini of which are 
 filled with epithelial cells (Plate V., Fig. i). In the centre fatty 
 degeneration is often present, small cysts being occasionally 
 produced in this way. At the periphery the growth may be seen 
 extending in all directions along the lymphatics, whilst a round- 
 celled infiltration of the surrounding tissues is also evident. 
 
 Where the stroma is very excessive, the cell elements, and, 
 indeed, the whole tumour, may undergo atrophy, owing to the 
 compression of the nutrient vessels, constituting the variety 
 known as atvopliic scivrluis. 
 
 Encephaloid, Medullary, or Acute Cancer, is the term given to 
 a growth of a similar nature, in which the stroma is much less 
 abundant than the cell elements. It constitutes a soft, rapidly 
 growing tumour abundantly supplied with bloodvessels, and very 
 early affecting neighbouring lymphatic glands. The skin over 
 such a tumour is stretched, and dilated blue veins can be seen 
 through it. Ulceration occurs early, and from this surface a foul, 
 bleeding, fungating mass sprouts up, formerly known as a ' fungus 
 haematodes.' Encephaloid cancer is met with in the breast, testis, 
 kidney, and a few other glandular organs. 
 
 On section it is found to be composed of a soft whitish mass, 
 somewhat resembling brain substance. It is usually very vascular, 
 perhaps pulsating, and haemorrhagic extravasation into its tissues 
 is not uncommon. An abundant juice is obtained on scraping. 
 Under the microscope large groups of spheroidal epithelial cells 
 are seen, held together by a scanty stroma. 
 
 Colloid Cancer results from a degeneration of the epithelial 
 
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 W 
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 C H 
 
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 _ u 
 5C 
 
TUMOURS AND CYSTS 
 
 cells of a glandular or columnar cancer. Its most frequent site is 
 within the abdominal cavity, in connection with cancers arising 
 from the stomach, intestine, or omentum. 
 
 To the naked eye colloid cancer presents an alveolar structure, 
 the spaces being filled Avith translucent gelatinous material of 
 varying density. Microscopically, the epithelial cells are rarely 
 distinguishable, being replaced by a structureless colloid sub- 
 stance. Towards the growing margin, however, the cells may be 
 seen in process of degeneration, globules of the material forming 
 within them and pressing the nucleus to one side. 
 
 The Treatment of Cancer consists in the removal of the tumour 
 by operation, together with a wide margin of healthy tissue around 
 it, or, in some cases, of the whole organ affected, as well as the 
 lymphatic area concerned, and, if practicable, in one mass, so as 
 not to cut across the lymphatic vessels passing from the growth 
 to the glands. If such is conducted in a thorough manner and at 
 a sufficiently early date, a good result may be anticipated ; but, 
 owing to the tendency of all cancers to spread along lymphatics, 
 its eradication is usually a matter of the greatest difficulty. 
 Recurrence is therefore very liable to ensue. 
 
 In cases where removal of the disease by the knife is im- 
 practicable, owing to its extent, it may sometimes be possible to 
 remove a portion of the disease, the remainder being dealt with by 
 caustics. Of these the most satisfactory is chloride of zinc, which 
 is usually applied as a paste, a little opium being added to allay 
 pain. In other instances it has been proposed to starve the 
 growth by tying the chief nutrient artery, and to diminish pain 
 by division of sensory nerves ; such can, however, only give the 
 most temporary relief. 
 
 Of recent years other methods have been suggested for the 
 treatment of inoperable malignant disease — e.g., the interstitial 
 injection of pyoktanin or methyl violet, or of various bacterial 
 products, such as Coley's fluid (p. 160). The evidence at present 
 forthcoming suggests that the practical value of these proceedings 
 is very small in the case of the cancers. Superficial cancers, such 
 as epithelioma labii, can be cured by exposure to the X-rays, but 
 it is doubtful whether deeply-seated foci can be influenced in 
 this way. 
 
 In hopeless cases, all that can be done is to keep any ulcerated 
 surface free from irritation, and if possible aseptic, whilst the 
 general health is maintained by suitable diet and drugs, and 
 excessive pain is kept in check by the administration of opium or 
 morphia. 
 
 Cysts. 
 
 By a cyst is usually meant a more or less rounded cavity, with 
 a distinct lining membrane, distended with some fluid or semi- 
 
182 
 
 A MANUAL OF SURGERY 
 
 solid material. The term is used very loosely, being applied to a 
 variety of manifestations which it is difficult to classify, owing to 
 the fact that conditions which are pathologically similar in origin 
 are sometimes termed cysts in one part of the body, and not so in 
 another. For practical purposes, however, they may be grouped 
 as follows : 
 
 I. Cysts of embryonic origin, or arising in connection with 
 embryonic remains. 
 
 II. Cysts arising from the distension of pre-existing spaces (dis- 
 tension cysts). 
 
 III. Cysts of new formation. 
 
 IV. Cysts of degeneration. 
 
 I. Cysts of Embryonic Origin, or arising in connection with 
 Embryonic Remains. 
 
 i. The most important cysts to be considered under this head- 
 ing are those known as Dermoids. These are characterized by the 
 existence in abnormal situations of cavities lined with epithelium, 
 from which may be developed any form of cutaneous appendage 
 
 — e.g., hairs, nails, teeth, etc. 
 — whilst the space is usually 
 occupied by sebaceous or 
 mucous contents. The struc- 
 ture of the lining wall is 
 very similar in nature to 
 l||#^v! V skin or mucous membrane, 
 
 % * ;1 ^ • P \^ 3 consisting of stratified epi- 
 
 fflMi*^^^\V. .. iasaia*, » thelium, from which a con- 
 
 siderable growth of sebaceous 
 glands and hair follicles often 
 takes place. 
 
 Several varieties of dermoids 
 are described : 
 
 (a) Sequestration Dermoids 
 are cysts arising from the 
 incomplete disappearance of 
 surface epithelium in situa- 
 tions where, during embryonic 
 life, fleshy segments coalesce. 
 Thus, in almost any part of 
 the middle line of the body 
 such tumours may develop, 
 owing to the fact that there is 
 here a union of two lateral segments. Similarly, they are not 
 uncommon about the face and neck, occurring along the lines 
 of the facial and branchial clefts. Perhaps the most common 
 position for them in this region is the upper portion of the 
 
 Fig. 43. — Dermoid Cyst, growing at 
 the Outer Angle of the Orbit. 
 (Bland Sutton.) 
 
TUMOURS AND CYSTS 1S3 
 
 orbito-nasal cleft, behind and to the outer side of the eye 
 Fig. 43). It is not unusual to find the skull defective beneath 
 them, and a pedicle extending from the deep side, connecting 
 them with the dura mater. Sequestration dermoids appear 
 as rounded, definitely limited tumours, over which the skin 
 glides freely, but are usually somewhat adherent to the deeper 
 parts. They are firm and elastic to the touch, and filled 
 with sebaceous material, containing fatty debris, flattened 
 epithelial cells, perhaps hairs, and occasionally teeth. This 
 form of dermoid may be removed without difficulty, but in 
 those occurring about the scalp, with the bone hollowed out 
 beneath them, it is perhaps advisable to delay operation till adult 
 life, unless the tumours are rapidly increasing in size. The reason 
 for this is that the bone gradually grows up around the pedicle, 
 and thus closes the communication with the cranial cavity. In 
 some cases it may be difficult to remove the whole of the lining 
 membrane by dissection, and under these circumstances the 
 portion left behind should be destroyed with cautery or caustics : 
 otherwise, recurrence is almost certain to follow. 
 
 (b) Dermoids may also arise in connection with embryonic 
 canals and passages, and have then been called Tubulo-Dermoids. 
 These are chiefly met with in connection with the thyro-glossal 
 duct (Chapter XXIX.) and the post-anal gut (Chapter XXII.). 
 
 (c) Ovarian Dermoids are usually unilocular, and of large size. 
 They are lined with skin, from which an abundant development 
 of cutaneous appendages is sometimes observed. Thus, the 
 cavity may be more or less filled with hair, whilst large masses 
 of teeth set in bony alveoli are also seen in this situation, and even 
 nipples and mammae. 
 
 2. Cysts occasionally arise in connection with the formation of the 
 teeth ; such have been already alluded to under the terms follicular 
 and epithelial odontomes (p. 171), the former being also known as 
 dentigerous cysts, the latter as fibro-cystic disease of the jaw. 
 
 3. Various cysts develop in connection with the remains of 
 the Wolffian body, as also from its tubules and duct. It must be 
 remembered that this body arises in the posterior abdominal wall 
 near to the origin of the kidney and testis, and that part of it 
 enters into the formation of the latter ; hence one is not surprised 
 to find that its remains are closely associated with that organ in 
 the scrotum. 
 
 In the male (Fig. 44) the Wolffian body atrophies almost com- 
 pletely, being represented by a few blind tubules, situated close 
 to the epididymis, and known as the paradidymis, or organ of 
 Giraldes. Fibro-cystic disease of the testis (adenoma testis) is 
 said to arise from this structure. The majority of the ducts of 
 the Wolffian body form the vasa efferentia testis ; a few of the 
 upper ones, however, contract no attachment to the gland, and 
 their free ends (known as Kobelt's tubes) may become dilated, 
 
1 84 
 
 A MANUAL OF SURGERY 
 
 and form small cysts, situated close to the hydatid of Morgagni, 
 which structure represents the remains of the Miillerian body and 
 duct. It is possible that an encysted hydrocele of the epididymis 
 sometimes arises from one of these unobliterated tubules. The 
 main duct of the Wolffian body forms the lower portions of the 
 epididymis and vas deferens. 
 
 In the female (Fig. 45) the remains of the Wolffian body are 
 sometimes met with as a series of closed tubes in the neighbour- 
 hood of the ovary (paroophoron). Cysts may arise in connection 
 with this structure, and are chiefly characterized by their inner 
 walls being the seat of proliferating papillomata. The Wolffian 
 tubules can almost always be recognised in the broad ligament, 
 
 Paradidymis or 
 
 A i'jJ~$£ Mesonephros. 
 
 Kobeh's tubes. 
 
 Fig. 44. 
 
 -Diagram of Adult Testicle, to show Relation of Mesonephros 
 and its Ducts. (Bland Sutton.) 
 
 constituting the parovarium, or organ of Rosenmuller. Parovarian 
 Cysts formed from the distension of this structure are usually 
 unilocular, and filled with a clear limpid serous fluid ; they have 
 no definite pedicle, and strip up the layers of the broad ligament. 
 Some of the terminal tubes may be converted into small cysts 
 which project from the fimbriated ends of the Fallopian tube, and 
 are known as cysts of Kobelt's tubes. The main Wolffian duct 
 generally atrophies, but occasionally runs down between the layers 
 of the broad ligament close to the uterus, to open in the vagina 
 near the urethral orifice, being then known as Gartner's duct. 
 Cysts may occasionally arise in connection with this structure, 
 projecting into the lateral fornix of the vagina. 
 
 4. The processus vaginalis, or funicular process, is the term 
 applied to the protrusion of peritoneum which precedes the testis 
 
TUMOURS AND CYSTS 
 
 185 
 
 to form the tunica vaginalis, and which in the female accompanies 
 the round ligament (canal of Nuck). Normally it becomes 
 obliterated, but sometimes portions of it remain patent, and are 
 distended with a clear straw-coloured serous fluid, constituting 
 in the male an encysted hydrocele of the cord, and in the female a 
 hydrocele of the round ligament. 
 
 II. Cysts due to the Distension of Pre-existing Spaces. 
 
 (a) Exudation Cysts arise from the distension of cavities which 
 are unprovided with excretory ducts, and are frequently of an 
 inflammatory nature. Such spaces may be lined with epithelium 
 or endothelium. As illustrations of epithelial cysts may be 
 
 Fig. 45 — Diagram to represent the Cyst Regions of the Ovary. 
 (Bland Sutton.) 
 
 A, Oophoron, or ovarian tissue; B, paroophoron, or tissue of the hilus ; C, 
 parovarium ; K, Kobelt's tubes ; G, Gartner's duct (= main Wolffian duct). 
 
 mentioned those which arise in connection with the thyroid body, 
 as also conditions due to the distension of the central canal of 
 the nervous system (syringo-myelocele), and those forms of 
 ovarian cysts which arise from distension of Graafian follicles. 
 
 Exudation cysts lined by a serous or endothelial wall are much 
 more numerous. Enlargements of bursas, hydroceles of the 
 tunica vaginalis, funicular process, or canal of Nuck, and some 
 forms of ganglia, are of this nature. Diverticula or hernial pro- 
 trusions of the synovial membrane of joints also occur, and are 
 known as Baker's cysts. 
 
 A Serous Cyst is supposed to arise from the distension of lymph 
 spaces, giving rise to uni- or multi-locular cavities, lined with 
 endothelium, and containing a limpid straw-coloured fluid. They 
 
186 A MANUAL OF SURGERY 
 
 are seen most commonly in the neck, axilla, or breast, and in the 
 latter structure may be surrounded by a dense, sclerosed, fibrous 
 tissue. It is usually possible to dissect them out, but occasionally 
 one has to rely on draining them or on stuffing them, so as to 
 insure healing by granulation. 
 
 Adventitious bursae are formed in a precisely similar manner. 
 
 (b) When a collection of blood forms in a pre-existing cavity, a 
 so-called Cyst of Extravasation is produced. Such is met with in 
 the pelvis or tunica vaginalis (hematocele), and also occasionally 
 on the surface of the brain, constituting what is known as an 
 arachnoid cyst. 
 
 (c) Retention Cysts always arise from obstruction to the escape 
 of some natural secretion from a gland duct or tubule. The 
 cavity thus formed is lined with epithelium, whilst, owing to the 
 irritation produced by the tension, a fibro-cicatricial wall of 
 variable thickness is developed outside. There is often a con- 
 siderable formation of intracystic growths, especially in the 
 breast, whilst the contents generally consist of the inspissated 
 secretion, perhaps mixed with blood. 
 
 Retention cysts may develop in connection with any glandular 
 tissue. The majority are described under the appropriate headings, 
 viz., Mammary cysts, Renal cysts, Pancreatic cyst, etc. 
 
 III. Cysts of New Formation are such as occur apart from 
 any embryonic condition or pre-existing cavity. The following 
 varieties may be described : 
 
 (a) An Implantation Cyst is one which arises from the accidental 
 intrusion into the subcutaneous or submucous tissues of epithelial 
 cells which retain their vitality, and are enabled to develop a cyst 
 very similar in nature to a dermoid ; in fact, it may be looked 
 on as an Acquired or Traumatic Dermoid. Such an occurrence is 
 usually brought about as the result of an injury, especially from 
 punctured wounds ; thus, cysts of this nature have been met 
 with in the fingers or palm of the hand as a consequence of the 
 penetration of some sharp instrument, whilst they are also occa- 
 sionally seen in the anterior chamber of the eye, following an 
 iridectomy. They are, moreover, observed in the axillae of cattle, 
 as a result of goading them with a sharp implement. The clinical 
 signs and treatment are similar to those of a dermoid cyst. 
 
 (b) Cysts sometimes form around foreign bodies, which thus 
 become encapsuled. They are lined by granulation tissue or 
 endothelium, surrounded by a variable amount of fibro-cicatricial 
 tissue. 
 
 (c) Blood Cysts are sometimes of doubtful origin. Some of them 
 certainly arise from extravasation of blood, and in such cases 
 coagulated blood, or a thin serous fluid, is found within, the cavity 
 being perhaps lined with laminated fibrin. In many cases a so- 
 called blood cyst is really a soft sarcoma, into which haemorrhage 
 
TUMOURS AND CYSTS 
 
 .87 
 
 has occurred ; but in addition to these, a few instances are on 
 record in which a thin-walled cavity existed, occupied by blood, 
 and readily refilling after it had been tapped. Such conditions 
 have been most frequently observed in the neck (see Chapter 
 XXIX.). 
 
 (d) Parasitic Cysts are produced by the irritation caused by the 
 growth within the tissues of certain living organisms. Thus, in 
 the disease known as trichinosis, derived from eating unsound 
 pork, the Trichina spiralis, a small round worm, 
 develops in large numbers in the voluntary 
 muscles, and becomes surrounded by a capsule 
 which is subsequently calcified. 
 
 The most important of these parasitic cysts 
 is that caused by the development within the 
 body of the scolex stage of the Tania echino- 
 coccus, giving rise to what are known as Hydatid 
 Cysts. This disease is much more common in 
 Australia than in this country. The Tceuia 
 ecliinococcus (Fig. 46) is a minute tapeworm, less 
 than half an inch in length, which inhabits the 
 intestinal canal of dogs ; it consists of four 
 segments, the posterior one being larger than 
 the rest of the body, and containing the genital 
 organs. When mature, this last segment be- 
 comes filled with ova, which are discharged, 
 and these find their way into the human 
 stomach by the media of water or uncooked 
 vegetables, such as watercress, which have been 
 contaminated with the dog's excreta. The pro- 
 cess of digestion sets the embryo free, and by 
 means of a crown of little hooks which it pos- 
 sesses, as well as four suckers, it is enabled to 
 bore its way through the walls of the stomach, 
 and thence travels by the bloodvessels to the 
 liver or some other part of the body. As a result 
 of the irritation caused by its presence, a sac 
 forms which originally consists of three layers ; 
 externally, a fibro-cicatricial layer, then an inter- 
 mediate lamellated layer of chitinous material 
 (true ectocyst), and finally the cyst is lined by a 
 protoplasmic germinal layer (endocyst), from 
 which may be developed solitary taenia heads or scolices, also 
 provided with four suckers and a circlet of hooks, whilst some- 
 times groups of them, known as brood-capsules, may arise in the 
 same way (Fig. 48). Daughter-cysts are not unfrequently formed 
 from the scolices, and they in their turn may pass through the 
 same changes, although as a rule they are barren. Occasionally 
 even the main cyst may be sterile (acephalocyst), and in such cases 
 
 &-, 
 
 ViX^ 
 
 Fig. 46. — T.3;nia 
 Echinococcus. 
 
 X ABOUT 20. 
 
A MANUAL OF SURGERY 
 
 the walls become very definitely laminated. The fluid contained 
 in the cyst varies much in amount, but is always of low specific 
 
 Fig. 47. — Hydatid Cyst (Diagrammatic) showing Daughter-Cysts and 
 Brood-Capsules growing from the Walls. (After Bland Sutton.) 
 
 Fig. 48.— Diagrammatic Section of Wall of Cyst. 
 a, Fibro-cellular capsule, here somewhat exaggerated ; b, lamellated chitinous 
 layer, or ectocyst ; c, brood-capsules developing from the protoplasmic 
 layer, or endocyst ; d, scolex, or separate head, enlarged. 
 
 gravity, not more than 1007 ; it is colourless, but slightly opales- 
 cent, limpid, and contains but a trace of albumen, although a 
 considerable amount of chloride of sodium is present. On 
 
TUMOURS AND CYSTS 
 
 examining the fluid microscopically, the characteristic hooklets 
 are observed. The organs usually affected by hydatid disease 
 are the liver, kidneys, and brain, but any part of the body may 
 be attacked. Occasionally in the liver, and usually in bone, 
 multiple cysts develop quite distinct from each other, and with no 
 general cyst- wall (exogenous multiplication). This can only occur 
 when the ectocyst is thin, allowing the scolices, which always 
 have a retractile neck, to push through and ' swarm off ' into 
 surrounding tissues. 
 
 Hydatid cysts give rise to no special symptoms, except those 
 caused by their size and situation, and they are likely to go on 
 growing until operative treatment becomes imperative on account 
 of some complication, or from the size of the mass. At any time 
 the cyst may rupture, either spontaneously or as the result of some 
 injury ; if into a serous cavity, such as the peritoneal or pleural, 
 this becomes infected, and an abundant development of scolices 
 and cysts ensues, giving rise to considerable localized inflam- 
 matory reaction ; moreover, the escape of the cyst fluid may 
 cause serious toxaemia, or, at any rate, urticaria, owing to the 
 presence therein of some toxic substance. 
 
 Occasionally the organism dies spontaneously, and then the cyst 
 shrivels up, and the laminated walls and daughter-cysts form 
 a firm leathery mass, perhaps infiltrated with lime salts and of 
 the consistency of wet mortar ; a thick fibro-cicatricial capsule 
 encloses the whole. At other times suppuration takes place within 
 the cyst and an abscess results. If acute, it bursts either exter- 
 nally, or may open into some serous cavity or hollow viscus ; in 
 the last case, the cyst may evacuate itself, and a spontaneous cure 
 result. Sometimes the abscess becomes chronic and encapsuled, 
 and may then remain quiescent for years. 
 
 For the diagnosis and treatment of hydatid cyst of the liver, see 
 Chapter XXXII.). In other regions, if the tumour cannot be 
 removed by dissection, reliance must be placed on drainage, 
 where the situation of the growth renders this practicable, or 
 aspiration, since it is usually found that removal of the fluid 
 contents causes death of the organism, probably by altering the 
 intra-cystic tension. 
 
 IV. Cysts of Degeneration arise in connection with tumours, 
 especially those where the blood-supply is not very abundant. 
 Thus, mucoid degeneration is not uncommon in fibromata, fibro- 
 myomata, chondromata, and even in the harder forms of cancer. 
 Occasionally cysts form in the sarcomata from this cause, but 
 more frequently as a result of haemorrhage. 
 
CHAPTER VIII. 
 
 WOUNDS. 
 
 A wound has been defined as the forcible solution of continuity 
 of any of the tissues of the body ; but the term is more commonly 
 limited to injuries of the soft parts, involving the skin or mucous 
 membranes. Lesions in which the skin does not participate, and 
 in which the deeper structures, such as bones, ligaments, etc., are 
 not involved, are spoken of as contusions. 
 
 A Contusion is any subcutaneous wound or injury due to the 
 agency of external violence, causing laceration of the cellular 
 tissue, without necessarily involving such deeper structures as 
 muscles, tendons, nerves or bones. The signs are usually very 
 obvious, viz., pain, bruising, or discoloration of the part, and 
 swelling. These are readily explained by the injury inflicted on 
 the subcutaneous tissues, which in the worst cases may be entirely 
 disorganized and separated from the skin. The amount of bruising 
 varies with the part injured and the severity of the lesion ; thus, 
 in the eyelids, scrotum, and vulva, where the tissues are lax, the 
 ecchymosis will be very extensive and of a black colour ; on the 
 scalp there is, on the other hand, but little swelling, if the injury 
 does not include bleeding beneath the aponeurosis of the occipito- 
 frontalis. Again, the condition of the patient's general health 
 influences the amount of blood effused ; in a strong man in good 
 training, but little bruising is seen, whilst in those of a languid 
 temperament and relaxed tissues, a slight injury often produces a 
 very conspicuous ecchymosis. Blebs and bullae may form over 
 the injured spot in bad cases. The changes that occur in a bruise 
 are well known, the colour passing from a blackish-purple through 
 various shades of brown and green to a yellow, which gradually 
 fades and disappears ; this is due to the disintegration of the red 
 corpuscles, and staining of the tissues by the haemoglobin thus 
 set free, or by the products formed during its removal. When 
 haemorrhage has taken place into the deeper parts or under dense 
 fasciae, it is often some days before the bruise ' comes out,' and 
 this may occur at some distant spot, e.g., in the eyelids after a 
 blow on the scalp, whilst after a fracture of the neck of the 
 
WOUNDS 191 
 
 humerus the blood may travel along the muscular and fascial 
 planes, and the bruise first appear about the elbow. 
 
 In a bruise or ecchymosis, the tissues are, as a rule, merely 
 infiltrated with blood, but occasionally the extravasation is more 
 localized, collecting in a cavity formed by the laceration of the 
 tissues, and remaining as a fluid swelling, or Haematoma. If 
 somewhat resembles an abscess to the touch, but differs from it in 
 its history, having supervened immediately after an injury, and 
 having appeared without any heat or other sign of inflammation ; 
 moreover, though at first fluid and soft, it soon becomes harder, 
 whereas an abscess is preceded by a stage of brawny infiltration, 
 and the softening occurs later. The subsequent history of a 
 haematoma varies somewhat according to circumstances, (a) A 
 deposit of fibrin may be formed peripherally, leaving for a time a 
 fluid centre, which gradually disappears, and the whole is finally 
 absorbed. This is well exemplified in a sub-pericranial cephal- 
 hematoma, where the contrast between the fibrinous deposit with- 
 out and the fluid centre is sometimes so accentuated as to give 
 the impression of a depressed fracture, (b) The fluid portion of 
 the blood may be absorbed almost entirely, and the solid fibrinous 
 residuum may become organized into a firm fibroid tumour which 
 persists indefinitely ; the mass is more or less laminated, and not 
 unfrequently pigmented, (c) The fibrin may be entirely absorbed, 
 and a slightly pigmented fibrous capsule formed containing serous 
 fluid, and constituting a definite cyst ; such is best seen in con- 
 nection with the cerebral tunics (arachnoid cyst), (d) Suppuration 
 may ensue owing to infection from within the body, or from an 
 invasion of organisms through abraded skin. 
 
 In forming an opinion as to the gravity of a subcutaneous 
 injury, one must be guided by the part injured, the extent of 
 tissue involved, the amount of blood extravasated, and the age 
 and vitality of the individual. In the less severe cases, though 
 there may be a good deal of bruising, recovery will ensue, but 
 under less favourable conditions sloughing and death of the 
 injured tissues may result. 
 
 The Treatment of a bruise usually consists in the application of 
 cold or evaporating lotions and pressure in order to check the 
 bleeding, but such must be used with care in old weakly individuals 
 or where much laceration of the tissues has taken place, for fear 
 of the injured parts dying. The skin should never be incised 
 except under special circumstances, such as the rupture of a large 
 artery, or when some definite advantage is to be gained by dealing 
 at once with the injured structures; for though under careful anti- 
 sepsis the dread of opening recent collections of blood no longer 
 exists, yet it should not be lightly undertaken. At the same time, 
 when a tense and painful haematoma exists, as under the fascia 
 lata of the thigh, recovery can be hastened and pain relieved by 
 an aseptic puncture, followed by careful compression. In general 
 
192 A MANUAL OF SURGERY 
 
 bruising of the body from a fall or extensive injury, pain can often 
 be relieved by applying fomentations or by a hot bath. There is 
 generally a certain amount of fever and constitutional disturbance 
 for a few days, and these are dealt with by purgatives and a suit- 
 able limitation of diet. 
 
 Open Wounds. 
 
 An open wound may be defined as a solution of continuity of 
 any superficial part of the body, including skin or mucous mem- 
 brane. Various kinds of wounds are described, such as the 
 incised, lacerated, contused, punctured, poisoned, and gunshot ; 
 but, of course, the most important distinction to draw is between 
 the infected and the non-infected. 
 
 1. Incised Wounds. — An incised wound is one made by any 
 sharp cutting instrument, but occasionally a wound not produced 
 in this manner may be characterized by similar appearances ; 
 e.g., the skin of the knee or elbow may be cleanly split open from 
 falling on it with the limb flexed, and occasionally a policeman's 
 truncheon will lay open the scalp almost as evenly as if a knife 
 had been employed. 
 
 The special features of an incised wound are as follows : 
 i. The haemorrhage is free, from the fact that the vessels are 
 cleanly divided. The amount necessarily depends on the size of 
 the vessels involved, and the vascularity of the part ; its continu- 
 ance, upon the density of the structures allowing or not of con- 
 traction and retraction of the severed ends. 
 
 2. Separation of the lips of the wound also occurs, the amount 
 depending upon the elasticity and character of the parts involved. 
 
 3. Bruising of the margins of the incision is absent, so that under 
 ordinary circumstances rapid healing (by first intention) should 
 obtain. The surfaces, to begin with, are lined by a microscopic 
 layer of damaged tissue, some of which may be actually dead ; 
 but if suitable precautions are taken, this is absorbed, and in no 
 way interferes with satisfactory union. 
 
 Treatment of Incised Wounds. — Seven essentials must be 
 attended to if healing by first intention is to be obtained, viz. : 
 
 (i.) The Arrest of all Bleeding. —If there is general oozing, 
 exposure to the air is often quite sufficient ; or sometimes it may 
 be supplemented by pressure for a few minutes with an aseptic 
 sponge. Arteries and veins will need a ligature, but if situated 
 close to the skin, they may often be secured by passing under the 
 bleeding spot the needle used for the suture. 
 
 (ii.) Sterilization of the Wound and its Surroundings. — When 
 made by the surgeon through skin which has been previously 
 purified, and if efficient precautions as to hands, instruments, etc., 
 have been taken, there is no need to flush out the wound with 
 any antiseptic. All such substances are more or less irritating, 
 and when introduced into a fresh wound are likely to increase 
 
WOUNDS 193 
 
 exudation and render drainage necessary. In such cases it will 
 suffice to cleanse the parts with sterilized salt solution. 
 
 In casualty work, however, a wound, though cleanly cut, is 
 made through dirty skin, and portions of clothing, dirt, and 
 splinters of wood or glass may be carried in. Under these 
 circumstances the wound and its surroundings must be thoroughly 
 purified, according to the rules given on p. 18, and a free use of 
 1 in 20 carbolic lotion, or even of Lister's ' strong mixture ' 
 (5 per cent, of carbolic acid with 'i per cent, of corrosive sub- 
 limate), is advisable, whilst foreign bodies are removed. 
 
 (iii.) The coaptation of the opposed surfaces by means of sutures 
 may now be undertaken. Many substances have been, and are, 
 employed for this purpose, but amongst the best are fine silver 
 wire, silk, horsehair, silkworm gut and catgut. In casualty work, 
 and for parts of the body where but little scar is subsequently 
 desirable, as in the face, horsehair and silkworm gut, being non- 
 absorbent, are perhaps the best materials to employ ; but in 
 ordinary operative work, which will be more certainly aseptic, 
 and where the after-treatment is more efficient, fine catgut or silk 
 may be used. There are three chief varieties of sutures, viz., 
 the buried, the deep, and the superficial. 
 
 Buried sutures are now largely employed, since a foreign body 
 may be safely inserted into the tissues, if both it and the wound 
 are aseptic. Catgut and silk are the agents made use of, and 
 nerves, tendons, muscles or fasciae are the structures mainly dealt 
 with. In deep wounds it is always most desirable to effect union 
 in this way of all the divided tissues (that is, to build the part up 
 again), and not merely to unite the skin over them. 
 
 Deep stitches, or sutures of relaxation, are required in cases where 
 there is difficulty in bringing the edges of the wound together, in 
 order to transfer the tension from the healing margin to tissues 
 further away, the edges being thereby relaxed. For this purpose 
 thick silver wire may be employed, inserted ior i| inches from 
 the margins, and tied directly, or lead buttons may be interposed 
 next to the skin, and the ends of the wire fastened round the 
 projecting edges, thus diffusing the pressure over a greater space. 
 They are generally removed at the end of two or three days. 
 
 Superficial stitches, or sutures of coaptation, must be so inserted 
 as to bring the edges of the wound into contact without undue 
 pressure, and without any folding in of the skin. Various 
 methods are employed, viz.: I. The interrupted suture (Fig. 49, A), 
 in which each stitch is separately finished off, the knot lying well 
 to one side of the incision. This is generally utilized for wounds 
 which are of irregular shape or in which there is tension. 2. The 
 glover s stitch (Fig. 49, B) is a continuous one, in which the thread 
 is carried on from point to point, and only fastened at the ends ; 
 it is not to be recommended. 3. The blanket or buttonhole stitch 
 (Fig. 49, C) is the form of continuous suture which should be 
 
 J 3 
 
£94 
 
 A MANUAL OF SURGERY 
 
 employed for extensive wounds or incisions. In it the needle, 
 after traversing the lips of the wound, is carried under the slack 
 of the thread, so that the loop of each stitch, as it is tightened, is 
 maintained at right angles to the edge of the wound, whilst the 
 intermediate portion lies parallel to it. To fasten it off, the needle 
 is passed in the opposite direction through the edges of the 
 incision, with the free end long enough to prevent it coming 
 through, and so enable it to be tied to the double portion carried 
 through by the needle. 4. The quilled suture is not often employed. 
 
 Fig. 49. — Various Forms of Suture. 
 
 A, interrupted suture ; B, continuous suture ; C, blanket stitch. At the lower 
 end the needle has just been passed, and the way in which it catches up 
 the loop :*s indicated. At the upper end the method of finishing off 
 (originally suggested by the late Mr. Maunsell) is shown : viz., the needle 
 is passed in the opposite direction to all the other stitches, the free end 
 being left long, so as to enable it to be tied into a knot with the double 
 thread which the needle has carried through. 
 
 It consists in tying the stitches round a quill or portion of catheter 
 on either side of the wound, so that the deep surfaces may be 
 maintained in apposition, whilst the superficial portions are left 
 clear for additional sutures. The only conditions under which it 
 is now used are in the operations for ruptured perineum, or for 
 extensive perineal or urethral fistulae. 5. The twisted or jigure-of-8 
 suture is still occasionally made use of for harelip or scalp wounds, 
 
WOUNDS 
 
 195 
 
 but has many disadvantages. A pin or needle is passed through 
 the sides of the wound, which are brought into apposition with 
 the fingers, and maintained by twisting silk around either end of 
 the needle in a figure-of-8 fashion. 
 
 Plasters are sometimes used instead of sutures, but the wounds 
 must be very small and insignificant which only require such 
 treatment. A fine aseptic suture is in most cases preferable. 
 
 (iv.) Drainage must, if necessary, be provided, in order to 
 guard against the irritation and tension caused by retained blood 
 or exudations. In wounds where there is doubt as to the com- 
 pleteness of the haemostasis, or where there has been much 
 tearing or laceration of the tissues, it is wise to insert a tube for 
 24 or 48 hours, in order to allow effused blood to escape ; but if 
 the wound is dry and aseptic, and efficient pressure can be exerted 
 by the dressings, it may be dispensed with. 
 
 When drainage is required, the indiarubber tube introduced by 
 Chassaignac answers well ; the end should be cut flush with the 
 surface, and stitched to the edges of the wound so as to prevent it 
 slipping in or out. Decalcified bone tubes have been substituted, 
 but w T ith no distinct advantage. For small wounds, a strand of 
 horsehair or a strip of gauze or protective will usually suffice. 
 
 (v.) All fresh sources of irritation and infection of the wound 
 must be excluded by some form of antiseptic or aseptic dressing. 
 
 (vi.) Rest to the injured part must be secured by such an 
 arrangement of splints, slings, or bandages as may be necessary. 
 
 (vii.) The general health of the patient is a most important 
 item to attend to. In an operation case the bowels should, if 
 possible, be previously opened, and the patient's diet carefully 
 regulated ; in casualty work a good purge should be administered 
 as soon as convenient, and the food and drink limited. 
 
 Under ordinary circumstances an aseptic incised wound heals 
 in about five to seven days, but the actual time when it is safe to 
 remove the stitches varies with the age and vigour of the indi- 
 vidual, the part of the body, and the amount of tension required 
 to draw the lips of the wound together. In ordinary aseptic 
 operation wounds one usually removes the stitches on the eighth 
 day ; but in the face it is often possible and advisable to take 
 them out earlier, partly because the healing process is quickly 
 accomplished in such a vascular region, partly in order to mini- 
 mize the amount of scarring. 
 
 Many conditions may arise to prevent the healing of an incised 
 wound by first intention, and they may be epitomized as essenti- 
 ally the reverse of the seven conditions mentioned above — viz., 
 (i.) Non-arrest of the bleeding, causing separation of the lips or 
 deeper portions of the wound ; (ii.) the presence of impure foreign 
 bodies or other septic material ; (iii.) the edges not being brought 
 into contact ; (iv.) imperfect drainage, leading to tension on the 
 stitches ; (v.) subsequent infection of the wound owing to a 
 
196 A MANUAL OF SURGERY 
 
 faulty dressing, etc. ; (vi.) lack of rest to the part ; and 
 (vii.) constitutional conditions, such as deficient general vitality 
 from disease or other causes, resulting in want of action in the 
 wound. 
 
 The most common cause of non-union is without question septic 
 contamination of the part. The essential nature of this process 
 and its dependence, either on pathogenic or non-pathogenic 
 germs, have been already explained (p. 5). The inflammatory 
 trouble is acute or subacute, according to the virulence of the 
 organisms and the resisting powers of the patient ; it may mani- 
 fest itself merely as a suppurative process within the wound, or as 
 an active cellulitis spreading into the adjacent tissues. It may 
 commence deeply around a buried stitch or 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 ; 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 supervene, whilst the general condition 
 may constitute an attack of septic traumatic fever, or may even 
 run over into a true septicaemia. 
 
 When the process starts quietly 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 
 usually be found, however, that the temperature is slightly raised, 
 and that some tensive pain is present. Sooner or later an abscess 
 develops and comes to the surface. 
 
 The local treatment of a septic wound consists essentially in the 
 relief of all tension, the removal, as far as possible, of all 
 putrescible material, and the application of warmth and moisture 
 to the part, if superficial, to encourage the local reparative activity 
 of the tissues. Stitches must be immediately removed, and the 
 wound widely opened up, care being taken to ascertain whether 
 or not the pus has burrowed, as if so it must be followed up. 
 Sloughs may be cut or scraped away under an anaesthetic, and all 
 putrid or putrescible material removed, if possible. 
 
 The parts are then thoroughly washed out with some antiseptic 
 solution, and may advisably be treated with peroxide of hydrogen 
 or liquefied carbolic acid ; but it must not be forgotten that where 
 the organisms have invaded the living tissues, no antiseptic is 
 likely to reach them, at any rate, not without also destroying the 
 tissues. The wound is then lightly, though thoroughly, packed 
 with gauze soaked in an emulsion of iodoform and glycerine, 
 and if there is a deep cavity, it may be desirable to introduce a 
 drainage-tube, especially when suppuration is present, since pus 
 does not easily escape along a gauze drainage wick. It is not 
 
WOUNDS 197 
 
 advisable to pack the gauze into the wound too tightly, as there- 
 by the escape of secretions may be prevented, and pain and 
 tension may ensue, whilst possibly bacteria may be driven into 
 the tissues and give rise to further trouble in the nature of 
 erysipelas or cellulitis. Warm, moist dressings, such as an anti- 
 septic fomentation, are then applied, or it may be desirable either 
 to immerse the limb in a hot antiseptic bath for an hour or two 
 daily, or to keep it in for some days. At the same time the bowels 
 must be freely opened, and the general health of the patient care- 
 fully watched. The more serious cases are dealt with in the same 
 manner as an attack of cellulitis (q.v. on p. 91). 
 
 When the union of the wound is interfered, with owing to an 
 accumulation of blood or serum in the deeper parts whilst the 
 integument is healing, it often suffices to partially open the 
 incision, squeeze or press out the fluid, and insert a small tube or 
 gauze drain. 
 
 II. Lacerated or Contused Wounds. — Such injuries are caused 
 by blunt instruments, by machinery, missiles, the wheels of a 
 vehicle, etc. They are characterized by the following signs : 
 
 1. The Haemorrhage is, as a rule, but slight, since the vessels 
 are torn across irregularly, and not cut cleanly ; the middle and 
 inner coats, w r hich give way first, are curled up within the con- 
 torted outer coat, forming a barrier sufficient to prevent loss of 
 blood. The vessels, being elastic, may be pulled out of their 
 sheaths, and are sometimes seen pulsating upon the surface. 
 
 2. The Lips gape less than in an incised wound, and are irregular, 
 torn, and bruised. More or less extensive portions of dead tissue 
 have to be disposed of before repair can take place, and hence this 
 form of wound usually heals by granulation. When a limb is 
 torn completely off, the tendons are often left long, and the 
 muscular bellies project from their fascial sheaths, as flabby con- 
 gested masses, since the skin gives way at a higher point than the 
 subjacent structures. 
 
 The Progress of the case depends largely upon the question 
 whether the wound is or is not aseptic. 
 
 In an Aseptic lacerated wound it may be possible to bring the 
 edges together by suture or otherwise, and, even though they 
 are a little bruised, healing by a slightly delayed first intention 
 is possible, if drainage is provided. If the wound remains open, 
 the dead tissue is absorbed or separated, and an aseptic granulating 
 surface results. There may be some simple traumatic fever for a 
 day or two, but it is of little consequence. 
 
 If the wound is Septic, however, inflammatory phenomena 
 supervene, resulting finally in a granulating surface. Three 
 stages may be described in the course of the case, viz. : 
 
 (a) The stage of injury, resulting in shock. 
 
 (b) The stage of inflammation and sloughing, associated with 
 
 septic traumatic fever. 
 
198 A MANUAL OF SURGERY 
 
 (c) The stage of repair by granulation, or prolonged suppura- 
 tion, with exhaustion and hectic fever in the worst cases. 
 The inflammatory period lasts a week, ten days, or more, accord- 
 ing to circumstances, and during this period the patient is liable 
 to various forms of septic trouble, including secondary haemor- 
 rhage, toxaemia, pyaemia, and traumatic gangrene. 
 
 The Treatment of contused and lacerated wounds varies with- 
 their character, and no absolute rule of practice can be laid down 
 to suit all cases. The following routine is that usually adopted : 
 
 (a) Immediate Treatment. — The great desideratum in all these 
 cases is to render the wound aseptic. To accomplish this in 
 severe injuries, it is wise to anaesthetize the patient, and then, 
 after shaving the skin, if necessary, the wound and its surround- 
 ings are scrubbed with soap and carbolic lotion (i in 20) by means 
 of a sterilized nail-brush. Foreign bodies are removed, and dead 
 or doubtful tissues cut away, if unimportant, whilst bleeding 
 vessels are secured by ligature. Ample provision must be made 
 for drainage, since the carbolic irrigation of itself causes much 
 exudation ; occasionally it is desirable to make a counter-opening 
 for this purpose. The wound is closed by sutures, but it is 
 advisable to remove ragged and torn fragments of skin with the 
 scissors or knife, if there is sufficient tissue around ; an antiseptic 
 dressing of the usual type is then applied. If, however, the skin 
 is scanty and asepsis not assured, it is better to leave the wound 
 open, or, at any rate, only to partially close it, packing it care- 
 fully with gauze impregnated with iodoform. 
 
 (b) Subsequent Treatment depends on whether or not the 
 measures adopted to obtain asepsis have been successful. If the 
 wound remains free from infection, nothing special is called for 
 beyond careful dressing. If it becomes septic, and the surface 
 is covered with sloughs, these must he removed by natural or 
 artificial means before healing can occur ; the use of antiseptic 
 poultices will considerably expedite matters, but it must be 
 remembered that secondary haemorrhage may occur when the 
 dead tissues are finally detached. During this period inflam- 
 matory fever continues, and the patient's general health must 
 be closely watched. When once a clean granulating surface is 
 obtained, it is treated in the same way as any healing wound, 
 skin-grafting possibly being needed in the more extensive cases. 
 
 The question of Amputation will sometimes be raised in dealing 
 with the graver forms of lacerated wounds, although many limbs 
 are now saved which would inevitably in former days have been 
 sacrificed. Hard-and-fast rules cannot be laid down as to when 
 to amputate and when not to do so ; each case must be treated 
 on its own merits. Apart from the local lesion, the following 
 points must be carefully considered : (a) The age and vitality of 
 the patient. An old person has less recuperative power than a 
 young one, and hence a damaged limb may often be left in a youth 
 
WOUNDS 199 
 
 which one would certainly remove in an elderly person. The 
 vitality of the individual is perhaps even more important than 
 the age, for some men at sixty are in a much more healthy and 
 resistant state than others at forty. The habits, as to temperance, 
 etc., must also be taken into consideration, and the existence of 
 general diseases, such as diabetes or albuminuria, might induce 
 one to resort to radical rather than conservative measures. 
 (b) The vitality of the extremity injured. A leg has to be sacrificed 
 more frequently than an arm, since the vitality and reparative 
 power of the latter are so much greater, (c) The septicity or not 
 of the wound is of the greatest significance, since, if infection can 
 be prevented, the chances of preserving the limb are greatly im- 
 proved, and one would then often delay operation, whereas sepsis 
 would turn the scale in favour of radical interference. 
 
 The local conditions which suggest or determine the perform- 
 ance of an amputation may be conveniently divided into two 
 groups, viz., where amputation is essential, or where it is doubtful. 
 
 A. Amputation is certainly called for — 
 
 1. To trim up the stump of a limb torn off by machinery, or cut 
 off by a railway train, or carried away by a cannon-ball. 
 
 2. When the whole limb or one complete segment of it has 
 been totally disorganized, or crushed to pulp, though still retain- 
 ing its connection with the body. 
 
 3. In cases wdiere gangrene is imminent or has supervened, 
 especially if it is of the spreading type. 
 
 4. When severe septic symptoms develop in a case where an 
 attempt is being made to save a limb, the retention of which was 
 from the first doubtful ; or when exhaustion supervenes from pro- 
 longed suppuration. 
 
 5. In severe compound lacerations of the foot in old people, 
 involving the bones and laying open the common synovial cavity. 
 Septic arthritis and necrosis are then very apt to ensue, whilst the 
 distance of the foot from the centre of the circulation increases the 
 likelihood of gangrene. 
 
 B. Amputation is doubtful in the following conditions : 
 
 1. Compound comminuted fractures in parts other than the 
 foot do not pev se require amputation, even if neighbouring joints 
 are implicated. By careful attention to antisepsis, free drainage, 
 and the removal of detached fragments of bone and foreign bodies, 
 which should usually be accomplished under an anaesthetic, limbs 
 formerly condemned to amputation can not only be preserved, but 
 also restored to a considerable degree of functional usefulness. 
 The final decision will mainly depend on the age, condition, and 
 previous habits of the individual. 
 
 2. When the soft parts have borne the brunt of the injury, and 
 have been extensively stripped from the bones, amputation is by 
 no means an essential, provided that they can be restored to their 
 original position, that there is a reasonable probability of their 
 
A MANUAL OF SURGERY 
 
 vitality being maintained, and that the utility of the limb will 
 not be hopelessly impaired, as a result of lesions to the nerves, 
 after the wound has healed. The surgeon has here to carefully 
 balance the risk run if an attempt is made to save the limb, and 
 the value that the limb if saved will subsequently be to the 
 patient. For instance, when the muscles of the forearm have 
 been extensively torn up in a machine accident, it is a question 
 whether it is worth while exposing the patient to the risk of grave 
 sepsis, when it is probable that under the best circumstances the 
 limb will be of little practical use. 
 
 3. Laceration of the main artery of a limb need not in itself 
 determine amputation ; but if in addition to this the bones, veins, 
 or nerves are injured, and especially in the lower extremities of 
 old people, amputation should be undertaken without delay. 
 
 As to the Period when a limb should be removed after an acci- 
 dent, there is no doubt that, as a general rule, the sooner amputa- 
 tion is performed, the better ; the longer it is delayed, the greater 
 the risk of septic infection and absorption. On the other hand, 
 the shock in some cases may be so profound that it is better policy 
 to delay interference until reaction is established ; this is especially 
 the case in severe crushes close to the hip-joint, primary amputa- 
 tion in this locality being frequently fatal. At the same time, if 
 shock is being perpetuated by the presence of a crushed limb, it 
 should be immediately removed. When sepsis is present, and it 
 seems desirable to remove the limb, there is no need to wait until 
 defervescence has occurred, as used to be taught ; as soon as the 
 septic part is taken away, the fever and concurrent phenomena 
 cease, provided that the amputation wound is maintained aseptic. 
 
 III. Punctured Wounds and Stabs. — These may be brought 
 about by any form of penetrating instrument, from a pin or needle 
 to a sword or bayonet. The external opening may be in itself 
 insignificant, the chief danger arising from the damage to deep 
 structures — bloodvessels or nerves being divided, and serous 
 cavities or viscera opened. The subsequent symptoms depend 
 almost entirely upon the question of sepsis ; there is always con- 
 siderable difficulty in efficiently draining the depths of a long and 
 narrow wound, and therefore collections of pus readily form and 
 burrow in all directions. 
 
 Wounds resulting from the modern sword-bayonet, though very 
 serious from their size and depth, are not so difficult to heal as 
 those inflicted by the old triangular blade. They should be 
 thoroughly syringed out with warm carbolic lotion (1 in 20), well 
 drained, and the skin opening not allowed to close until all dis- 
 charge has ceased ; if necessary, a counter-opening is made at a 
 dependent spot. Serious haemorrhage or paralysis, indicating 
 that important vessels or nerves have been divided, calls for 
 
PLATE VI. 
 
 Skiagram of Hand, with Needle embedded in the Palm, close to the 
 
 Carpus. 
 
 To face p. 200.] 
 
PLATE VII. 
 
 Splinter of Glass in Hand, close to Metacarpal Bone of the Index 
 
 Finger. 
 It will be noted that the glass casts quite as dense a shadow as the needle in Plate \ I. 
 
 TofolUw Plate VI.] 
 
IVOUNDS 
 
 immediate opening up of the wound, so as to expose and deal 
 with the injured structures. 
 
 The commonest punctured wounds met with in civil practice 
 are those produced by needles, which are frequently broken off 
 short in the body, especially in the hands, feet, knees, or nates. 
 If seen soon after the injury, it is advisable to undertake their 
 immediate removal, a proceeding sometimes very simple, but 
 occasionally necessitating a deep and difficult dissection. Should 
 the needle not be removed, it may travel about the body along 
 the muscular and fascial planes, and there is no knowing where 
 it may lodge or come to the surface, or how long it may remain 
 in the body. It occasionally finds its ways into the pelvis of the 
 kidney, and constitutes the nucleus of a renal calculus. 
 
 One of the most troublesome and painful forms of penetrating 
 wound is that caused by a fish-hook, since the barbed end catches 
 in the tissues, and it is impossible to withdraw it without in- 
 creasing the size of the wound considerably. The simplest plan 
 of treatment is to push the hook on and make it protrude through 
 the skin elsewhere to such an extent as to enable the barb to be 
 cut away, when the remainder of the hook will be set free. 
 
 For the detection of penetrating foreign bodies of a metallic 
 nature, or of splinters of glass or stone, the so-called X rays of 
 Rontgen are exceedingly valuable. They are produced by passing 
 a powerful electric current through a modified Crookes tube, or, 
 as it is now termed, a ' focus tube.' This consists of a thin glass 
 bulb, into which are fixed two terminals— one, the negative, 
 concave, and the other, or positive pole, a platinum plate set at 
 an angle so as to reflect the rays generated at the negative end to 
 the convexity of the bulb. A very high vacuum must be present 
 in the tube. The rays thus generated, though invisible to the 
 naked eye, have an actinic power, and are capable of affecting a 
 photographic plate in the same way as ordinary sunlight. They 
 are also able to penetrate many substances which are impermeable 
 to ordinary light, although others resist their passage. Most of 
 the soft tissues of the body are readily traversed, but bones and 
 to a much less degree tendons are sufficiently resistant to cast a 
 shadow on the plate, and it is the fixation of these shadows that 
 constitutes the peculiarity of the so-called ' skiagram.' If a limb 
 with a supposed foreign body within it is placed over a sensitive 
 dry plate, held in a non-metalic dark slide or a black envelope, 
 and the tube just above it, so that the convex portion on which 
 the rays impinge is nearest the limb, a skiagram is produced 
 which, on development, shows the osseous tissues, the outline of 
 the limb, and the foreign body, if it exist (Plates VI. and VII.). 
 
 A modification of this process has led to the production of the 
 Cryptoscope. This consists of a cardboard screen coated with 
 platino-cyanide of potassium or tungstate of soda, and if employed 
 instead of a sensitive plate on the further side of the limb to the 
 
A MANUAL OF SURGERY 
 
 tube, the appearances produced can be seen by the naked eye. 
 Since it is possible in this case to move the limb from side to side, 
 or to rotate it, a better idea can be obtained of the position of the 
 foreign body ; by simple skiagraphy, it is often difficult to tell on 
 which side of a bone the foreign substance lies. Still better results 
 have been obtained by the application to this method of the 
 principle of the stereoscope. Special methods of localizing foreign 
 bodies have been introduced of late, but they are too complicated 
 to be referred to here. 
 
 IV. Gunshot Wounds. — It is impossible in a work such as this 
 to go minutely into the subject of gunshot wounds, but it is 
 essential to indicate their most important features, and in what 
 respect they differ from other forms of injury already described. 
 The character of a gunshot wound varies according to the nature 
 of the projectile, the arm employed, the velocity of the missile, 
 the distance from the body at which the firearm was discharged, 
 the part of the body struck, and the direction of the shot. 
 
 The wounds inflicted by the modern small-bore rifle (e.g., the 
 Lee-Metford, Mauser, or Krag-Jorgenson) are very different to 
 those produced in former days. The desiderata that have been 
 considered in the evolution of the modern rifle have been to secure 
 great muzzle velocity, a low trajectory, and clean and hard hitting. 
 To this end the barrel has been rifled so as to cause the bullet to 
 rotate on its own logitudinal axis (without such rifling the bullet 
 would rotate on its short axis), and the bullet has been greatly 
 modified, whilst the old form of gunpowder has given way to 
 more highly explosive substances. 
 
 The modern bullet is a long, thin, conical body, consisting of 
 a core of lead hardened by the addition of 2 per cent, of antimony, 
 enclosed in a cover, jacket or mantle of some smooth, hard metal, 
 e g., 80 per cent, of copper and 20 per cent, of nickel (Lee-Metford 
 and Mauser). The muzzle velocity is very high, amounting to 
 2,000 feet per second for a Lee-Metford rifle, and 2,300 feet per 
 second for a Mauser The trajectory is nearly flat ; anything 
 within 500 yards may be fired at point-blank, whilst in a range 
 of 2,000 yards the bullet only rises 194 feet, as compared with 
 866 feet for a Snider bullet. 
 
 The effect of these arms varies to some extent with the range, 
 but not nearly so much so as was formerly maintained ; and 
 although the worst wounds are usually produced at a short range, 
 say 500 or 750 yards, yet quite simple wounds with no disruptive 
 phenomena may also be caused at a similar distance. One of the 
 best marked features of these wounds is that the bullet travels 
 straight and direct, without lateral deviation or deflection, as was 
 so commonly the case in the old days. Simple flesh wounds are 
 of no great importance per se, granted that important vessels and 
 nerves are not injured. The aperture of entry is small, and looks 
 
WOUNDS 20^5 
 
 somewhat ' like a bug- bite ' ; the aperture of exit is slightly larger, 
 and tends to be a little more slit-like. A certain amount of extra- 
 vasation occurs into the tissues around the track, but the external 
 bleeding is often slight. There is but little tendency to carry in 
 portions of clothing or septic material, and the wound heals by 
 first intention if reasonable precautions are taken. The external 
 cicatrices finally look very similar to those produced by bad acne 
 pustules. Vessels and nerves are not likely to be injured unless 
 they are actually in the line of the bullet ; the accurate limitation 
 of the damage to this line is evident when one hears of a bullet 
 passing between the abdominal aorta and the vena cava without 
 either being injured. If a large artery is cleanly hit, the patient 
 bleeds freely, and may die of haemorrhage, unless it can be con- 
 trolled by a tourniquet. If the artery is button-holed, a traumatic 
 aneurism may result, whilst arterio-venous wounds have been 
 common in the recent South African campaign. There has been 
 some difference of opinion as to the character of the injuries to 
 bones ; that large masses of cancellous tissue (e.g., the lower end 
 of the femur) can be drilled cleanly without fracture is certain ; 
 but such wounds are sometimes associated with much splintering 
 and involvement of neighbouring joints, possibly as a result of a 
 short range, or of expansion of the bullet from the tearing down 
 of the mantle. If a bullet hits cleanly the compact shaft of a long 
 bone, it may smash the whole bone into small fragments, or the 
 force may be more localized in its action, though always severe. 
 Such comminuted wounds are very likely to become septic, if 
 there is a long transport to the field hospital, and then fragments 
 undergo necrosis and serious inflammatory phenomena may 
 follow. Head wounds are much less fatal than might be 
 imagined from the experimental work that has been undertaken. 
 At close range frightful disruptive effects are produced which are 
 almost certain to be fatal (see Chapter XXIII.) ; at a longer range 
 comparatively little mischief is done, except along the line of the 
 missile. The inner table is always more splintered than the 
 outer, and of course a certain amount of brain substance may 
 escape. Abdominal wounds are also much less serious than 
 formerly, a mortality of 90 per cent. (American Civil War) being 
 replaced by one of 40 per cent, in the recent campaign, and that 
 without operation (Treves). The mere penetration of one or more 
 coils of intestine is not sufficient to cause general peritonitis ; the 
 wound is very small, and peristalsis seems to come to an end 
 entirely as soon as the patient is struck, so that neighbouring coils 
 of intestine or the omentum suffice to prevent faecal extravasa- 
 tion ; indeed, many of the patients suffer but little constitutional or 
 local disturbance. Of course, an empty intestinal canal is a favour- 
 able condition, and this is not unfrequently present on the field 
 of battle. Bloodvessels may be wounded in the mesentery, and 
 death result from haemorrhage ; solid viscera, such as the liver 
 
204 A MANUAL OF SURGERY 
 
 or spleen, are often damaged but little, granting a fairly long 
 range. On the whole, the effects of these modern bullets is to 
 disable without killing, unless a vital part is struck. 
 
 Soft-nosed Bullets {e.g., the Dum-Dum) are characterized by the 
 mantle being absent at the top, whilst the lead core is usually free 
 from antimony. The result of this is that as soon as the bullet 
 strikes, the lead core mushrooms out, and terrible mutilation or 
 destruction of surrounding tissues ensues, whilst bones are com- 
 minuted and solid viscera pulped. A similar result follows from 
 rubbing or cutting off the top of the Lee-Metford or Mauser 
 bullet, or even from incising the cover in two or three places. 
 
 Martini-Henry and Snider Bullets produce wounds which are 
 intermediate in their severity between the preceding two. The 
 aperture of entry is usually small, that of exit large and with 
 everted edges. Portions of clothing are frequently carried in by 
 these missiles, and add to the risks of sepsis. 
 
 Shell Wounds have no special peculiarities beyond their severity 
 and the ghastly nature of the injuries which may be inflicted by 
 them, depending on the irregular shape of the fragments into 
 which the shell bursts. 
 
 Dangerous wounds may be inflicted by small shot, as, for 
 instance, when one of the pellets enters the eye, whilst the wads 
 or other portions of the cartridge may also be carried into the 
 body. A blank cartridge, if discharged at a short distance, may 
 produce a severe wound, and under such circumstances the skin 
 around is likely to be burned and blackened, leaving a permanent 
 bluish-black tattooing of the tissues. 
 
 The Treatment of gunshot wounds is conducted in accordance 
 with general surgical principles, although it may have to be 
 somewhat modified by the patient's environment and by the fact 
 that after a battle the pressure of work may be such that all 
 lengthy operative procedures have to be discarded. The first 
 essential is to protect the wound from infection, and for this 
 purpose the small packet of antiseptic dressing carried by all our 
 soldiers is admirable. Bleeding is, if possible, controlled by a 
 tourniquet ; and splints must be improvised for broken limbs, if 
 practicable. As soon as the wounded man reaches the field 
 hospital, the wound is more thoroughly explored and cleansed ; 
 foreign bodies are removed, bleeding points secured, and if the 
 bullet has not escaped and can be readily detected, it should be 
 extracted. When lodged deeply, various appliances have been 
 introduced to locate the exact position of a bullet, e.g., Nelaton's 
 porcelain-ended probe or more complicated electrical contrivances, 
 such as the telephone probe. Skiagraphy has also a large field 
 of usefulness before it in this direction. Comminuted fractures 
 are carefully investigated, detached fragments of bone are 
 removed, and if an attempt is made to save the limb, splints, etc., 
 are carefully applied. Primary amputations for bullet wounds 
 
WOUNDS 205 
 
 are not very common at the present day, except when great com- 
 minution of bone or hopeless involvement of vessels and nerves 
 has occurred. Wounds of the skull always demand the most 
 careful attention ; even when the bullet has penetrated cleanly 
 and escaped, each opening must be trephined so as to allow of 
 the removal of depressed splinters of the inner table. This rule 
 holds good even when a bullet has merely ploughed a groove or 
 track along the calvarium without penetration. The results of 
 such treatment have been most admirable. 
 
 The treatment of abdominal wounds produced by small-bore 
 rifle fire is generally one of expectancy. It has now been 
 abundantly proved that patients can recover in the m@st astonish- 
 ing fashion from bullet wounds which have traversed the 
 abdomen from side to side or from front to back, and therefore 
 unless there is some very clear indication, operation is better 
 avoided. Moreover, the practical difficulties connected with 
 abdominal sections, the frequent lack of sterilized water, of towels, 
 and the dirty condition in which the patient is, owing to the 
 exigencies of the campaign, together with the length of time that 
 such an operation takes — all these constitute reasons for not 
 interfering unnecessarily. Abdominal distension from haemorrhage 
 is one of the chief indications for laparotomy. In civil practice 
 the ordinary rules of treatment are followed (Chapter XXXII.). 
 
 V. Poisoned Wounds. — The great majority of poisoned wounds 
 are due to some definite micro-organism, and we have discussed 
 their nature and characteristics elsewhere. A few only remain to 
 be dealt with here. 
 
 Stings of Insects, such as bees and wasps, may be exceedingly 
 irritating and painful, but are not dangerous, unless some local 
 complication, such as erysipelas, supervenes, or the stings are 
 very numerous, as when a swarm of angry bees settles on a 
 person, or the part involved is such as to lead to serious swelling, 
 as in the pharynx or tongue, cedema of the glottis possibly arising 
 under such circumstances. All that is usually needed is the 
 application of a weak alkaline lotion, whilst a common and 
 efficient domestic remedy is a sliced fresh onion applied to the 
 part. Care must also be exercised to ascertain that the sting 
 and poison sac are not left in the body. 
 
 Some varieties of flies and spiders are also extremely virulent, 
 and it is possible that actual disease can be transmitted by the 
 former. Thus, if a fly bites a person after feeding on putrid 
 carrion, some form of septic inflammation may be originated ; 
 anthrax may also be spread in this way. Mosquitoes, too, play 
 an important role in the growth and development of filariae. 
 
 Snake-bites require but little notice here, as they are exceedingly 
 rare in this country, the common adder (Pelias herns) being the 
 only venomous one likely to be met with, and even with this the 
 
206 A MANUAL OF SURGERY 
 
 poison is not sufficiently virulent to do much harm unless the 
 individual attacked is a child or a person in a very bad state of 
 health. The poison is conveyed to the wound from the glands 
 and poison sac situated on either side of the upper jaw through 
 fine canals in the specialized teeth, which open at their apices ; 
 these teeth are so delicate in some snakes that it may be difficult 
 to find the wounds produced by them. The effects of an adder's 
 bite are not, as a rule, noticed immediately, but come on in the 
 course of an hour or so ; extreme prostration supervenes, with a 
 weak pulse, cold clammy perspiration, dilatation of the pupils, 
 and perhaps delirium in bad cases, merging into coma. 
 
 The Treatment consists in preventing the absorption of the 
 virus by tying a ligature firmly above the wound, which should 
 then be laid open so as to allow of free bleeding, and the surface 
 excised or cauterized. The collapse resulting from absorption of 
 the poison is best remedied by the administration of stimulants or 
 the hypodermic injection of strychnine. 
 
 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 in this way. 
 The symptoms come on rapidly, and are extremely severe, although 
 they are modified according to the variety of snake. The treatment 
 must necessarily be more energetic ; probably the introduction of 
 Fraser's antivenine will be the means of saving life. 
 
 The Anatomical Tubercle, or Butcher's Wart ( Verruca necrogenica), 
 consists in a papillomatous development usually on the knuckles 
 or wrists, of those who are exposed to wounds either in the dead- 
 house or slaughter-house. It is in all probability a manifestation 
 of tuberculous infection, and, indeed, resembles somewhat closely 
 the appearance of lupus when it develops on the hands. Treat- 
 ment consists in the application of a powerful caustic, whilst in 
 bad cases it is necessary to scrape the surface before cauterizing. 
 
 Dissection or Post-mortem Wounds have obtained an unenviable 
 notoriety as being fertile in the production of serious inflammatory 
 disturbance, and although the graver forms are less common now 
 than formerly, yet they are still met with occasionally. It is 
 well known that bodies are most virulent within a few hours of 
 death, and hence the post-mortem room is more frequently respon- 
 sible for these affections than the dissecting room ; moreover, the 
 care which is expended upon the preparation of subjects by in- 
 jecting them with antiseptics reduces the dangers which might 
 arise from the latter source. 
 
 Inflammatory disturbances may arise under these conditions 
 from several distinct causes : 
 
 1. The presence of strong antiseptics, such as arsenic, often 
 irritates abrasions, and causes tenderness and congestion of the 
 matrices of the nails. 
 
 2. The organisms occurring in actual putrid material have no 
 
WOUNDS 207 
 
 power of attacking living tissues, although some irritation may be 
 caused by them if small sores or abrasions are present. 
 
 3. Pathogenic organisms are frequently found in bodies soon 
 after death, and are especially virulent when developing in the 
 exudations from serous membranes, such as the peritoneum, and 
 hence both the surgeon who operates on the living subject, and 
 the pathologist who examines the body after death, are alike 
 exposed to serious risk either from an accidental puncture or from 
 the infection of some abraded surface. It is even possible for 
 infection to occur through the hair follicles of an unbroken skin. 
 
 The lesions originated by any of these means vary in their 
 nature with the method of inoculation, the virulence of the 
 organisms, and the power of resistance of the individual. In the 
 simpler cases all that ensues is a limited irritation of some abrasion 
 or scratch, which rapidly disappears on the application of some 
 sedative or antiseptic lotion. Suppurative folliculitis, or even 
 boils, arise from infection of the hair follicles, and in worse cases 
 the various forms of onychia, paronychia, or diffuse cellulitis, 
 with or without suppuration in the nearest lymphatic glands. 
 Severe toxaemic symptoms usually accompany the last-named 
 conditions, and even acute septicaemia may develop. The 
 immediate treatment indicated for a dissection wound is to tie 
 a ligature or handkerchief around the base of the wounded 
 finger, so as to encourage bleeding and prevent the absorption 
 of toxic materials ; the part is then well washed under a tap of 
 cold water, immersed in an antiseptic solution, and sucked for 
 some minutes ; an antiseptic dressing must then be applied. 
 Any inflammation which arises subsequently must be treated 
 according to the general rules of surgery. 
 
 A common result of poisoned wounds of the fingers, whatever 
 their origin, is inflammation of the nail matrix (Chapter XIV.), or 
 of the tissues of the fingers, constituting a whitlow ; and it will 
 be convenient to describe the latter condition at this place. 
 
 A Whitlow (Paronychia or Panaritium) occurs in four different 
 forms, of which one is a true cellulitis, another a teno-synovitis, 
 a third is a localized inflammation of the skin, and the fourth 
 involves the terminal phalanx. 
 
 (a) The Subcuticular whitlow consists merely in a development of pus 
 beneath the cuticle which separates it from the cutis vera. It is very 
 painful, but otherwise is of little importance A boracic poultice, preceded 
 by the removal of the loose cuticle, is all that is needed in its treatment. 
 
 (b) The Subcutaneous whitlow is a true cellulitis, commencing in the pulp 
 of a finger, but often spreading upwards to involve the palm. The finger 
 becomes swollen and painful, the pain being increased by pressure or by 
 hanging down the arm. Gradually both these symptoms increase in amount, 
 the back of the finger becoming cedematous, and the pulp more or less red. 
 The swelling is at first hard and brawny, and even when pus is present it may 
 be difficult to detect fluctuation unless the abscess is nearly pointing. Con- 
 stitutional symptoms are not, as a rule, very severe, though the intensity of 
 
208 
 
 A MANUAL OF SURGERY 
 
 the pain may exhaust the patient. The hand should be elevated, and the 
 finger poulticed. A free incision should be early adopted, but, though free, 
 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 finger, and the incisions 
 must then be suitably modified. Antiseptic fomentations may be continued 
 after such an incision, the constant moisture adding greatly to the patient's 
 comfort. 
 
 (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 inability of the patient to bend the finger, and the 
 extreme pain caused on attempting to do so, owing to the involvement of the 
 tendon. The swelling also is more marked, and usually extends to the dorsum 
 of the hand. It is important to remember that the flexor sheaths communi- 
 cate with the common palmar sheath — always in the case of the thumb, 
 
 usually in the little finger, but not in the index, 
 middle, and ring fingers (Fig. 50). In the last 
 case suppuration ceases at the level of the 
 heads of the metacarpal bones ; but occasion- 
 ally it oversteps this limit, and involves the 
 palm in the same way as in the thumb and 
 little finger. Free and early incision must be 
 made to anticipate such extension, and also to 
 limit as far as possible the adhesions which 
 the tendons are liable to contract, or to prevent 
 them from sloughing owing to the acuteness 
 of the inflammation. In neglected cases the 
 pus may burrow to the dorsum of the fingers, 
 necessitating counter-openings ; or the peri- 
 osteum may be affected, leading to disease or 
 death of the phalanges ; the interphalangeal 
 joints may also be disorganized. If the palm 
 is involved, care must be taken in incising the 
 abscess not to wound the superficial palmar 
 arch or its branches. The incision should be 
 made along the middle of the metacarpal bones 
 involved, and not higher than the centre of the 
 palm ; but an opening may also be necessary 
 close to the level of the wrist-joint, and this 
 can be made in the middle line without danger. 
 (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 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, constitute the 
 treatment required 
 
 Repair of Wounds. 
 
 In former days five different methods of repair were described, 
 but increased knowledge and further research warrant us in 
 making the statement that there is but one method of repair, 
 which, however, is modified according to the conditions of the 
 wound, and that this process is essentially the same whatever 
 tissue of the body is involved, be it bone, muscle, tendon, or 
 subcutaneous connective tissue. It must be noted that repair is 
 not synonymous with regeneration. It is very unusual for any 
 tissue which has suffered from a serious lesion to be regenerated ; 
 
 Fig. 50. — Diagram of Syno- 
 vial Sheaths of Flexor 
 Tendons of Hand. (After 
 Keen and White.) 
 
WOUNDS 209 
 
 fibro-cicatricial tissue, or some modification of it, forms the new- 
 bond of union between the damaged parts. In a few tissues, how- 
 ever, true regeneration has been noted — e.g., in striped muscle, 
 bone, tendon, nerves, and glandular structures, provided the 
 injured parts have been brought into close opposition. 
 
 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 obstruc- 
 tion 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 ieucocytes, whose 
 function is to remove all dead or damaged tissue, as well as to 
 break up, disintegrate, and finally absorb, any blood-clot which 
 is present. These cells are derived from the surrounding vessels, 
 and are accompanied by a certain amount of serous oozing, so 
 that we have here the early manifestations of a slight inflamma- 
 tory reaction, which, if it does not extend beyond certain limits, 
 is a beneficial proceeding. Should it, however, become excessive, 
 as when bacterial invasion is present, injurious results may follow. 
 Much discussion has arisen among pathologists as to whether or 
 not this stage of repair is to be considered inflammatory in origin ; 
 the phenomena are, however, so exactly similar to those occurring 
 in the earliest stages of inflammation that it is impossible to draw 
 any line of distinction between them. 
 
 (b) The exudation of leucocytes is soon followed by the appear- 
 ance of a number of larger cells with more distinct nuclei, and in 
 which cell division is always accompanied by karyokinesis ; these 
 are termed fibroblasts, and are now considered the active agents in 
 the reparative process. There is some difference of opinion as to 
 the origin of these cells ; formerly they were supposed to be 
 migrated leucocytes, but more recent researches indicate that 
 they are derived from the multiplication of fixed or wandering 
 connective tissue corpuscles or of the endothelial cells lining the 
 neighbouring capillaries or lymphatics. Whatever their origin, 
 they soon form a layer of cellular tissue which lies upon or 
 between the surfaces or lips of the wound, whilst the previously 
 effused leucocytes disappear, some finding their way back into 
 the circulation, and others serving as pabulum for the nutrition 
 of the fibroblasts. 
 
 {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 proto- 
 
 J 4 
 
A MANUAL OF SURGERY 
 
 plasm (Fig. 51, (7), 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. 51, b), or 
 occasionally they unite with the vessel from which they started. 
 The connective tissue cells may also become spindle-shaped, 
 and send out branching processes to unite with the offshoots 
 from the vessel walls. After a time these protoplasmic threads 
 become canalized (Fig. 51, c), and a communication is estab- 
 lished between them and the mother vessel, so that blood passes 
 into them. The new capillary wall, at first homogeneous, soon 
 
 Fig. 51. — 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, or with the branching processes of connec- 
 tive tissue cells ; c, the canalization of these processes. 
 
 becomes lined with definite endothelial cells, and strengthened by 
 the connective tissue which forms around it. By this means 
 a soft vascular tissue is produced, known as granulation tissue 
 (Plate V., Fig. 2), consisting of loops of capillaries supported 
 by large nucleated cells with a varying amount of intercellular 
 substance, which soon becomes fibrillated in texture. 
 
 (d) The transformation of this granulation tissue into ftbvo- 
 cicatricial tissue is next proceeded with. Formerly it was sup- 
 posed that the cells of the granulation tissue were themselves 
 transformed into the fibres from which scar tissue is developed, 
 
WOUNDS 
 
 but this idea is now abandoned in favour of one which maintains 
 that the fibrillae are derived as an intercellular exudation. By the 
 contraction of these fibres the cells become flattened out and 
 compressed, and the newly-formed vessels constricted, so that as 
 time passes the scar tissue becomes less and less vascular, and 
 consequently firmer and denser, as well as smaller. 
 
 (e) Whilst this last stage is in progress, the surface of the 
 wound is covered over with cuticle, which spreads inwards from 
 healthy epithelium in the neighbourhood of the wound, and 
 especially from the deeper layers of the rete Malpighii. 
 
 As already stated, the general process of repair sketched above 
 
 Fig. 52. — Diagram of Healing by First Intention. (After Billroth.) 
 
 The wound is occupied by a fibro-cellular growth, into which loops of 
 capillaries extend, constituting granulation tissue, whilst the epithelium 
 has united across the surface. 
 
 is modified according to the character and condition of the wound. 
 Four chief modifications are met with in surgery : 
 
 1. Healing by First Intention or Primary Union occurs in cleanly- 
 cut aseptic wounds where the lips are unbruised and brought 
 together, so that no extensive collection of blood or discharge 
 between them is possible. A thin layer of blood-clot lies between 
 the surfaces of the wound and penetrates into its meshes, and the 
 contraction of this clot is at first the chief means of keeping the 
 deeper parts in apposition. There is but a microscopic line of 
 damaged tissue, which, together with the blood-clot, is easily 
 absorbed, and the process runs a typical course, as sketched 
 out above, union being effected in five to seven days. (See 
 Fig. 52, and Plate VIII., Fig. 1.) 
 
 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 
 
 14 — 2 
 
A MANUAL OF SURGERY 
 
 of substance, so that the lips of the wound are not, or cannot be 
 approximated ; as also (b) when the surface of the wound is 
 bruised or damaged so that portions of tissue have to separate by 
 sloughing ; or (c) when the advent of sepsis has prevented the 
 occurrence of primary union. 
 
 When a small amount of aseptic dead tissue is present, it is 
 removed as previously described (p. 69) by an invasion of leuco- 
 cytes from the surrounding vessels, which disintegrate and gradu- 
 ally absorb it. These are followed by the fibroblasts, which form 
 a layer of granulation tissue on the surface of the wound (Fig. 53). 
 If there is much slough to be dealt with, the vitality of the granu- 
 lation tissue cannot be maintained beyond a certain distance from 
 its source of nutrition, and so by a process of simple anaemic 
 
 Fig. 53. 
 
 -Diagrammatic Representation of the Later Stages of 
 Healing by Granulation. (After Billroth.) 
 
 ulceration the unabsorbed dead portion is cast off and a granu- 
 lating surface remains. If the slough is septic, ulcerative inflam- 
 mation occurs in the adjacent living tissue, which brings about a 
 similar result, though accompanied by suppuration and septic 
 fever. When, however, there is a simple loss of substance, 
 with no bruising or damage to the tissues, the course of events is 
 as follows : The blood-stream in the superficial capillaries having 
 been arrested, adjacent vessels become dilated, and from these 
 an exudation of plasma and leucocytes results. The plasma 
 coagulates on the surface and forms a layer of fibrin, entangled 
 in the meshes of which are 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 vascularized from below into granulation 
 tissue, this process occupying from four to seven days (Plate V., 
 Fig. 2). 
 
 The healing of a granulating wound is brought about by the 
 
WOUNDS 213 
 
 conversion of the granulations into fibro-cicatricial tissue, and 
 by the surface becoming covered with cuticle. The contractile 
 tendency inherent in all cicatricial tissue produces two results 
 from its presence in the base of the wound beneath the super- 
 ficial layer of granulations : (i.) The surface area of the 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, and the wound 
 may remain open as a so-called chronic ulcer. When the granu- 
 lating surface is very extensive, contraction may proceed to such 
 an extent as to obliterate many of the vascular channels, and by 
 thus depriving the superficial tissues of their adequate nutrition, 
 the healing process may be indefinitely prolonged. (ii.) The 
 depth of the wound is diminished, partly by the continuous growth 
 of granulation tissue from below upwards, but also by the con- 
 tractile base lifting the deeper structures to the surface. If 
 the base of the wound cannot be raised, the cicatrix is usually 
 depressed and adherent to the underlying parts. 
 
 During the process of repair the wound takes on the appearances 
 already described as characteristic of a healing ulcer (p. 63). 
 
 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 sepsis be present, pus is likely to 
 accumulate beneath the scab and give trouble. 
 
 4. Healing by Organization of Blood-clot is only observed in 
 strictly aseptic wounds where there is definite loss of substance, 
 as in the deep channels made in the treatment of bones thickened 
 by chronic osteitis. Blood is allowed to collect and coagulate so 
 as to fill the cavity, and the surface is covered with protective to 
 prevent irritation from the dressings. The dark coagulum shows 
 no trace of change for some days, but gradually the peripheral 
 portions become granular and yellowish-white in colour ; these 
 are gradually vascularized and transformed into granulation 
 tissue, which in time spreads over the whole surface from 
 periphery to centre, and then healing occurs as described above. 
 The clot is absolutely passive in this process, being infiltrated by 
 leucocytes and removed by degrees, and thus merely serves as a 
 basis of support or scaffolding for the building up of the granula- 
 tion tissue which replaces it. 
 
 A Scar is a mass of fibroid tissue covered by epithelium, which 
 has been formed in the repair of a wound (Plate VIII., Fig. 2). It 
 is at first vascular, and contains cells of the connective tissue type ; 
 but after a time, as contraction continues, the cell elements become 
 flattened out, fewer in number and less obvious, the intercellular 
 
2i 4 A MANUAL OF SURGERY 
 
 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. Lymphatics, nerves, 
 hairs, and cutaneous glands are all absent, except perhaps at the 
 periphery, and the epithelial covering itself is merely a uniform 
 layer without papilla?. 
 
 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 web-like mass of fibroid tissue then forms, limiting 
 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. The Treatment of such conditions consists in dividing 
 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 of time it may be advisable to do this slowly, even by 
 gradual extension with a weight and pulley, so as to avoid any 
 risk of lacerating the deeper parts, which are usually contracted 
 secondarily. The raw surface formed by the opening out of the 
 contraction has now to be covered with epithelium by some form 
 of skin-grafting or by a plastic operation ; most of the cases can 
 be dealt with by Thiersch's method, but the results, though 
 promising for a time, are often ultimately disappointing. 
 
 2. Overgrowth of the scar tissue is sometimes met with, con- 
 stituting what is known as the false or Alibert's Keloid. This 
 most frequently occurs in the scars of burns or of wounds in 
 tuberculous patients, but may arise from any cicatrix, presenting 
 itself as a fibroid indurated mass of a dusky red colour, with 
 perhaps a number of dilated vessels coursing over it, which 
 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 
 

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WOUNDS 215 
 
 cicatrix and in the stitch holes. After a longer or shorter interval 
 it often disappears spontaneously. 
 
 3. Ulceration of Scars, the result of defective nutrition, is a 
 troublesome condition to deal with, as repair is usually slow. 
 
 4. Painful Scars arise from either the implication of a nerve 
 terminal in the cicatrix, or the pressure of a contracting scar upon 
 the bulbous end of a divided nerve, as in amputation stumps. In 
 each case further operation is necessary ; in the former the cicatrix, 
 or at any rate the painful portion of it, is excised, whilst in the 
 latter the stump must be opened up, and the enlarged end of the 
 affected nerve removed. 
 
 5. Malignant Disease of Scars is of an epitheliomatous type, and 
 appears as a hard tumour with everted edges, a thickened base, 
 and usually a good deal of foetid discharge. 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 lymphatic implication will be noted. As 
 soon, however, as the malignant growth invades healthy tissues, 
 the usual phenomena show themselves. The diseased tissues may 
 be freely dissected out, having regard to subjacent structures, and 
 the wound closed by some plastic method. 
 
 General Conditions connected with Wounds. 
 
 I. Shock. — By the term 'shock' is meant a general depressed 
 condition of the nervous system, resulting from some energetic 
 stimulus, which is either transmitted to the vital centres in the 
 medulla from the peripheral sensory or sympathetic nerves of an 
 injured part, or may descend to them from a disturbance of the 
 emotional centres through the nerves of special sense. Local 
 Shock is a curious condition of insensibility to pain on handling, 
 which is sometimes present after severe injuries, and is especially 
 seen in gunshot wounds. Possibly it is due to some temporary 
 paralysis of the sensory nerves. 
 
 The term collapse is applied to a condition very 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 septic absorption is taking place, the symptoms 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 collapse 
 due to acute peritonitis. 
 
 The degree of shock experienced in any particular case is 
 mainly influenced by the following factors : 
 
 (fl) The severity and extent of the injury, w r hich may be calcu- 
 
2i6 A MANUAL OF SURGERY 
 
 lated either by the number of sensory nerve terminals affected, 
 i.e., the superficial extent of the lesion, or by the depth to which 
 the injury extends. Speaking generally, the amount of shock 
 varies directly with the depth of the wound, since the deeper the 
 wound, the greater the violence which has produced it ; but in 
 some cases extensive superficial wounds produce a more severe 
 effect than limited deep ones, owing to the larger number of nerves 
 involved, along which stimuli can be carried to the centres ; thus, 
 an extensive superficial burn is more likely to produce fatal shock 
 than the complete incineration of an extremity. 
 
 (b) The site of the injury. The more essential and sensitive the 
 organ injured, and the more closely it is connected with the chief 
 sympathetic or cerebral centres, the greater will be the shock ; 
 thus, a small wound of the intestine, stomach, or any of the viscera, 
 is much more serious than an extensive accident to one of the 
 limbs. This fact is sometimes of practical value in the determina- 
 tion of the exact nature of abdominal injuries. When severe 
 shock with abdominal pain lasts for twenty-four hours after an 
 accident, the surgeon may be almost certain that some internal 
 viscus has been seriously damaged, and should at once consider 
 the advisability of performing laparotomy. 
 
 (c) The nervous susceptibility of the patient is a most important 
 element, for the more highly organized the nervous system, the 
 greater is the amount of shock experienced, and vice versa. Prison 
 surgeons bear this out, for amongst the coarser and baser types of 
 criminals operations may be performed without an anaesthetic in a 
 surprising manner. 
 
 (d) The expectation or not of the injury. When the whole nervous 
 system is maintained in a state of tension, anxiously expecting the 
 receipt of some painful impression, the effect produced will natu- 
 rally be increased ; whilst if the attention is diverted, and interest 
 actively aroused in other things, the shock at the time is much 
 diminished, though its effects may be subsequently greater. 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 slight 
 momentary giddiness and faintness (known ordinarily as an attack 
 of syncope or a fainting fit) to immediate and complete prostration, 
 insensibility, and even death. The pulse is at first small, slow, 
 and weak, but soon becomes irregular, extremely rapid, and often 
 imperceptible ; the countenance is pallid and shrunken, and the 
 brow covered with cold sweat ; the respirations are slow and 
 shallow, whilst the temperature is usually subnormal. 
 
 After an interval, the length of which depends on the severity 
 of the lesion and the treatment adopted, reaction occurs, being 
 introduced by increased depth and frequency of the respirations ; 
 
WOUNDS 217 
 
 the pulse becomes slower and fuller, the surface warmer, whilst 
 consciousness and muscular power are gradually restored. During 
 this period it is not unusual for an attack of vomiting to supervene, 
 probably due to hyperaemia of the brain following the anaemia 
 which has been responsible for most of the preceding symptoms. 
 
 When the accident or operation has resulted in serious loss of 
 blood, the phenomena of haemorrhage are associated with those of 
 shock ; the pulse is sometimes of the haemorrhagic type (p. 223) ; 
 the blood is altered in its characters, and great restlessness may 
 be present. 
 
 Sometimes reaction is accompanied by great irritability, either 
 of the mental or muscular systems ; in the one case leading to 
 traumatic delirium, which is always of grave import, and in the 
 other to intense restlessness, as in the shock which follows exten- 
 sive burns. It is possible that in both these conditions a toxic 
 element has been introduced. The term evethitic shock is some- 
 times applied to these manifestations. 
 
 Occasionally the evidences of shock are delayed in their ap- 
 pearance for some time after the injury, and come on gradually. 
 Especially is this the case after railway accidents when no great 
 injury has been experienced ; for a time the anxiety and excite- 
 ment are such that no depression is noticed, but as the mental 
 perturbation passes off, the individual experiences symptoms very 
 similar to the above, but probably rather of the nature of neuras- 
 thenia than of real shock (see Chapter XXL). When an accident 
 occurs to a person in a state of intoxication, it is not unusual for 
 the phenomena of shock to be delayed for some time, only showing 
 themselves when the effect of the alcohol has passed away. 
 
 Pathology. — The post-mortem evidences are not very charac- 
 teristic, but they all point to a loss of control of the nervous system 
 over the vascular, resulting in anaemia of the brain and superficial 
 parts of the body, and enormous engorgement of the abdominal 
 viscera, lungs, and great venous trunks ; the heart contains 
 practically no blood, although it is probable that the right side is 
 much distended at the time of death, especially when due to 
 sudden injury, and subsequently empties itself by post-mortem 
 contraction. The explanation of the phenomena of shock is by no 
 means simple, and several factors are probably needed to produce 
 the complex result. 1. Reflex inhibition of the heart's action 
 through the cardio-inhibitory centre in the medulla explains the 
 early syncope with slow pulse. It is a well-known physiological 
 fact 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 produced. 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 
 
2i8 A MANUAL OF SURGERY 
 
 epigastrium, or by drinking a glass of very cold water, when 
 hot. Tins inhibition of the heart's action is never prolonged in 
 mammals. 2. Inhibition of the vasomotor centre in the medulla 
 is probably the cause of the maintained depression of the patient 
 after an injury. This produces dilatation of the smaller arterioles, 
 especially in the splanchnic area, and thus a marked lowering of 
 the general blood-pressure follows. The supply of blood to the 
 brain and surface is therefore diminished, the portal system being 
 overfull. Most of the symptoms of shock can be explained in this 
 way, although it is evident that a large haemorrhage ought to 
 produce exactly the same effects. 3. A third factor has therefore 
 been suggested in the production of shock, viz., exhaustion of the 
 nerve centres, which thus lose their control over the muscular and 
 circulatory systems. 
 
 Diagnosis. — 1. From the general results of hemorrhage. Rest- 
 lessness and thirst are then prominent signs, together with a sense 
 of dyspnoea, causing rapid respiratory efforts ; the mental con- 
 dition, moreover, is less affected, and the patient is generally 
 sensible ; the surface is excessively blanched, and the pulse may 
 have a marked haemorrhagic wave. 2. In concussion of the brain 
 there are superadded to the symptoms of shock those more par- 
 ticularly connected with the region affected, i.e., the intellectual 
 centres, so that unconsciousness is the predominant feature, whilst 
 loss of memory of the accident and of the events which followed 
 is often noticed. 3. When vomiting is approaching under the 
 influence of an anesthetic, the patient's pulse usually becomes weak 
 and rapid, and the countenance pale. This condition closely simu- 
 lates shock, and is often distinguished from it only by the progress 
 of the case. Under such circumstances, if vomiting is plainly 
 imminent, it is sometimes wise to increase the amount of anaes- 
 thetic, as the patient is usually not fully under its influence. 
 
 Treatment. — In slight cases very little is needed beyond resting 
 quietly for a few minutes, or the exhibition of some aromatic 
 stimulant to the nostrils, such as ammonia or smelling-salts. In 
 the more severe cases the patient is laid recumbent, with the head 
 low ; hot bottles, well protected, and blankets are applied to the 
 trunk and extremities to maintain and increase the bodily tem- 
 perature. If able to swallow, a little warm tea or stimulant may 
 be administered ; but if unconscious, a hot coffee or brandy 
 enema, small in bulk, or a hypodermic injection of ether or 
 strychnine (11\_ ii.-vi. of the B.P. injection), is necessary. It must 
 be borne in mind that the patient has, in most cases, only to be 
 tided over a certain period of depression before reaction naturally 
 follows, so that it is important to economize vital power, and not 
 to waste it by over-stimulation. 
 
 The injection of hot saline fluid (1 drachm of chloride of sodium 
 to 1 pint of water) into a superficial vein, the rectum, or the subcu- 
 taneous tissues (submammary or gluteal for choice), has been 
 
WOUNDS 219 
 
 employed with considerable success of recent years. The modus 
 operandi of intravenous infusion is described at p. 224 ; the fluid 
 should be introduced at a temperature between 105 and no° F. 
 Several pints may be injected to begin with, the exact amount 
 being governed by the reaction of the patient. If after a few hours 
 symptoms of depression again supervene, the injection should be 
 repeated. 
 
 An important question is often raised as to the advisability of 
 performing an operation during shock. As a general rule, it may 
 be stated that operation should be deferred until reaction has 
 come on, unless the presence of the injured organ, such as a badly 
 crushed limb, is evidently prolonging the condition. Under these 
 circumstances a hypodermic injection of morphia may improve 
 the condition by relieving pain ; otherwise the condition should be 
 at once dealt with, and it will be often found that, as the patient 
 passes under the influence of the anaesthetic, the pulse improves, 
 and the state of shock disappears, the anaesthetic shielding the 
 medullary centres from the painful afferent stimuli. In urgent 
 cases, especially when due to an intra-peritoneal lesion, where 
 operation must be undertaken without delay, the use of a saline 
 injection into the venous system prior to operation is often most 
 advantageous. 
 
 Shock may to a large extent be prevented during operation by 
 a careful attention to such details as keeping the patient well 
 covered up and as warm as possible, by perhaps operating on a 
 hot-water table, by minimizing haemorrhage through bloodless 
 methods of operating or the use of forci-pressure forceps, and by 
 rapidity of execution. A hypodermic injection of strychnine, or a 
 brandy and beef-tea enema, given just before the operation, is also 
 useful ; and it must be remembered that incomplete anaesthesia 
 tends to increase the shock rather than to prevent its occurrence. 
 It is also advisable, in cases where the pulse is weak, to use ether 
 rather than chloroform. 
 
 II. Traumatic Fever. — Traumatic fever is that which follows 
 the receipt of an injury, whether simple or compound, or after an 
 operation. Two main varieties are described : 
 
 (a) Simple Traumatic Fever occurs after subcutaneous injuries, 
 such as sprains, contusions, fractures, etc., and after aseptic 
 operation wounds or compound injuries. It is thus found in con- 
 ditions where micro-organisms are absent, or, if present, are in 
 such a state as to be practically impotent. The generally acknow- 
 ledged cause is the absorption from the blood-clot or inflammatory 
 exudation of some chemical substance (possibly the fibrin fer- 
 ment), which has a pyrogenic effect upon the medullary centres. 
 Probably the fever following aseptic operations is largely de- 
 termined by the use of irritating antiseptics, which increase the 
 exudation, and lead to considerable damage of the tissues ; if mild 
 
220 A MANUAL OF SURGERY 
 
 antiseptics or sterilized salt solution are alone used to irrigate 
 open aseptic wounds, this so-called ' reactionary fever ' will be 
 absent, unless other elements, such as retained serous discharge 
 or accumulation of blood, are present. Occasionally fever is 
 observed in cases where we have no grounds for supposing that 
 absorption of fibrin ferment is taking place ; it may then be due 
 to some peripheral irritation, e.g., a badly-fitting splint, and dis- 
 appears immediately on the removal of the cause. 
 
 The symptoms are those of slight pyrexia, reaching ioo° or 
 ioi° F. within twenty-four or forty-eight hours of the injury, with 
 coated tongue, loss of appetite, etc., gradually passing off in three 
 or four days. If thus limited, it is of no prognostic importance. 
 
 (b) Symptomatic Traumatic Fever is that caused by the absorp- 
 tion either of the products of putrefaction, resulting from the vital 
 activity of non-pathogenic organisms in discharges, blood-clot, or 
 dead tissue ; or from the absorption of the toxins connected with 
 a development of pathogenic organisms in the wound or its sur- 
 roundings ; or from the supervention of some general infective 
 disorder. All these different conditions have been dealt with else- 
 where, and require no further notice. 
 
 III. Traumatic Delirium. — -Although delirium is merely a 
 symptom which is superadded to others in certain cases, it is 
 occasionally of so pronounced a character as to demand special 
 attention. Three forms are met with : 
 
 (a) The Active Delirium, which accompanies severe injuries, 
 particularly in plethoric, and often in previously healthy indi- 
 viduals, whose environment has been suddenly changed from that 
 of everyday life to a sick-bed in a hospital ward. Septic con- 
 tamination of the wound is usually present, and the delirious state 
 is associated and runs a parallel course with the traumatic 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 exhibition 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 light, but nourishing ; the bowels are thoroughly 
 opened, and an icebag to the head may be useful. The wound 
 should be freed from any septic accumulation. 
 
 (b) Delirium of a Low Muttering Type is met with in individuals 
 of low vitality, 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 septic or 
 infective diseases. The patient usually lies on his back, staring 
 
WOUNDS 
 
 vacantly upwards, is incoherent, takes no notice of surrounding 
 objects, and is observed to pick at the bedclothes and mutter to 
 himself unintelligibly. There is often, in addition, an involuntary 
 escape of urine or faeces. The mouth is generally open, the 
 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) Nervous Traumatic Delirium 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 sleeplessness and wandering at night, or the 
 patient may have short snatches of sleep, from which he awakes 
 semi-delirious. This gradually increases, and is followed by 
 violent delirium of the worst type (delirium tremens), 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 excitement 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 confined. The pulse and temperature vary con- 
 siderably, and the skin is often moist and clammy. The violent 
 stage is always followed by profound exhaustion, in which the 
 patient may gradually sink into a state of coma and die. In the 
 case of a fractured leg, the struggles of the patient will cause con- 
 siderable displacement of the limb, and necessitate constant 
 attention to prevent further mischief. The limb should never be 
 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 
 considered imminent, either from the previous history of the 
 patient, the tremulous state of his hands and tongue, or his sleep- 
 lessness, the best treatment to adopt is to support the strength by 
 suitable food and a medium dose of stimulant, combined with free 
 purging and, if need be, soporifics (chloral, bromide, paraldehyde, 
 or morphia) ; 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 
 restraint as possible. Nourishing food (possibly of a fluid type), 
 w r ith a certain amount of stimulant, should be administered during 
 the quiet intervals, and sleep obtained by drugs, especially morphia 
 hypodermically ; a quarter of a grain should be given at first, and 
 more if necessary. Free purging is of course essential. 
 
C H A P T E R IX. 
 
 HEMORRHAGE. 
 
 J >Y the term Jia inorr/iage is meant any loss of blood, whether in- 
 significant anci immediately arrested by natural means, or more 
 excessive and requiring treatment to prevent its continuance. 
 Although most commonly due to some injury, whether sub- 
 cutaneous or inflicted through the skin, it may be predisposed to 
 by weakness of the vascular tissues, especially if associated with 
 increased blood-pressure. Certain diseases, such as purpura and 
 scurvy, are characterized by a tendency to bleeding, and there is 
 one congenital condition, haemophilia, in which it is difficult to 
 stop the flow of blood when once started. 
 
 The character of the bleeding differs according to the vessel 
 from which the blood escapes. Arterial Haemorrhage consists 
 in a flow of bright scarlet 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 suffi- 
 ciently 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 respira- 
 tory or other influences. Capillary Haemorrhage is marked by 
 general oozing from a raw surface, the blood trickling down into 
 the wound, 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 will 
 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 haemorrhage 
 is also met with in the form of small localized petechiae, arising 
 from injuries, or from changes in the blood or vessel walls 
 (as in purpura, scurvy, and septicaemia). Epistaxis is the term 
 
HEMORRHAGE 
 
 given to bleeding from the nose. By Hseinatemesis 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 has been torn, or it may have originated from the 
 upper part of the intestinal tract. The blood is usually curdled 
 and brownish in colour, somewhat resembling coffee-grounds, 
 from the action of the gastric juice upon it. Haemoptysis is the 
 title given to the escape of blood from the air-passages, whether it 
 results from injury or disease. Hematuria is a condition in which 
 blood is passed in the urine. By Melaena is meant the passage of 
 dark tarry blood with the faeces. It is always an evidence of 
 disease or injury to the intestine sufficiently far from the anus to 
 allow the blood to become altered in character by the action of 
 the intestinal juices. Blood derived from the rectal mucous 
 membrane usually retains its bright red colour. 
 
 Constitutional Effects. — 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 lips, 
 ears, and eyelids are livid ; the patient gasps, his respirations 
 become quick and sighing, and death ensues after perhaps a few 
 convulsive twitches of the limbs. If consciousness is retained at 
 all, patients often complain of the sight failing, and a sense ot 
 increasing darkness, immediately preceding the fatal termination. 
 These effects depend as much on the rapidity of the bleeding as 
 on the total amount of blood lost ; people can stand gradual loss 
 of blood much better than when it escapes suddenly. 
 
 If the haemorrhage is not so great as to kill immediately, the 
 patient faints, and on recovering is in a condition of severe collapse 
 and weakness, which continues for some time ; he is also liable to 
 recurrent attacks of syncope, any one of which may be fatal. 
 
 If the haemorrhage is more gradual, but continuous, as in cases 
 of piles or uterine fibroids, the patient becomes profoundly anaemic, 
 and the lips, ears, and conjunctivae are pearly white ; dyspnoea 
 ensues, owing to the insufficient amount of blood present, and in 
 consequence the patient is extremely restless, tossing about in bed. 
 Any sudden exertion, or even sometimes the attempt to sit up, is 
 followed by a sensation of faintness ; noises are heard in the ears, 
 the sight becomes dim, or is even temporarily 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, large, and compressible, 
 but collapsing entirely between each beat, and markedly dicrotic. 
 These peculiar features are due to the sudden passage of a small 
 amount of blood through a vessel which is practically empty and 
 entirely collapsed. From the defective vis-a-tevgo, oedema of the 
 extremities may result. 
 
 During the continuance of haemorrhage the blood pressure 
 necessarily falls ; but unless a volume equal to a third of the 
 
22 4 A MANUAL OF SURGERY 
 
 total bulk of blood in the body is lost, it quickly rises again to the 
 normal after the bleeding has ceased. This rise in blood pressure 
 is partly due to a diminution in the size of the vascular area, 
 owing to vasomotor contraction of the peripheral arterioles and of 
 the splanchnic area, but is also caused by an increased flow of 
 lymph into the circulation. This lymph is accompanied by a 
 large number of leucocytes, and hence well-marked leucocytosis, 
 lasting for five or six days, always follows any severe haemorrhage. 
 The number of red blood-cells is also reduced, whilst the amount 
 of haemoglobin in each is diminished, and the specific gravity of 
 the blood falls considerably. 
 
 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. Stimulants may be necessary to maintain the 
 heart's action, but should be given with discretion for fear of re- 
 starting the bleeding. 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 Transfusion is meant the transference of blood from one 
 individual to another ; it may be accomplished by two methods, 
 the direct and indirect. Direct or immediate transfusion consists in 
 injecting the blood of the donor directly into the vessels of the 
 recipient. The objection to this method is that an individual can 
 rarely spare sufficient blood to be of any real use, and hence the 
 results are unsatisfactory. Indirect or mediate transfusion is carried 
 out by whipping the blood from some healthy individual or 
 individuals so as to remove the fibrin, and after straining through 
 fine linen it is injected, either pure, or diluted with saline solution. 
 During the last few years it has been recognised, however, 
 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 than 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 re- 
 placed by what is known as Infusion, which consists in injecting 
 large quantities of some bland fluid into the vessels, and by this 
 means greatly improved results have been obtained. All the 
 apparatus needed is a metal or glass cannula (Fig. 54), the end of 
 which is bulbous, blunt, and bevelled, which can be tied into a 
 vein, and connected by means of a rubber tube with a reservoir 
 containing the fluid (Fig. 55). A vein, e.g., the median basilic or 
 internal saphena, should be exposed, tied below and opened by a 
 
HEMORRHAGE 
 
 225 
 
 longitudinal or oblique incision ; the cannula, filled with lotion 
 so as to exclude air, is then inserted, and a ligature placed round 
 the vessel just below the bulb, so that on withdrawal it can be 
 tightened. The amount injected varies with the circumstances 
 and the effects produced, but, to be efficacious, some pints are 
 usually needed ; 4 or 5 pints have not uncommonly been employed 
 for the purpose. As a rule, one injection is all that is required in 
 dealing with ha-morrhage, but where shock is present it may need 
 to be repeated two or three times. 
 
 Fir,. 54 — Cannula suitable for 
 
 Infusion. 
 
 Fig. 55. — Infusion into Vein of Forearm. 
 
 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 -6 per cent.), at a temperature of 105 ° to no F. The 
 dried crystals of salt should be dissolved in a small quantity of 
 boiling water, so as to sterilize it, and this is then diluted to the 
 required bulk. Of course, the apparatus is most scrupulously 
 purified, either by boiling for some minutes or by effective 
 immersion in carbolic lotion, and no air must be admitted. The 
 injection is made slowly, so that the solution may be gradually 
 mixed with the blood. It has been found by experiment that 
 
 T 5 
 
226 A MANUAL OF SURGERY 
 
 after an infusion following haemorrhage 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 sucked up by 
 the tissues, and explains why it is sometimes necessary to repeat 
 the injection more than once. 
 
 Another plan sometimes used with success consists in the intro- 
 duction of warm fluid into the rectum, or through an aspirator 
 needle connected with a tube and funnel into the loose connective 
 tissue of the buttock, abdomen, or submammary region. In the 
 latter case the funnel must be held at some height in order to gain 
 sufficient pressure, and by this means several pints may be injected. 
 
 Natural Arrest of Haemorrhage. 
 
 This can best be described under two headings, viz., (i) the 
 temporary arrest, and (2) the permanent. The processes are 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. 
 
 The Temporary arrest of arterial haemorrhage is brought about 
 by three principal factors : 
 
 (1) The coagulation of the blood, which occurs in and around 
 the vessel, and without which death would ensue from the merest 
 scratch. The greater the loss, up to half of the total amount of 
 blood in the body, the more coagulable it becomes. 
 
 (2) Diminution in the force of the heart's action always follows 
 haemorrhage, from anaemia of the cerebral centres, a beneficent 
 provision whereby coagulation is facilitated and the flow of blood 
 checked. Unless the syncope is profound, stimulants should 
 therefore be carefully avoided, for fear of causing a recurrence of 
 the bleeding by increasing the power of the heart's beat. 
 
 (3) Changes in and around the vessel play a most important 
 part in completing the process. They consist in the retraction of 
 the artery within its sheath by reason of its inherent longitudinal 
 elasticity ; if, however, it is only partially divided (or, as it is 
 called, ' button-holed '), this condition cannot 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, as the 
 force and calibre of the blood-stream diminish, the external 
 coagulum is able to increase in size by fresh deposits of fibrin, 
 until at last its resistance is too great for the diminished cardiac 
 impulse to overcome, and the sheath is filled with clot, which 
 extends to the divided mouth of the vessel. From this an internal 
 
HEMORRHAGE 
 
 227 
 
 coagulum next develops, which sometimes extends upwards as 
 far as the nearest 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. 
 
 After the cessation of the haemorrhage, the internal coagulum, 
 soft in consistence and dark red in colour, extends from the mouth 
 of the vessel, or from the site of the ligature, for some distance, 
 and perhaps to the next collateral branch (Fig. 56). The vessel 
 wall contracts upon this coagulum, with which, however, it does 
 not unite, except at and near its base. As a result of the injury, 
 a simple plastic arteritis is set up, evidenced by a hyperaemic 
 condition of the vessel wall, due to dilatation of the vasa vasorum, 
 
 Fig. 56. — Early Stage of Oblitera- 
 tion of Artery after Ligature. 
 
 The thrombus is seen above and below 
 the site of ligature, that on the proxi- 
 mal (upper) side being the larger ; 
 commencing cell infiltration of the 
 bases of the clots is also indicated. 
 
 In both these diagrams the arteries 
 throughout for clearness' sake; in 
 tracted. 
 
 Fig. 57. — Later Stages of the 
 Same Process. 
 
 The clots are shrinking, and the lowest 
 portions are being transformed into 
 granulation tissue. Proliferation of 
 the tunica intima is also seen, reach- 
 ing beyond the apices of the clots, 
 have been represented of the same size 
 reality, the lumen would be much con- 
 
 and its infiltration with leucocytes, which also invade 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, 
 probably derived from the leucocytes, occasionally assisting in 
 this process (Fig. 59). The tunica intima proliferates con- 
 currently, causing a secondary infiltration with the larger fibro- 
 blastic cells in that part of the thrombus which is adherent to 
 the vessel wall (Fig. 58) ; whilst a growth of cellular buds or 
 granulations, which gradually increase in size and encroach on 
 the lumen of the vessel, springs up in those parts where the apex 
 of the clot lies free and unadherent (Fig. 57). Thus, the base of the 
 
228 
 
 A MANUAL OF SURGERY 
 
 clot is transformed into a cellular mass derived from proliferation 
 of the tunica intima, and by the development of new vessels from 
 the vasa vasorum into granulation tissue ; whilst the cellular 
 buds which grow from the walls, and extend nearly to the next 
 collateral branch, are also similarly changed. The free conical 
 extremity of the clot contracts, and is gradually removed, partly 
 by the activity of leucocytes which infiltrate it from the base, 
 partly by the erosive action of the surrounding granulation tissue. 
 A similar set of changes occurs at the distal side of the ligature 
 in an artery tied in its continuity, although the thrombus is 
 smaller and less firm. The ligature itself may be infiltrated by 
 leucocytes, and replaced by granulation tissue, or may be en- 
 
 Fig. 58. — 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, undergoing proliferative changes, and 
 therefore thickened. C, Blood-clot lying in lumen of vessel, becoming 
 infiltrated with leucocytes (small dark cells) and larger fibroblasts derived 
 from the endothelium. 
 
 capsuled. A rod of granulation tissue is thus developed, blocking 
 the vessel, and this, by the usual process of repair, is transformed 
 into a firm cicatricial cord in the course of a few months (Fig. 59). 
 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 forma- 
 tion results, which is quite sufficient for the occlusion of the 
 vessel. 
 
 The arrest of haemorrhage from veins and capillaries is more 
 easily accomplished, the collapse of the walls, together with the 
 
HEMORRHAGE 
 
 229 
 
 formation of the external coagulum, being sufficient for this 
 purpose. The later steps are similar to those occurring in an 
 artery, except that there is but little internal coagulum. In 
 capillaries, unless some constitutional condition such as haemo- 
 philia is present, the mere falling together of the walls is sufficient 
 to allow coagulation to take place, and thus stop the bleeding. 
 
 Surgical Treatment of Haemorrhage. 
 
 Many different methods are needed, under varying circum- 
 stances, for the effective arrest of haemorrhage. It may be laid 
 
 Fig. 59. — Organized Thrombus in Vessel, showing the newly formed 
 Connective Tissue occupying the Lumen of the Vessel, and vascu- 
 larized FROM THE VASA VASORUM. (TlLLMANNS.) 
 
 Two giant cells are seen in the centre. 
 
 down as a preliminary axiom that digital pressure over the 
 bleeding-point will always temporarily check the most furious 
 outburst, whilst means for its permanent stoppage are being 
 arranged. 
 
 Where the bleeding, though profuse, does not come from any one 
 particular vessel, the following measures can be utilized : 
 
 1. Cold may be employed in the form of ice, cold water or 
 lotion, or simple exposure to the air, all clots, rags, pledgets, etc., 
 being removed for this purpose ; it must, however, be remembered 
 that ice and unsterilized water may convey sepsis. Such treat- 
 ment is of most value for general oozing from vascular structures 
 or into cavities, such as the mouth, vagina, or rectum. 
 
 2. Position. — Where the bleeding is from one of the extremities, 
 especially the lower, elevation is a most important factor in 
 arresting it. The veins are emptied by the force of gravity, and 
 
230 A MANUAL OF SURGERY 
 
 this is always followed by a reflex contraction of the arteries, 
 a proceeding of which surgeons also avail themselves in order 
 to exsanguinate a limb previous to applying the rubber tour- 
 niquet in operations which one desires to render as bloodless as 
 possible. 
 
 3. Direct Pressure. — The skilful application of an antiseptic 
 dressing, combined with pressure, is often effectual in arresting 
 haemorrhage. General oozing from cut surfaces, which can be 
 brought into apposition, as from an amputation wound, may be 
 checked by applying a Arm bandage over them. In cavities or 
 hollows, either natural or made by operation, bleeding may be 
 stopped by plugging with strips of dressing, or by graduated 
 layers of antiseptic wool. This form of packing has in a large 
 measure taken the place of the old ' graduated compress,' which 
 consisted of layers of lint devoid of antiseptic qualities, gradually 
 increasing in size, superposed one over the other. Such dressings 
 should be retained firmly in position for twenty-four hours, after 
 which, if no further haemorrhage has occurred, the bandages may 
 be slackened, but it is usually advisable to retain the deep plugs 
 a little longer. 
 
 4. Hot Water (130 to 160 F.) is a powerful haemostatic. A 
 certain proportion of carbolic acid or corrosive sublimate should 
 be present to render the water aseptic, or it should have been 
 previously boiled ; it must also be sufficiently hot, otherwise bleed- 
 ing is encouraged rather than checked. It is supposed to act by 
 stimulating the involuntary muscular fibres of the vessel wall to 
 contract ; but probably the coagulation of the albumen of the 
 blood is an important factor, as unless the water is hot enough to 
 blanch the surface of the wound the bleeding is not stayed. 
 
 5. Chemical Agents may be used to check oozing from spongy 
 parts, or bleeding from deep organs or cavities. If they are 
 applied locally, and act primarily by causing coagulation of the 
 blood, they are known as Styptics, or astringents. Such are the 
 liquor ferri perchloridi or pernitratis, tincture of matico, tannic or 
 gallic acids, alum, nitrate of silver, fibrin ferment, styptic colloid, 
 cocaine, suprarenal extract (adrenalin), etc. If the drug is 
 administered internally, and acts by increasing the coagulability 
 of the blood, or by causing constriction of the vessels, it is termed 
 a Haemostatic — e.g., opium, ergot, turpentine, hamamelis, acetate 
 of lead, chloride of calcium, etc. In applying a styptic, it is 
 essential that the surface of the wound should first be thoroughly 
 cleansed, and all coagula removed. A portion of the dressing 
 dipped in the solution is applied to the surface, or the drug is 
 sprinkled or sprayed upon it. The objection to most of these 
 agents is that healing by first intention is often hindered, whilst 
 in the case of perchloride of iron extensive sloughing may result. 
 Probably the most powerful styptic is suprarenal extract, which, 
 however, loses its virtues when kept in solution for more than an 
 
HEMORRHAGE 231 
 
 hour or two. One of the dried tabloids (grs. 5) may be dissolved 
 in 2 drachms of a 5 per cent, cocaine solution, and this is sprayed 
 over the part, or applied on a piece of dressing. 
 
 6. Cauterization is not very largely employed for the arrest of 
 haemorrhage, except from bones and from tissues thickened by 
 inflammation, where retraction and contraction of the vessels are 
 difficult. It need in no way interfere with primary union if the 
 skin is not touched, for the minute sloughs formed, are quite 
 aseptic, and will either be absorbed or cast off in the discharges. 
 The chief objection to this method is the risk of secondary 
 haemorrhage when the sloughs separate. The cautery is some- 
 times used for the bloodless removal of vascular tumours, either 
 as a galvano-cautery, or a Pacquelin's knife, or the ordinary clamp 
 and cautery. It must be remembered that, in order to effectually 
 seal the mouths of the vessels, the cautery must be at a dull red 
 or black heat ; a bright red-hot iron cuts through a vessel as 
 cleanly as a knife, and does not stop the haemorrhage. 
 
 When the bleeding is more serious, mid originates from some definite 
 vessel or vessels, other and more vigorous measures have to be 
 adopted. Digital pressure suffices to arrest it for a time, whilst 
 preparations are being made to ligature or otherwise treat the 
 wounded vessel. If possible, a ligature should be applied with 
 antiseptic precautions, but other means are used : 
 
 1. Acupressure was introduced by the late Sir James Simpson 
 in order to obviate the use of ligatures. The introduction of 
 aseptic absorbable animal ligatures has made such a method only 
 necessary in exceptional circumstances. A needle is passed 
 either under the vessel from the skin, or over the vessel from the 
 surface of the wound, and, if placed accurately, is quite sufficient 
 to stay the bleeding. With it, however, is sometimes combined 
 the pressure of a loop of silk or wire passed figure-of-8 fashion 
 around the ends of the needle. 
 
 2. Forcipressure is a plan of stopping haemorrhage by crushing 
 the divided end of the vessel between the strong and deeply 
 serrated blades of a pair of forceps with scissor handles pro- 
 vided with a catch ; those known by the name of Spencer Wells 
 are the most convenient. In dealing with small vessels, it is 
 quite sufficient to leave the forceps applied for a few minutes, 
 perhaps twisting them before removal ; but with the larger it is 
 advisable to apply a ligature. 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. 
 
 3. Torsion was used as a means of sealing the ends of divided 
 vessels before aseptic ligatures were introduced. It may be applied 
 in two ways, viz., (a) Limited Torsion, which is employed for the 
 larger vessels. The artery is drawn out of its sheath for about 
 half an inch with one pair of forceps, and held close to the tissues 
 
232 A MANUAL OF SURGERY 
 
 by another pair applied transversely, whilst the grasped end is 
 twisted sufficiently to thoroughly close it ; it should not, however, 
 be twisted off. (b) Free Torsion is used for the smaller vessels 
 which cannot be so completely isolated from surrounding struc- 
 tures ; the vessel is laid hold of with its sheath or connective 
 tissue covering, and twisted as much as necessary. 
 
 The effect of torsion is that the inner and middle coats are 
 ruptured just above the spot grasped, and tend to curl upwards 
 into the lumen of the vessel, whilst the outer coat is twisted up 
 beyond. A coagulum forms upon the injured structures, and the 
 subsequent processes to secure permanent occlusion are similar 
 to those described above. The advantages claimed in favour of 
 torsion are that it is easier to twist the vessels than to tie them, 
 that there is less liability of secondary haemorrhage, and that no 
 foreign body is left in the wound. As to the ease of application, 
 it is doubtful whether torsion has any advantage over ligature, 
 and certainly when asepsis is maintained the two last statements 
 do not hold good, for secondary haemorrhage is practically un- 
 known in aseptic surgery, and the catgut ligature is not more of 
 a foreign body than the damaged end of a twisted vessel. Torsion 
 is, however, occasionally useful in plastic work. 
 
 4. Ligature is at the present day the method most frequently 
 employed for arresting bleeding from a definite source. 
 
 The material used 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 
 finally absorbed, or so pure and unirritating as to become encap- 
 suled in the tissues. Catgut suitably prepared is the substance 
 most frequently employed, but inasmuch as commercial catgut, 
 even when rendered aseptic by immersion in carbolic acid, swells 
 up in warm blood serum, and becomes a soft, pulpy mass in half 
 an hour, it is necessary to harden and render it more resistant by 
 steeping it for twelve hours in a solution of chromic acid (5 parts 
 of gut to 1 of chromic acid in 100 parts of water), and subse- 
 quently for twelve hours in 100 parts of sulphurous acid solution. 
 It is then dried, and is of a greenish colour. It must not be 
 forgotten that catgut is prepared from sheeps' intestines, by 
 allowing the latter to putrefy in water and then scraping away the 
 mucous and muscular coats, leaving only the submucous tissue 
 with its elastic fibres, which is twisted up into long strands. It 
 is obvious that very efficient sterilization is necessary to make a 
 material thus prepared fit for surgical work (p. 18). 
 
 Sterilized silk is another agent employed, whilst animal 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 the ox, as a material for tying vessels in 
 their continuity, and excellent results have followed its employment. 
 Recently a celluloid ligature has been introduced, and holds out 
 
HEMORRHAGE 
 
 233 
 
 Reef Knot 
 
 prospects of replacing by a safe and harmless material all these 
 more dangerous animal preparations. 
 
 Ligatures may be applied either to the divided end of an artery 
 in an open wound, or to an artery in its continuity, the effects and 
 final means of occlusion being in both cases very similar. 
 
 When applied to the open cud of a divided vessel, care should 
 be taken to select a ligature the thickness of which is proportionate 
 to the lumen of the vessel to be tied. 
 The artery should be cleanly picked up 
 with forceps, so as to include as little 
 surrounding tissue as possible, and 
 where a sheath exists, should be with- 
 drawn from it. The ligature is then 
 passed round it and tied in a knot 
 which will not slip, e.g., the reef knot 
 (Fig. 60). When the application of a 
 ligature is difficult, as in very dense 
 
 fibroid tissue, it may be advisable to pass it under the vessel by 
 means of an ordinary curved needle, and then to tie it. 
 
 For ligation in continuity, see p. 280. 
 
 Effects of Ligature — 1. On the Vessel Wall. — The immediate 
 result, 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 con- 
 stricted and thrown into folds within 
 the grasp of the ligature (Fig. 61). If 
 an artery is tied in its continuity, the 
 same effect is produced on each side of 
 the ligature. The changes already 
 described, by means of which the 
 artery is obliterated and transformed 
 into a fibro-cicatricial cord, then mani- 
 fest themselves in due order. An 
 exudation of plastic lymph and cells 
 occurs into the sheath and around the 
 ligature, and if the latter is aseptic, the 
 whole is embedded in this plastic mass, 
 which undergoes the ordinary changes 
 seen in repair. If the ligature, how- 
 ever, is septic and irritating, it has to 
 cut its way out through the vessel wall 
 by an ulcerative process akin to the 
 separation of a septic slough, thus ex- 
 posing the patient to the risk of secondary haemorrhage from the 
 disintegration of the internal coagulum. The period at which a 
 septic ligature is separated varies with the size of the vessel, 
 from a week or eight days for an artery the size of the radial 
 
 Fig. 61. — Effect of Tying a 
 Ligature firmly around 
 an Artery. 
 
 The ligature was tied at two 
 levels, and the artery then 
 laid open longitudinally. 
 
234 A MANUAL OF SURGERY 
 
 or ulnar to twelve or fourteen clays for the subclavian or 
 carotid. 
 
 Of late years an old idea has been resuscitated, and has gained 
 a considerable amount of support from some surgeons, viz., that 
 occlusion of a vessel is satisfactorily accomplished by merely 
 bringing the walls into close apposition by an animal ligature of 
 suitable size, and that division of the inner and middle coats is 
 not only unnecessary, but prejudicial, and favours secondary 
 haemorrhage. Where asepsis is fully maintained, satisfactory 
 occlusion follows either plan ; but it appears to us that the division 
 and curling up of the inner and middle coats must facilitate 
 the deposit of fibrin and process of repair. At any rate, it would 
 seem safer to apply a ligature to a main vessel on the face of a 
 stump with sufficient tightness rather than to err on the other side. 
 In cases where, perforce, the artery must be tied at a spot where 
 extensive atheroma or calcareous degeneration is present, it may 
 be advisable to use broad animal ligatures, such as strips of ox 
 aorta (Harwell), or prepared portions of gold-beaters' skin, and 
 only to tighten the knot sufficiently to occlude the vessel with as 
 little damage to the coats as possible. The same plan must also 
 be adopted in dealing with arteries of great size, such as the 
 innominate, the first part of the subclavian, or the common iliac ; 
 the non-observance of this precaution results in aneurismal dila- 
 tion at the point of ligature, and this to secondary haemorrhage 
 and death. 
 
 It is a well-known fact that all arteries are maintained in the 
 body more or less upon the stretch, as evidenced by their retrac- 
 tion within the sheath on complete division. A certain amount 
 of longitudinal tension must therefore always exist upon any 
 part of an artery to which a ligature has been applied in its 
 continuity, a condition which may presumably predispose to 
 secondary haemorrhage. To obviate this, it has been suggested 
 that two ligatures should be applied, and the vessel divided 
 between them. This plan may be used with advantage in situa- 
 tions where the artery is easily accessible, but is scarcely feasible 
 in some of the deeper operations. 
 
 2. The Ligature itself undergoes changes, which result in its 
 partial or total absorption, if such be possible, or in its becoming 
 encapsuled if absolutely unabsorbent. The leucocytes attack 
 any soft material, such as silk or catgut, insinuating themselves 
 amongst the fibrillae, and finally remove them by a similar digestive 
 process to that which leads to the absorption of a small aseptic 
 slough. Multinucleated giant-cells are often present, and probably 
 take some part in the proceeding. Finally every trace of the liga- 
 ture disappears, and its place is taken by fibrous tissue, incor- 
 porated with that arising from the end of the vessel. Chromicized 
 gut usually lasts for about a fortnight, but not unfrequently much 
 longer ; silk is similarly attacked and removed, but more slowly. 
 
HEMORRHAGE 235 
 
 Other animal substances employed are dealt with in the same 
 way, and even silver wire is not unaffected, its surface becoming 
 roughened after a time and slightly eroded. 
 
 3. The effect on the Circulation is the same whether ligature 
 or any other plan of occlusion is adopted. The passage of the 
 blood through the vessel ceases, and its proximal end as far as 
 the next patent branch, though remaining somewhat distended 
 for a short time by the impact of the blood-stream, soon begins 
 to contract, and is ultimately converted into a fibrous cord, which 
 may or may not be pervious for a short distance. Blood is 
 conveyed to the vessels of the limb below the ligature by anasto- 
 mosing branches which rapidly undergo dilatation, and establish 
 a collateral circulation, sufficiently free as a general rule to main- 
 tain the vitality of the part. These collateral branches become 
 permanently enlarged, lengthened, and tortuous, and their walls 
 thickened. If for any reason the collateral circulation is in- 
 sufficient, gangrene is likely to supervene, starting in the parts 
 furthest away from the centre of the circulation, or in the structures 
 of least vitality, and spreading upwards until a part is reached 
 which receives enough blood to keep it alive. 
 
 Arterial Haemorrhage. 
 
 Three forms of arterial haemorrhage are described, viz., primary, 
 reactionary, and secondary. 
 
 Primary Arterial Haemorrhage is met with under two conditions 
 — from an open wound, or where an artery is ruptured or 
 punctured subcutaneously, so that extravasation into the tissues 
 occurs, constituting either a severe bruise if the artery is small, 
 or if the vessel is large what has been badly termed a ' diffuse 
 traumatic aneurism.' The general rules for the surgical treatment 
 of both these conditions are identical, and although the agent 
 employed to finally arrest the bleeding varies according to the 
 surgeon's personal predilections, yet the underlying principles 
 hold good in all cases. We shall limit ourselves mainly to 
 speaking of the ligature, as we almost always employ this agent. 
 
 A. Primary arterial haemorrhage from an open wound. The 
 blood is here poured forth upon the surface, and escapes freely, so 
 that the full constitutional effects are experienced. 
 
 The principles that guide us in the Treatment of primary arterial 
 haemorrhage were first recognised by the late Mr. John Bell, but 
 the importance of acting upon them, and not trusting to the 
 Hunterian plan of ligature at a distance, was first fully insisted 
 upon by Guthrie, whose large experience, confirmed by that of 
 later surgeons, demonstrated their accuracy. They may be 
 enunciated as follows : 
 
 1. That the vessel must be secured at the bleeding-point, an operation 
 to expose it being undertaken if necessary. However infiltrated 
 
236 A MANUAL OF SURGERY 
 
 the part, the rule of cutting down to expose the wounded vessel is 
 to be adhered to, with one or two exceptions noted below, 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 
 puncture having passed between the bones. In the axilla and 
 groin such uncertainty often exists, (b) Proximal ligature of a 
 vessel at some distance above the bleeding spot is very commonly 
 insufficient to arrest the haemorrhage, since collateral circulation 
 is quickly established, or, though apparently effective for a time, 
 reactionary haemorrhage is very likely to ensue. 
 
 2. That both ends of the wounded vessel must be secured if it is 
 completely divided, whilst if it is only punctured, a ligature must 
 be placed on each side of the puncture, and the complete division 
 of the vessel effected. The ease with which collateral circulation 
 is established justifies such treatment in the case of all arteries 
 of large size. Thus, where the facial artery is divided, jets of 
 blood are emitted from each end quite freely, and with nearly 
 as much force from the distal as from the proximal. Occasionally 
 the distal end of a bleeding vessel retracts amongst the infiltrated 
 tissues to such an extent as to render its isolation impracticable. 
 The surgeon must then trust to plugging of the wound from the 
 bottom, but not until every effort has been made to secure it. 
 
 It is only needful to undertake the measures detailed above in 
 cases where primary haemorrhage is actually proceeding. If it 
 has been once arrested, it is unnecessary to search for the bleeding 
 spot unless the patient is very faint and collapsed, and the surgeon 
 has reason to anticipate that a large trunk has been injured. 
 Under such circumstances it may be needful to seek for and tie 
 it at once, otherwise recurrent haemorrhage is likely to ensue 
 when the heart's action becomes more vigorous. 
 
 There are a few exceptions to the general rule of tying a 
 wounded vessel at the injured spot, e.g., where the depth of the 
 dissection needed might endanger important parts, as in dealing 
 with the deep palmar and plantar arches, or with the secondary 
 branches of the carotid. 
 
 In the actual treatment of any particular case, temporary arrest 
 of the bleeding may usually be effected by digital compression 
 either of the bleeding point or of the main trunk at a favourable 
 spot nearer to the heart, against some resisting structure, such 
 as a subjacent 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 
 transverse 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 
 
HEMORRHAGE 237 
 
 third part of its course against the first rib by the finger or thumb 
 placed immediately behind the clavicle, the palm of the hand 
 resting over the shoulder. A good deal of force is required in 
 order to maintain the pressure, and this may be gained by super- 
 imposing the fingers or thumb of the other hand. Where the 
 pressure is to be kept up for some time, the handle of a doorkey 
 well padded may be employed in the same way, or an incision 
 may be made and the vessel exposed, and directly controlled by 
 digital pressure. The facial artery is compressed against the 
 lower jaw just in front of the masseter muscle. Bleeding from 
 the labial and coronary arteries is commanded by inserting the 
 index- finger into the corner of the mouth, and compressing the 
 lip between it and the thumb outside. The temporal artery should 
 be compressed against the zygoma just in front of the ear, 
 the occipital at a spot about i\ inches from the occipital pro- 
 tuberance against the superior 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 radial and ulnar arteries are easily 
 commanded just above the wrist by using both hands to grasp 
 the forearm, one for each vessel. The abdominal aorta is tem- 
 porarily controlled in slim individuals with ease by pressure through 
 the abdominal wall against the body of the third lumbar vertebra 
 at a point a little 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 just below Poupart's 
 ligament. The surgeon should stand on the same side of the 
 patient as the artery to be controlled, and use either the finger- 
 tips or thumbs to press the vessel upwards and backwards against 
 the pubic ramus. The fingers of one hand placed over the other 
 may sometimes be necessary to maintain sufficient command, or 
 the thigh may be encircled by the two hands, and one thumb laid 
 over the other. Care must be taken not to let the vessel roll to 
 one side or the other, and so escape compression. When the 
 artery has to be controlled for some time, as in an amputation, 
 the hands may be used alternately, the one to rest the other. 
 Such pressure will suffice for the temporary arrest of haemorrhage 
 from any part of the lower limb. If it is desirable to control the 
 anterior and posterior tibial arteries close to the ankle during opera- 
 tions upon the foot, the assistant who steadies the limb accom- 
 plishes this by grasping the toes with one hand, and with the 
 other compressing the vessels, the posterior tibial at a spot a 
 finger's breadth behind the internal malleolus, the anterior midway 
 between the two malleoli. 
 
 As digital compression cannot, however, be comfortably main- 
 tained for long, mechanical compression of a limb as by tourniquet 
 or elastic bandage must be resorted to. Possibly the screw , 
 tourniquet will be the best to apply, as it can be relaxed and 
 
238 A MANUAL OF SURGERY 
 
 tightened again as often as is necessary during the operation. 
 In some cases it is advisable to exsanguinate the limb by eleva- 
 tion before applying the tourniquet. 
 
 The wound is then, if need be, enlarged by incisions, which 
 whilst freely laying the parts open should inflict the least possible 
 damage on surrounding structures. All coagula are removed, 
 and the wounded vessel looked for. It may be needful to relax 
 the tourniquet, and allow a jet or two to escape, in order to ascer- 
 tain its position. Both ends should be sought for and tied, a 
 proceeding easier said than done. This especially applies to the 
 distal end, which retracts, and often does not bleed at the time of 
 operation, but may do so when the collateral circulation becomes 
 established. 
 
 B. For Subcutaneous Rupture of an Artery, see p. 247. 
 
 Recurrent, Intermediate, or Reactionary Arterial Haemorrhage. 
 
 Such are the terms applied to bleeding which recurs within 
 twenty-four hours of an accident or operation. Its occurrence 
 is an evidence of the failure of the means employed to per- 
 manently arrest the primary loss of blood, and may result from 
 two chief causes : (a) Defective application of a ligature, which 
 comes undone from being badly tied (a 'granny' knot), or slips 
 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 sufficiently 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. The term should not 
 be applied to the oozing of blood or blood-stained serum so 
 common after operations, but only used for those cases which 
 demand treatment, and where considerable pain and tension are 
 caused by the accumulation of blood in the wound. 
 
 Treatment. — Elevation and the pressure of a firm bandage are 
 often quite sufficient to arrest this form of bleeding; but if un- 
 successful, the wound must be opened up, washed out w r ith hot 
 or cold lotion, and any bleeding vessel 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 its healing need be occasioned. Should the 
 bleeding persist, antiseptic plugging must be resorted to. 
 
HEMORRHAGE 
 
 239 
 
 Secondary Haemorrhage. 
 
 Under this title are included all forms of haemorrhage from 
 wounds which occur after the lapse of twenty-four hours. It 
 is usually due to sepsis, and was formerly very common, being a 
 frequent cause of a fatal termination ; but since the introduction 
 of antiseptic surgery it is but seldom seen. Where antisepsis, 
 however, cannot be efficiently carried out, as in the mouth, 
 pharynx, etc., it is still occasionally met with. 
 
 The Fundamental Cause in the production of secondary haemor- 
 rhage is without doubt a septic condition of the wound. This 
 may act in various ways. Thus, in a vessel entirely divided, 
 the cocci may gain entrance through the open mouth to the 
 internal coagulum, and by causing its disintegration, break 
 down the barrier which Nature had raised against such an 
 occurrence. This process is assisted by an ulcerative form of 
 periarteritis, which leads to the maceration and softening of an 
 absorbent ligature, and to weakening of the vessel walls. It is 
 in this latter way that secondary haemorrhage is induced in 
 vessels ligatured in their continuity, the loss of support due to 
 the opening up of the septic wound being also an element of 
 danger. We desire here to emphasize the marked alterations 
 in all the conditions existing in a septic as opposed to an aseptic 
 wound. In the latter it is not only the clot in the lumen of the 
 vessel which is relied on to prevent accidents, but the vital action 
 of all the tissues is calculated to work in the same direction, that 
 of ensuring the patient against haemorrhage ; in fact, the occur- 
 rence of secondary haemorrhage in an aseptic wound is almost 
 impossible. On the other hand, when sepsis supervenes, a 
 destructive process replaces that of repair, and the activity of 
 the part is temporarily paralyzed by the toxic influence of the 
 micro-organisms and their products. 
 
 Various other conditions may be mentioned, however, as Con- 
 tributory Causes of secondary haemorrhage : (i.) The ligature 
 may be coarse, irritating, or septic, or it may consist of material 
 too readily absorbed. (ii.) Its mode of application may be 
 faulty. Thus, it may have included other structures, and so 
 becomes loose, offering an insufficient bar to the blood-pressure ; 
 or the sheath may have been opened too freely, and thus the 
 vitality of the vessel wall dependent on the vasa vasorum is 
 diminished. In large vessels, such as the innominate and first 
 part of the subclavian, the mere division of the inner and middle 
 coats weakens the wall to such an extent as to render it incapable 
 of withstanding even a normal blood-pressure, so that aneurismal 
 dilatation and secondary haemorrhage are almost certain to result, 
 even in aseptic cases, (iii.) The ligature may have been placed 
 too near a branch immediately concerned in the establishment of 
 
240 A MANUAL OF SURGERY 
 
 the collateral circulation (though if asepsis is maintained this is 
 comparatively unimportant), or where there is a considerable 
 back-flow, or the part may not have been kept absolutely at rest, 
 (iv.) The condition of the arterial wall at the site of ligature may 
 be unhealthy, being possibly the seat of atheroma or fatty de- 
 generation, a most important complication if the wound becomes 
 septic, (v.) The state of the blood may be unfavourable to the 
 repair of any wound, whether in an artery or not, e.g., in albu- 
 minuria or diabetes, (vi.) Increased blood-pressure after the 
 ligature of a vessel may lead to secondary haemorrhage, as in 
 plethora, Bright's disease, traumatic fever, or from injudicious 
 excitement, or the unwise administration of stimulants. 
 
 The Phenomena are usually preceded by those of septic con- 
 tamination of the wound, to which a slight occasional loss of 
 blood is added. This continues with more or less frequency and 
 severity, until either the patient is worn out by the constant 
 repetition of small losses, or is destroyed by one or two severe 
 gushes from the larger vessels. The earlier the bleeding occurs, 
 the less serious it is, as it probably comes from the smaller 
 vessels, and can be easily dealt with. When, however, it does 
 not supervene till late, as on the tenth or twelfth day, it usually 
 arises from the larger trunks, and is increasingly severe. When 
 originating from a vessel tied in its continuity, it generally 
 comes from the distal end, and that for the following reasons : 
 (a) The internal coagulum is here less firm, and forms later. than 
 at the proximal end ; (b) the pressure at the distal side of the 
 ligature, which is at first nil, is continually increasing as the 
 collateral circulation is established, whilst proximally it gradually 
 diminishes as the vessel contracts, and the blood-flow is deflected 
 into other channels ; and (c) the main vasa vasorum always run 
 into and along the vessel wall in the same direction as the blood- 
 stream. Hence the effect of isolating the artery in its sheath and 
 ligating it is to diminish the vitality of the arterial tunics and to 
 impede repair just below the point of ligature. 
 
 The Treatment is a matter of grave anxiety until the wound 
 gets into a healthy state, inasmuch as the surgeon can never be 
 certain that the bleeding will not break out again, although it 
 may have been temporarily stayed ; hence such a case must be 
 most carefully watched. If the wound is in a limb, a tourniquet 
 should be lightly adjusted above it as a precautionary measure, 
 so that at a moment's notice it may be tightened. 
 
 When arising from an artery entirely divided across, as in an 
 amputation stump, elevation of the part, exposure to the external 
 air, bathing it with cold lotion, and then redressing and firmly 
 bandaging it, may be all that is needed in the early and mild cases. 
 A recurrence will necessitate the reopening of the wound, and 
 the application of ligatures to the bleeding points, if practicable. 
 The actual cautery may be employed where the tissues are too 
 
HEMORRHAGE 
 
 241 
 
 rotten to hold a ligature. Means should be adopted to remove 
 septic sloughs, as by a Volkmann's spoon, and if possible to render 
 the wound aseptic by swabbing it out with strong carbolic lotion 
 (1 in 20), or with a solution of chloride of zinc. The wound 
 should then be powdered with iodoform, packed with cyanide 
 gauze, and firmly bandaged. If occurring later in the case, the 
 wound should be freely opened up, and an attempt made to secure 
 the bleeding vessel by isolating it for some little distance from 
 surrounding structures. If this fails, owing to the sloughy or 
 septic state of the tissues, 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 ligature can alone be depended on, should local 
 treatment be unsuccessful. 
 
 When coming from an artery tied in its continuity, the means 
 indicated above should be adopted in the early stages. Later on, 
 the treatment varies a little according to the situation. If from 
 a vessel of the trunk, such as the carotid or iliac, the wound must 
 be freely opened up, and the artery secured again above and 
 below, whilst every effort is made to combat the septic condition 
 by plugging with antiseptic materials. Failing this, if proximal 
 ligature is impossible, one can only trust to pressure. In the 
 arm, after using cold, pressure, and elevation, one would re-tie 
 above and below through the original wound. If this fails, a 
 ligature should be applied higher up through a separate incision, 
 or finally amputation be performed. In the leg, however, it is 
 scarcely wise to attempt re-ligature at a higher spot, owing to 
 the less abundant collateral circulation. If the haemorrhage 
 ceases, gangrene is very likely to ensue ; whilst if the latter does 
 not supervene, haemostasis will probably not be effected. Under 
 such circumstances amputation must be undertaken without 
 delay. 
 
 Venous Haemorrhage. 
 
 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 welling up in a 
 dark, purplish stream from the wound, and rendering its arrest the 
 more difficult 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 of Venous Haemorrhage. —The same means to a large 
 extent must be employed as for arterial haemorrhage, but it is 
 less frequently required, since the smaller veins collapse naturally, 
 and thus the bleeding stops. It is never advisable to occlude the 
 whole circumference of a large vein if it can be avoided, since a 
 puncture or tear can often be secured without seriously encroach- 
 
 16 
 
242 A MANUAL OF SURGERY 
 
 ing upon the calibre of the tube. 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 stuffed. 
 
 The dangers of venous haemorrhage are fourfold : (i) The con- 
 stitutional symptoms arising from the actual loss of blood, details 
 of which have been given above ; (2) the thrombus which forms 
 may become displaced as an embolus ; (3) septic infection of the 
 thrombus lying in the mouth of the vessel may lead to pyaemia ; 
 and (4) the entrance of air into veins, which, though rarely met 
 with, is fraught with the most urgent danger to the patient. The 
 air becomes churned up in the cavities of the right side of the 
 heart, forming a spumous, frothy mixture amongst the columnar 
 carneae, which the heart can only with difficulty eject ; thus the 
 circulation is brought to a standstill in spite of forcible cardiac 
 contractions, and the patient dies from anaemia of the lungs and 
 brain. 
 
 The Cause of the entry of air is usually a wound of some vein 
 in what is known as the ' dangerous region ' of the neck or axilla, 
 but it may occur in other positions. There is but little blood- 
 pressure within the veins at any time, but during inspiration the 
 movements of the thorax exercise an aspiratory or suction effect 
 upon the blood in the veins of the neck, a most important element 
 in the maintenance of the venous flow. Any condition which 
 tends to prevent 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 
 button-holed as by excision of a portion of the walls or division 
 of a branch close to the main trunk, or if undue traction is exer- 
 cised 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 very distended, and the intravenous 
 pressure high, as is often seen in the operation of tracheotomy, 
 then the wound of a vein, even in the dangerous area, usually 
 results in loss of blood rather than entrance of air. 
 
 Signs. — The entrance of air into a wounded vein is accompanied 
 by a hissing, gurgling, or sucking sound, which is quite charac- 
 teristic. A few bubbles of air may also be seen clinging about 
 the aperture in the vessel. If only a small amount has entered, 
 no bad results may follow ; but the usual effect of this accident is 
 to produce sudden and severe faintness, and if the patient is con- 
 scious, a feeling of dyspnoea and distress, which is partly cardiac 
 in origin, partly due to obstruction to the flow of blood through 
 the lungs. The pulse becomes rapid and almost imperceptible, 
 the pupils widely dilated, and death usually follows, preceded 
 perhaps by convulsions, although the fatal issue may be postponed 
 for a few hours. If the patient survives, no after-effects remain. 
 
HEMORRHAGE 
 
 243 
 
 Treatment.— This accident can usually be avoided by dealing 
 cautiously with all veins in operations about the neck. 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 vein should be secured by ligature as soon as possible. Com- 
 pression of the chest has been recommended by some authorities in 
 order to squeeze out the air that has entered ; but there is little 
 chance of attaining this end. 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. 
 
 Capillary Haemorrhage. 
 
 This is usually of little significance. It is characterized by a 
 general oozing from the wounded surface, the blood trickling 
 down to fill the cavity from the bottom. It is often very abun- 
 dant from inflamed parts, and especially from fibro-cicatricial 
 tissue, which prevents the closure of the vessel mouths. It can 
 usually be arrested by a little pressure, or by the application of 
 cold or hot water, by styptics, cauterization, or plugging. 
 
 Methods of dealing with Haemorrhage from Special Sources. 
 
 Carotid Artery. — Treatment is impossible unless the surgeon is on the spot, 
 when both ends should be tied. 
 
 Jugular Vein. — Tie, or stitch, if possible, without occluding the whole 
 lumen. 
 
 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 the external carotid between the superior thyroid and lingual has been 
 recommended 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 vertebral. 
 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 styptics must be depended on. It is most essen- 
 tial that the carotid should not be tied by mistake in these cases, as therebv 
 more blood is directed to the vertebral trunk, and the bleeding is correspond- 
 ingly increased. 
 
 The Internal Mammary Artery rarely calls for treatment, since a punctured 
 wound of this vessel is usually complicated with some graver mischief to heart, 
 
 16 — 2 
 
244 
 
 A MANUAL OF SURGERY 
 
 liver or lungs. If recognised, tie at the bleeding spot, possibly removing a 
 costal cartilage to gain access. The vessel lies about \ inch outside the border 
 of the sternum. 
 
 Intercostal Haemorrhage usually results from penetrating wounds also in- 
 volving 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, like a 
 pocket, through the wound into the pleural cavity, and then stuffing it tightly 
 with wool or strips of gauze, so that on pulling upon it the vessel may be 
 effectually compressed. 
 
 Wounds of the Vessels of the Extremities need treatment according to the 
 principles enunciated above. Only one or two require special mention. 
 
 Wounds of the Palmar Arches were formerly much more dreaded than 
 they are at present, when thorough antisepsis and the use of the elastic 
 tourniquet allow us to explore the depths of a 
 wound without much danger or difficulty. The 
 position of the wound will 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 
 mainly affects the superficial arch, whilst pres- 
 sure on the radial will chiefly influence the deep. 
 A wound of the superficial arch presents little 
 trouble in 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. 62, 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 in such cases, and 
 passive movement of the fingers must be early 
 undertaken, in order to prevent troublesome 
 adhesions. Failing such means, or in septic 
 wounds, a modification of the old graduated 
 compress may be employed ; the wound is care- 
 fully and thoroughly plugged with 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 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, how- 
 ever, 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 part of the axillary. 
 
 Bleeding from the Plantar Arch must be conducted on exactly 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 
 
 Fig. 62. — Hand, to show 
 position of Palmar 
 Arches. 
 
 A, Radial artery ; B, Ulnar 
 artery ; C, Superficial 
 arch ; D, Deep arch. 
 
HEMORRHAGE 245 
 
 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 ischii. 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 hemorrhagic diathesis, is meant a congenital and 
 hereditary disease characterized by a tendency to persistent and uncon- 
 trollable bleeding from slight wounds, whether open or subcutaneous. This 
 condition is often associated with extravasation of blood into the joints, and 
 certain consecutive phenomena (Chap. XX.). The family history is always 
 interesting, the disease being usually transmitted through the females to the 
 males of a succeeding generation, whilst the former often escape entirely. 
 The pathological cause of this affection has not yet been ascertained, no 
 change in the vessels or constitution of the blood having been discovered. 
 Unless haemorrhage is actually occurring, nothing abnormal is noticed, but 
 any injury is sure to be followed by excessive bleeding ; spontaneous sub- 
 cutaneous 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 haemophilia should be directed more to correcting the 
 constitutional defect than to pursuing the usual practice in dealing with 
 haemorrhage. The application or administration of haemostatics, and sub- 
 stances which tend to promote coagulation and the formation of fibrin, should 
 be resorted to. Calcium chloride, 1 drachm to i pint of water, given by 
 enema, or 30 grs. by the mouth, repeated several times a day, has been 
 recommended, 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. 
 
CHAPTER X. 
 
 INJURIES AND DISEASES OF ARTERIES— ANEURISM- 
 LIGATURE OF ARTERIES. 
 
 Injuries of Arteries. 
 
 Contusion of an artery is the result of violence applied directly to 
 the vessel wall. The effects vary with the severity of the injury 
 and with the condition of the arterial tunics. If atheroma or 
 calcification exists, thrombosis often follows slight injuries, and 
 dry or senile gangrene may ensue ; but in healthy arteries a good 
 deal of violence is needed to produce such an effect, as their 
 natural elasticity enables them to yield or slip aside, and thus the 
 consequences are usually insignificant. 
 
 Rupture or Laceration may follow more severe blows or strains, 
 weakness or disease of the arterial wall predisposing to it. It 
 occasionally results from attempts to reduce old-standing disloca- 
 tions, or to break down intra-articular adhesions when the vessel 
 has become fixed in some abnormal position. If the rupture is 
 partial, the inner and middle coats are usually torn through, 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 other cases, where the injury to the coats is 
 slight, a thrombus may form, which leads to obliteration ; or, if 
 the lesion is limited to one side, the clot may become organized 
 over that spot, narrowing, but not interfering with the lumen of the 
 vessel, and leaving an area of weakness from which an aneurism 
 may subsequently develop. Again, when complicated with a septic 
 wound, an ulcerative form of peri-arteritis may ensue, giving rise 
 later on to secondary haemorrhage. It is also stated that the 
 adventitia is occasionally torn without injury to the tunica intima, 
 and that an aneurism may result from a protrusion of the latter 
 coat through the wound in the former ; such an occurrence must 
 be exceedingly rare. A dissecting aneurism (p. 259) may also 
 result under special circumstances from such an accident. 
 
 Complete Rupture of an artery often leads to but little haemor- 
 rhage in a severe lacerated wound, such as is produced when a 
 
INJURIES AND DISEASES OF ARTERIES 247 
 
 limb 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, however, the artery is ruptured in a subcutaneous injury, such 
 as a fracture or dislocation, extensive extravasation often ensues, 
 constituting the condition badly termed a Diffuse Traumatic 
 Aneurism. The objection to this name lies in the fact that there 
 is no true sac wall as in an aneurism, the only boundary con- 
 sisting of an ill-defined mass, partly coagulum, partly inflammatory 
 exudation, and in part thickened and infiltrated tissues. A similar 
 condition may ensue from a punctured wound dividing a vessel, 
 where the track leading to it is valvular or becomes closed by 
 clot or some external application. 
 
 Symptoms. — The patient usually feels a snap, as though some- 
 thing had given way, accompanied by a sudden pain, localized to 
 the part injured, and often shooting down the limb in the line of 
 the vessel. These are succeeded by the following phenomena : 
 
 (a) Locally, the formation of a diffuse, rapidly increasing swelling, 
 the skin over which is at first normal, but soon becomes dis- 
 tended and bluish, and finally bright red and cedematous, when 
 the tumour is threatening to give way. There is no increased 
 local heat except in the later stages. Distinct pulsation is usually 
 present, and some amount of bruit, synchronous with the 
 heart's action, although these subsequently become less obvious. 
 
 (b) Distally, 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 
 cedematous if the extravasated blood presses upon the venous 
 trunks, (c) Generally, the signs of haemorrhage and shock manifest 
 themselves in varying degree, according to the amount of blood 
 lost and the character of the violence. 
 
 Results. — (1) 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, cedematous, 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 gangrene 
 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 
 
248 A MANUAL OF SURGERY 
 
 thus occluded. Collateral circulation may be established, and 
 thereby the health and vitality of the limb are maintained, whilst 
 the blood-clot is absorbed or organized. 
 
 The Treatment is necessarily the same as for a divided artery 
 communicating with an open wound, viz., to cut down and tie 
 both ends. The circulation is first temporarily arrested by an 
 elastic 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 
 stuffed 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 cedematous and unhealthy state of the surrounding 
 parts this is impracticable, it will be necessary either to tie the 
 main trunk on the cardiac side of the rupture, or to trust to the 
 pressure of a graduated compress. If gangrene is imminent, 
 or if secondary haemorrhage occurs, amputation is the only 
 resource. 
 
 Penetrating Wounds of arteries, if completely dividing the 
 vessel, are always followed by haemorrhage, although the blood 
 may be unable to escape if the wound in the skin is small or 
 valvular, or if the opening is closed by blood-clot or dressing ; 
 under these circumstances, the signs due to subcutaneous rupture 
 of a vessel are produced. The amount of bleeding in open wounds 
 varies according to the character, direction, and extent of the 
 lesion, and with the size of the vessel. If a large artery is cleanly 
 cut across, the bleeding is copious, whilst from a small vessel it 
 soon ceases, owing to the contraction and retraction of the coats. 
 When an artery is buttonholed — i.e., when a small segment of the 
 wall is cut through — the haemorrhage is often continuous and 
 prolonged, since retraction cannot take place. The treatment of 
 this condition consists in completing the division of the injured 
 trunk, if it is a small one, thus allowing of contraction and re- 
 traction, or, if the vessel is of large size, in tying it above and 
 below the opening, and dividing it between the ligatures. 
 
 If the wound is in the long axis of the vessel, it gapes but little, 
 and the loss of blood is often slight, whilst if transverse or oblique, 
 both contraction and retraction tend to increase the size of the 
 opening, rendering it more nearly circular, and therefore the 
 haemorrhage in such cases is considerable. 
 
 If a small artery is divided close to its origin from a large main 
 trunk, the blood escapes with a jet, the strength of which is 
 proportionate to the blood-pressure in the main trunk, and not 
 to the size of the vessel divided. In such a case the main 
 trunk must be tied above and below the wound, and divided 
 
INJURIES AND DISEASES OF ARTERIES 249 
 
 between the ligatures, and the distal end of the divided 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 
 obliteration, and with some success. Small longitudinal wounds 
 may certainly be sutured, the stitches being of the finest silk and 
 applied so that the edges of the tunica intima are brought accur- 
 ately into apposition ; Heidenhain reports a case where a wound 
 1-5 cms. long in the axillary artery was successfully sutured in 
 this way. End-to-end union of a divided artery has also been 
 obtained in one case," the upper end being invaginated into the 
 lower ; such a procedure can, however, only be required under 
 very exceptional circumstances. 
 
 In punctured wounds of arteries the size of the penetrating 
 body is all-important. A vessel may be traversed by a needle 
 without haemorrhage 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 are not so frequent in the present 
 day as formerly, when venesection was in vogue. They follow 
 penetrating wounds which involve an artery and vein lying in 
 close contact, e.g., at the bend of the elbow between the median 
 basilic vein and the brachial artery, in the neck between the 
 internal jugular and carotid, in the groin between the femoral 
 vessels, and occasionally in the orbit. Two conditions may result. 
 
 An Aneurismal Varix is produced by a direct communication 
 between an artery and a vein, no dilated passage intervening 
 between the vessels (Fig. 63, A). The venous walls, unfitted to 
 withstand arterial pressure, are thereby dilated and rendered 
 varicose. A pulsating venous tumour results, the dilatation 
 extending 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 imprisoned 
 bluebottle buzzing in a thin paper bag. 
 
 Treatment. — Nothing is usually required beyond the application 
 of an elastic bandage or support to prevent further enlargement. 
 Should pain or inconvenience arise, the artery should be secured 
 above and below the abnormal communication with the vein. 
 Occasionally the latter is so distended that it has to be removed 
 before the artery can be reached. This operation should not be 
 undertaken in the neck for the carotid-jugular varix unless 
 
 * J. B. Murphy, Medical Record, January 16, 1897. 
 
250 
 
 A MANUAL OF SURGERY 
 
 absolutely essential. In the orbit electrolysis may be used with 
 advantage. 
 
 A Varicose Aneurism, though brought about by the same cause, 
 differs from the above in that an aneurismal sac exists between 
 the artery and the dilated vein (Fig. 63, B). It is produced when 
 the vessels are placed at a short distance from each other, or 
 when extravasation of blood has separated them. The aneurism 
 is of the false type, its walls being composed entirely of newly- 
 formed organized clot and cicatricial tissue ; it is almost certain 
 to become diffuse. The physical signs are similar to those of 
 aneurismal varix, except that the aneurism can be sometimes 
 
 A B 
 
 Fig. 63. — Diagrams of Aneurismal Varix and Varicose Aneurism. 
 
 A, Artery; V, Vein; AN, Aneurism. 
 
 detected by palpation, whilst a soft bruit may be heard over it, 
 and the distension of the veins is not quite so marked. 
 
 Surgical Treatment is always required in these cases. Simple 
 ligature of the artery above and below the abnormal communi- 
 cation will sometimes suffice, allowing the blood in the sac to 
 coagulate ; the veins will subsequently diminish in size, when 
 the arterial blood-pressure is removed. Occasionally, however, 
 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. In the less 
 urgent cases digital pressure to the artery above the sac is some- 
 times successful. 
 
 Inflammation of Arteries. 
 
 Various forms of inflammation of the arterial wall are met 
 with, which are usually named from the cause producing them — 
 Traumatic, Infective, or Embolic arteritis. The terms Endarteritis 
 and Periarteritis are used to distinguish inflammatory conditions 
 which respectively start from the tunica intima, or reach the vessel 
 from without ; in both cases, however, the middle coat is generally 
 
INJURIES AND DISEASES OF ARTERIES 251 
 
 involved, and the process may even finally spread beyond it, so 
 that the whole thickness of the arterial wall is attacked. 
 
 1. Traumatic or Plastic Arteritis is the result of some injury, 
 such as total or partial division of the vessel, laceration, bruising, 
 etc. The phenomena are merely those of repair, resulting in 
 occlusion of the vessel, viz., congestion of and exudation into the 
 vessel walls from the vasa vasorum, together with proliferation of 
 the tunica intima ; they have been already described at p. 227. 
 
 2. Infective Arteritis is a condition in which the arterial wall 
 becomes invaded and softened by bacteria. It frequently results 
 from inflammation advancing inwards from the exterior (peri- 
 arteritis), and is usually seen in connection with septic wounds 
 and spreading ulceration. The vasa vasorum are dilated, and an 
 exudation of leucocytes occurs, as a result of the bacterial in- 
 vasion ; the peptonizing action of the toxins thereby produced 
 leads to softening of the vessel walls, the fibres of which lose their 
 cohesion with each other. Finally, their resisting power may be 
 so impaired that they yield before the blood-pressure and cause 
 haemorrhage, unless thrombosis has previously sealed the vessel. 
 In the smaller arteries this is usually the case, but in those larger 
 than the radial there is considerable danger of bleeding, especially 
 if the irritation is confined to one side of the vessel. Secondary 
 haemorrhage from arteries tied in their continuity is generally due 
 to this cause, as also bleeding from phthisical cavities, the vessels 
 having previously lost the support of surrounding tissues, and 
 being more or less dilated or aneurismal. Acute abscesses, septic 
 ligatures, and malignant tumours may weaken an arterial wall 
 and lead to haemorrhage, whilst the infective agent sometimes 
 reaches the walls from within, as from an infective embolus. 
 
 3. Embolic Arteritis. — When a vessel is blocked by a simple 
 embolus, obliteration as a result of a simple plastic arteritis is 
 the usual consequence. If the embolus contains some irritating 
 or infective material, as in a case of infective endocarditis or 
 pyaemia, an abscess may result ; but if the irritant is less intense, 
 the process may stop shore 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. 
 
 4. Acute Endarteritis is met with rather as a pathological 
 curiosity than as a condition of any clinical import. It is usually 
 associated with acute endocarditis, however produced, or may 
 accompany some of the chronic forms described below. It is 
 evidenced by the presence on the inner aspect of the vessel of 
 more or less raised patches, somewhat pinkish and gelatinous in 
 appearance, soft and elastic in consistency, and although the 
 polish is lost, the endothelium is usually intact. It is found in the 
 aorta, or in smaller vessels, especially near inflamed wounds. 
 
 5. Chronic Endarteritis is an exceedingly common affection, 
 and the following forms may be described : 
 
252 
 
 A MANUAL OF SURGERY 
 
 (a) Simple Chronic Endarteritis, resulting in Atheroma (Gr. 
 d#?//»7, 'gruel' or 'pap'). This condition is constantly found in 
 elderly people, but especially in drinkers and those who have 
 suffered from chronic Bright's disease, gout, or syphilis ; it arises 
 from continual strain and increased blood-pressure, and hence 
 often starts in the convexity of the aortic arch, at the spot where 
 the impact of the blood-stream is most felt as it is ejected from 
 the ventricle, or in places where a vessel passes over or around 
 some bony projection, or at the bifurcation of a main artery, or 
 where a large branch is given off, thus causing a sudden decrease 
 
 Fig. 64. — Section of Atheromatous Cerebral Artery, x 50. (Ziegler.) 
 
 a, Intima considerably thickened; b, bounding elastic lamella of intima ; 
 c, media; d, adventitia ; e, necrosed denucleated tissue with masses of fatty 
 detritus ; /, and f lt detritus with cholesterine tablets ; g, intima infiltrated 
 with leucocytes; h, infiltration of adventitia with leucocytes. 
 
 in its lumen. It is rarely found in the smaller arteries, except 
 those of the heart or brain. 
 
 The pathological phenomena consist at first of a proliferation 
 of the deeper parts of the tunica intima, giving rise to opaque, 
 milky-looking, non-vascular patches (Fig. 64, g), which may 
 organize into fibroid tissue, or undergo fatty degeneration (e and 
 /). They are arranged longitudinally or around the mouths of 
 large branches. The tunica media is more or less involved in the 
 process, and the adventitia is often thickened externally. As 
 soon as the fatty changes have commenced, the patches become 
 
INJURIES AND DISEASES OF ARTERIES 253 
 
 yellowish in colour, somewhat elevated from the inner surface, 
 and irregular in outline ; they 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,' although no true pus exists, the pultaceous material 
 consisting of fatty granules and debris, with oil globules and 
 plates of cholesterine (Fig. 64, /j). It maybe absorbed entirely, 
 leaving a weakened spot in the wall of the vessel, from which an 
 aneurism may arise ; or the tunica intima may give way over it, 
 allowing the contents to be swept into the general circulation, 
 where it probably does no harm, and the raw surface left behind 
 
 Fig. 65. — Syphilitic Arteritis, x 150. (Ziegler ) 
 
 a, Intima greatly thickened by newly-formed fibro-cellular tissue ; b, fenes- 
 trated elastic lamina of Henle ; c, muscle fibres of media, infiltrated 
 towards the left ; d, adventitia thickened by cell infiltration and hyperplasia. 
 
 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 open- 
 ing into the substance of the wall and strip up the inner from the 
 outer layers, constituting a ' dissecting aneurism ' ; or a localized 
 thrombus may form, causing occlusion of the vessel. 
 
 Not uncommonly the cheesy contents of the abscess become 
 inspissated, and later on infiltrated with lime salts, resulting in 
 the formation of calcareous plates, which are either covered with 
 endothelium, or exposed to the blood stream, and hence may cause 
 
254 A MANUAL OF SURGERY 
 
 thrombosis, or become detached as an embolus, or the blood may 
 get in under the plate and form a dissecting aneurism. 
 
 A condition of endarteritis evidenced by proliferation of the 
 tunica intima is always met with in chronically inflamed tissues, 
 as also in diabetes ; such does not, however, run on to atheroma. 
 
 (b) Chronic Syphilitic Endarteritis is chiefly met with in the 
 tertiary stage of the disease, and is characterized by an over- 
 growth of the tunica intima (Fig. 65, a), which is at first limited 
 by Henle's elastic lamina (b), but is subsequently associated with 
 infiltration of the media (c), and much more so of the adven- 
 titia (d). The change occurs in the smaller arteries, especially 
 those of the brain or kidneys, or in the neighbourhood of gummata, 
 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 (1) in 
 attacking small arteries ; (2) in affecting the whole circumfer- 
 ence 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 hemi- 
 plegia, may result. 
 
 (c) It is still more or less an open question whether the so- 
 called Endarteritis obliterans or proliferans is truly syphilitic or 
 not. In some cases a syphilitic history has been present, but in 
 other marked instances it has been entirely absent. The main 
 arteries are gradually obliterated in persons apparently sound in 
 health, as a result of which the peripheral parts become anaemic, 
 diminished in vitality, or even gangrenous. The tunica intima is 
 converted into a thickened and vascular mass, which narrows and 
 finally occludes the lumen. This disease, which is by no means 
 common, is associated with considerable local pain. 
 
 (d) Chronic Tuberculous Endarteritis is met with as a prolifera- 
 tion of the tunica intima, with or without thickening of the 
 adventitia, in all places in which tubercle is actively developing ; 
 in fact, tubercles are usually formed around arterioles, and as the 
 mass grows the vessel is slowly occluded and replaced by the 
 typical anatomical structure of the miliary tubercle. The tuber- 
 culous 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. 
 
 Degeneration of Arteries. 
 
 Fatty Degeneration occurs independently of atheroma, involving 
 merely the tunica intima, and manifesting itself in small patches, 
 yellowish in colour and stellate in shape. As a rule, it is of but 
 little significance ; but occasionally the infiltration is deeper, and 
 
INJURIES AND DISEASES OF ARTERIES 
 
 255 
 
 the tunica intima gives way, causing the so-called fatty evasion, 
 and then an aneurism, possibly of the dissecting type, may arise. 
 The most usual seat of this trouble is the aorta. 
 
 Primary Calcareous Degeneration (Fig. 66) 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 transform the elastic expansile vessels into rigid 
 tubes like gas-pipes, through which can alone pass a fixed and 
 unchangeable minimal supply of blood. 
 
 Fig. 66. 
 
 -Primary Calcareous Degeneration of Arteries. 
 College of Surgeons' Museum.) 
 
 (From 
 
 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 may be produced, or a similar result may 
 arise from the lodgment of an embolus. Senile gangrene is a 
 common termination of such arterial changes. From the general 
 rigidity of the vessel, and the method of deposit of the lime-salts, 
 it follows that aneurism is not likely to occur. 
 
 Amyloid Degeneration of the viscera commences in the arterial 
 walls, but is described elsewhere (p. 53). 
 
 The Effects of Arterial Inflammation and Degeneration are 
 both local and peripheral. Locally, Thrombosis may be produced 
 whenever the lining endothelium is removed and a raw surface 
 
256 A MANUAL OF SURGERY 
 
 exposed, upon which fibrin 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 is likely to 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. Oblitera- 
 tion of the artery may follow, either in consequence of thrombosis, 
 or from excessive proliferation of the tunica intima (as in syphilitic 
 or tuberculous disease), or from gradually increasing pressure from 
 without. Lastly, Spontaneous Rupture is another local effect 
 occasionally met with. 
 
 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 gan- 
 grene is due to calcareous changes in the arteries, fatty degenera- 
 tion 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 tumour filled with blood communicating with 
 the interior of an artery, and due to dilatation of part or the whole 
 of the vessel walls. 
 
 Causes. — Aneurisms have been divided into the spontaneous 
 and the traumatic, the distinction between them being that in the 
 former the coats of the artery are primarily diseased, whereas 
 in the latter they may be previously healthy. However, it must 
 not be forgotten that persons with diseased arteries are just as 
 liable to injury as, and even more so than, those with healthy 
 vessels, and thus no strict line of separation can be drawn between 
 the two forms. The causes of aneurism may be conveniently 
 grouped under two headings : 
 
 i. Changes in the Vessel Walls, by which their resistance to 
 the intravascular pressure is diminished. Many varieties of 
 disease, e.g., atheroma, whether starting from within or without, 
 predispose to aneurismal dilatation, especially if occurring in 
 syphilitic or 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. Calcifica- 
 tion, on the other hand, is antagonistic to aneurismal dilatation. 
 Any injury, a contusion, a penetrating wound, or a strain, may so 
 interfere 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 embolus in the smaller arteries is stated 
 
ANEURISM 
 
 257 
 
 to be one of the most common causes of spontaneous dilatation 
 of these vessels in the brain and extremities of young people. 
 
 2. Increase in the Blood-Pressure is another factor, especially 
 when due to heavy strain or exertion, which leads to irregular 
 excitement and increased action of the heart. Steady laborious 
 employment, 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 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 climates 
 than in the more lethargic and ease-loving inhabitants of the 
 South. The energy and activity of the Anglo-Saxon race espec- 
 ially predispose them to this disease. 
 
 Structure of an Aneurism. — Formerly much stress was placed 
 on the terms true and false, the word ' true ' meaning that all the 
 coats of the vessel were present, whilst the ' false ' were those 
 in which the sac wall comprised little or none of the original 
 arterial tunics. This distinction is of comparatively little value, 
 since no aneurism which has attained to any size is in reality true. 
 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 replaced 
 by a mass of newly-formed fibrous tissue, due to a condensation 
 and matting together of the surrounding structures, with or 
 without an internal lining of laminated fibrin deposited on parts 
 where the endothelium of the tunica intima 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 merely contains fluid blood, the amount of which varies 
 with each beat of the heart ; but as the tumour grows, and 
 especially if of the sacculated type, the whole or part of the 
 interior becomes lined with a deposit of fibrin, upon which, again, 
 other layers form, until possibly in rare cases the entire cavity is 
 filled, and a spontaneous cure results. The oldest laminae are 
 dry and yellowish-white in colour (the so-called active clot of Broca) ; 
 those more recently deposited are softer and more reddish, whilst 
 the last formed is merely like ordinary blood coagulum (the passive 
 clot of Broca). No single lamina covers the whole area, but layer 
 is arranged over layer (Fig. 67) in such a manner that the oldest 
 and necessarily the smallest laminae are nearest to the sac wall. 
 
 Three chief varieties of aneurism have been described : ■ the 
 fusiform, sacculated, and dissecting. 
 
 1 . The Fusiform Aneurism (Fig. 68, A) is one in which the whole 
 
 r 7 
 
258 
 
 A MANUAL OF SURGERY 
 
 lumen of the vessel is more or less equally expanded, so that the 
 swelling is tubular in character. It is due rather to a general 
 increase of blood-pressure, or to a widely extended disease of the 
 arterial walls, than to any localized lesion or injury, and hence is 
 more commonly met with in the larger internal vessels 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 
 plates being indicated by flocculi of fibrin, which are attached to 
 them, although no regular laminated deposit is present. The 
 
 Fig. 67. — 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. 
 
 tunica media is stretched, atrophied, and in the later stages 
 practically non-existent, whilst the adventitia is much thickened 
 by inflammatory new formation and by incorporation with the 
 surrounding tissues. The progress of fusiform aneurisms is 
 generally slow, so that in some situations, e.g., the thorax, they 
 may attain enormous dimensions, and cause grave symptoms by 
 their pressure. A natural cure is almost impossible, and hence, 
 if unchecked by treatment, a fatal termination is caused by 
 rupture or by implication of important neighbouring structures. 
 Frequently one portion of the aneurysmal wall yields more 
 
ANEURISM 
 
 259 
 
 than another, and thus to the fusiform swelling is superadded a 
 localized sacculation, which by its rapid increase in size may 
 quickly destroy life 
 
 2. A Sacculated Aneurism (Figs. 67 and 68, 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 trau- 
 matic aneurisms are of this type, whether they are due to the 
 yielding of a cicatrix, or to the partial division of the coats of the 
 vessel, and hence they are most commonly met with in the ex- 
 tremities. It is possible that in some very early specimens all 
 
 Fig. 68. — Diagrams of Fusiform, Sacculated, and Dissecting 
 
 Aneurisms. 
 
 In the first the walls are expanded, but more or less normal in texture ; in the 
 sacculated, the normal structure of the arterial wall ceases abruptly at the 
 commencement of the saccule ; in the dissecting, 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. 
 
 the vascular tunics may be present, but such an occurrence 
 must be extremely rare. Generally one can trace the inner 
 and middle coats to the mouth of the saccule, and there they are 
 suddenly lost, the wall being constituted by a mass of ribro- 
 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, and they 
 generally rupture or become diffuse, although occasionally a 
 natural cure results. The blood as it enters the sac impinges 
 against the wall furthest removed from the heart, and thence 
 eddies back in circles, coagulation being thereby favoured. 
 
 3. A Dissecting Aneurism (Fig. 68, C) is one in which the blood 
 
 17 — 2 
 
260 A MANUAL OF SURGERY 
 
 forms a cavity within the wall of the vessel by stripping up the 
 inner from the outer half, the line of cleavage being within the 
 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 limited to this 
 cavity for some time, or it may find its way outwards, and become 
 diffused, or burst back through another atheromatous spot into 
 the interior of the vessel. The condition occurs chiefly in the 
 thoracic 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 lightly grasped in any position the fingers 
 are separated. If the supplying vessel is compressed on the 
 proximal side, the pulsation ceases, and the tumour diminishes 
 in size and becomes softer ; this is more marked in fusiform than 
 in sacculated aneurisms. The application of pressure to the sac 
 itself, whilst the afferent trunk is compressed above, will still 
 further diminish its size. On removing the pressure, the swelling 
 regains its old dimensions in a certain definite number of beats, 
 usually not more than two or three. Pressure on the distal side 
 of the sac makes it more tense and the pulsation more marked, 
 unless such compression is very prolonged. On auscultating the 
 tumour, a bruit of variable character may be heard. Usually it 
 is loud, harsh, and systolic, but sometimes quiet and musical. It 
 is occasionally double in some forms of sacculated aneurism, and 
 in the aorta when regurgitation through the aortic valves is also 
 present. The bruit is loudest and most rasping in the fusiform 
 variety, and may be absent in the sacculated form, where the 
 mouth is small and the cavity nearly full of clot. Great dis- 
 tension of the sac is unfavourable to the production of the bruit. 
 
 The Extrinsic Signs of aneurism are those occurring in neigh- 
 bouring or distal structures from its constantly increasing size 
 and pressure, and the interference produced by it with the 
 circulation. The pulse in the vessels below is diminished and 
 delayed, its diminution being caused partly by the obstruction 
 experienced, but also in 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. The dicrotic notch is 
 usually absent. The smaller vessels engaged in establishing 
 collateral circulation may be compressed, and thus the vitality of 
 the limb considerably impaired. Pressure on the accompanying 
 vein or veins results in diminution of their calibre, and possibly a 
 localized thrombosis, together with congestion and cedema distally, 
 
ANEURISM 261 
 
 whilst gangrene may be the final outcome if the case is not 
 efficiently treated. Compression of nerves occasions neuralgia, 
 spasm, or paralysis. Muscles are displaced, expanded, and attenu- 
 ated ; bones may be eroded, as evidenced by a deep, constant, 
 boring pain, and even spontaneous fracture may ensue ; whilst 
 joints are encroached upon and disorganized. Tubes, such as the 
 trachea or oesophagus, are often injuriously constricted and laid 
 open by ulceration. It is an interesting fact to note that resisting 
 tissues, like bone, are much more liable to be eroded than elastic, 
 yielding structures, such as cartilage, and in cases where the 
 vertebral column is encroached upon by an abdominal or thoracic 
 aneurism, the bones always manifest greater destructive changes 
 than the intervertebral discs. 
 
 The increased difficulty in propelling the blood through the 
 sac usually induces a certain amount of compensatory hyper- 
 trophy of the heart. Emboli consisting of fragments of fibrin 
 occasionally become detached, 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 be induced as 
 a result of the diminished blood supply to peripheral parts, 
 especially if associated with interference with the venous return. 
 It is usually of the dry type, involving merely one or two fingers 
 or toes ; but when attacking more fleshy parts, or if due to venous 
 congestion, it is moist in character. 
 
 The Differential Diagnosis of a circumscribed aneurism is not 
 difficult, if due weight is given to the above symptoms and signs, 
 but the following conditions may simulate it somewhat closely : 
 1. 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 pulsation 
 ceasing entirely if the tumour is lifted from the vessel, or allowed 
 to fall away from it by assuming a suitable position ; by 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. More- 
 over, the pulse below is not affected in the same way or to the 
 same extent as when an aneurism is present. 2. A pulsating 
 sarcoma or navus 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 limits are not so 
 accurately defined. 3. The pain caused by an aneurism may 
 lead it to be mistaken for rheumatism or neuralgia (e.g., for sciatica 
 
262 A MANUAL OF SURGERY 
 
 in popliteal aneurism), and in every case of obstinate pain of this 
 kind the arteries should always be carefully examined with the 
 intention of eliminating such a possible cause of the trouble. 
 
 Natural Terminations and Results. — i. Spontaneous Cure, though 
 of unusual occurrence, may arise in sacculated aneurisms from a 
 variety of circumstances, and is a well-recognised phenomenon. 
 (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 cause 
 obliteration of its cavity. Such a termination can only occur in 
 saccules with small mouths, and that also 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, (b) 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. 
 
 In the non-inflammatory conditions the sac becomes more and 
 more firm, the pulsation less forcible and distinct, the bruit 
 diminishes, and finally consolidation is effected, a firm fibroid 
 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 recognise the fibroid mass 
 resulting from the spontaneous consolidation of an aneurism, and 
 in making a diagnosis the history has mainly to be depended on. 
 The existence of a tumour in the line of an artery, the probable 
 occlusion of the main trunk, and the fact that the circulation is 
 carried on by means of collateral branches, are the chief points 
 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 
 experiences 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 (constituting what 
 is sometimes called a leaking aneurism), the tumour gradually 
 increases in size, and its outline is less clearly limited ; the pulsa- 
 tion diminishes in force and distinctness, and the signs of pressure 
 
ANEURISM 263 
 
 upon the veins or nerves become more urgent, until, perhaps, 
 gangrene supervenes. If the aneurism ruptures suddenly the 
 patient experiences severe pain in the part, which becomes tense, 
 swollen, and brawny ; all pulsation ceases, both in the aneurism 
 and below it, and gangrene of the limb follows, or even death from 
 syncope, arising from the amount of blood extravasated, either 
 externally if the skin gives way, or into the tissues and under the 
 fascia?. Suppuration may also occur in these cases, the skin be- 
 coming red and inflamed, and finally external rupture may follow. 
 In the absence of history the recognition of diffuse aneurisms is by 
 no means simple, especially when they become inflamed, and then 
 only the most careful attention to the facts to be made out by 
 digital examination can determine the nature of the case. 
 
 3. Suppuration is an exceedingly serious, but by no means a 
 usual, complication. It may arise in the following ways : (a) After 
 ligature of the main vessel above, especially when the wound 
 becomes septic, and there is a good deal of loose cellular tissue 
 around the sac, as in the axilla ; (b) after diffusion, partial or 
 complete, of an aneurism, where there is great tension upon sur- 
 rounding parts. Auto-infection or the presence of an infective 
 embolus may finally determine the suppurative process. The 
 tumour shows signs of inflammation, becoming hot, red, painful, 
 and swollen, and the skin over it may pit on pressure ; whilst fever 
 and general constitutional disturbance are also present. 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 septic 
 poisoning, unless efficient treatment is adopted. Occasionally, but 
 very rarely, the afferent trunk becomes 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 or contra-indicated, such as in internal 
 aneurisms ; it is then to be looked on rather as palliative in nature 
 than curative. The general condition of the patient must be care- 
 fully investigated, since aneurisms are associated either with 
 plethora or with an enfeebled and cachectic state of the system. 
 
 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 are freely opened by a calomel purge at the commencement 
 of treatment, and watery stools should be subsequently induced 
 by 20 grain doses of pulv. jalapae co. two or three times a week, 
 so as to increase the plasticity of the blood. The heart's impulse 
 
264 A MANUAL OF SURGERY 
 
 may be diminished by the use of aconite, or even by venesection 
 when it is very forcible. Iodide of potassium is useful both for 
 reducing blood-pressure and in cases where a syphilitic history is 
 present. The diet must be diminished, all stimulating articles 
 being eliminated, and only highly nutritious material allowed, 
 and that mainly of the nitrogenous type, with as little fluid as 
 possible. Various special methods, £.g\,Tufnell's, Valsalva's, etc., 
 have been recommended, but it usually suffices to limit the dietary 
 as much as is in conformity with the patient's comfort and well- 
 being, and not to allow more than about a pint of fluid in 
 the day. 
 
 In weakly individuals, whilst enjoining strictly a recumbent 
 posture, the surgeon should prescribe iron and a somewhat more 
 liberal diet, in order to improve the quality of the blood. 
 
 II. Surgical Treatment. — Whichever of the plans described 
 below is selected in any particular case, the general health must 
 be carefully attended to, and the condition of internal organs fully 
 investigated beforehand, as great harm may follow injudicious 
 interference, if internal aneurisms co-exist. 
 
 i. Compression may be continuous or intermittent. If inter- 
 mittent, it is applied over the main vessel leading to the aneurism 
 by means of fingers (digital compression), or by mechanical con- 
 trivances, 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. There seems to be no 
 necessity to completely arrest the flow of blood through the sac, 
 so long as the blood-pressure is sufficiently diminished to permit 
 of coagulation within it. Continuous pressure can, as a rule, only 
 be maintained under an anaesthetic, and in such cases the circula- 
 tion through the sac is entirely stopped, so as to allow not only of 
 its contraction, but also in some instances of the rapid coagulation 
 of its contents. Such pressure may be effected by the fingers of 
 relays of dressers, taking shifts of ten to fifteen minutes at a time ; 
 but inasmuch as this is excessively tiring and difficult to maintain 
 efficiently, arrangements should be made whereby some weight, 
 such as a conical shot-bag, rests upon the thumb or finger em- 
 ployed, thereby relieving muscular strain. Tourniquets may be 
 similarly utilized, but are less satisfactory, since they require 
 more skilful and accurate adaptation, and are liable not only to 
 slip out of place, but also to bruise the coats of the vessels. The 
 best appliance of this nature is probably Petit's tourniquet. 
 Esmarch's elastic bandage has been used with success, principally 
 for aneurisms of the lower extremities, notably the popliteal. 
 The limb is first elevated for some moments, and then the elastic 
 bandage applied from the toes to the upper part of the limb, 
 passing loosely over the aneurism. An indiarubber tourniquet 
 is then placed round the thigh, so as to arrest the circulation 
 completely (Reid's method). The limb has in this way been left 
 
ANEURISM 265 
 
 bloodless for an hour and a half, but we cannot recommend the 
 proceeding. 
 
 Although in suitable cases compression certainly has been 
 successful, especially in the hands of the Dublin surgeons, and 
 may be given a trial before ligature, yet it is unwise to per- 
 severe with it for too long if signs of improvement are not quickly 
 observed, lest the collateral circulation be increased to an unde- 
 sirable extent, and the success of the subsequent operation 
 jeopardized. Especially is this the case in plethoric individuals 
 with high arterial tension. On the other hand, in feeble, weakly 
 patients, where gangrene of the limb might be anticipated, the 
 opening up of the collateral circulation by compression, even if 
 the aneurism is not thereby cured, is by no means a disadvantage. 
 
 Necessarily the part of the skin to which pressure is applied 
 must be carefully protected from local irritation by shaving and 
 removal of hairs, by the use of dry aseptic dusting-powders, and 
 by the surface of any pad employed being perfectly smooth, and 
 the skin not wrinkled beneath it. 
 
 2. Ligature of the main vessels leading to or coming from the 
 aneurismal sac must next be considered. The oldest procedure, 
 the Operation of Antyllus, consisted in laying open the sac, 
 turning out the clots, securing the vessel above -and below, and 
 allowing the wound to heal by granulation (Fig. 69, A). Per- 
 formed, as it was originally, without anaesthetics or antiseptics, 
 it was naturally attended with great mortality, since, even if 
 secondary haemorrhage did not occur from the main trunk, it was 
 liable to follow from any of the branches which arose from the 
 dilated portion of the vessel. 
 
 In Anel's Method (Fig. 69, B) the artery was tied just above 
 the sac on the cardiac side, with no branch intervening ; this also 
 proved dangerous, since secondary haemorrhage frequently re- 
 sulted, 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 periarteritis. 
 
 Hunter's Operation (Fig. 69, 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 to 
 be attained is not to absolutely cut off 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 of fibrinous 
 clot within it. The sac thus becomes consolidated, and finally 
 transformed into a mass of firm fibroid tissue. The operation is 
 most likely to succeed in cases where the aneurism is well defined 
 and not large enough to exercise injurious pressure on surround- 
 ing parts, whilst 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 (1) in cases where 
 
266 
 
 A MANUAL OF SURGERY 
 
 serious cardiac disease co-exists, or when an internal aneurism is 
 also present, rendering undesirable any sudden 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 limb 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 impractible 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 to totally 
 cut off the circulation through it (Fig. 69, D). In Wardrop's 
 
 Fig. 69. — 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. 
 
 Operation a ligature is placed on one or more of the distal branches 
 (Fig. 69, 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 partially controlled, the diminution 
 of the size of the aneurism goes on much more slowly, and the 
 chances of the deposition of clot in the sac are 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 few days. In the majority of cases this only continues for 
 a short time, and is by no means an unfavourable sign, indicating 
 the re-establishment of the collateral circulation ; but if it com- 
 mences a week or ten days after the operation, 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 
 
ANEURISM 267 
 
 superficial femoral for popliteal aneurism, and where one or more 
 large and important collateral branches carry blood into the 
 artery below the ligature or directly into the sac. The early 
 recurrence of pulsation needs no treatment in most instances, since 
 it disappears spontaneously ; but when it comes on at a later 
 stage, it demands serious attention. Rest, elevation of the limb 
 and judicious pressure over the trunk above the site of ligature, 
 should first 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, when the tumour 
 is rapidly increasing or threatening to become diffuse, or if gan- 
 grene is impending. 
 
 3. Complete Extirpation of the aneurismal sac may be looked 
 on as the best and most satisfactory method of treatment. The 
 sac is thus dealt with as if it were a tumour, although, owing to 
 the adhesions always present, complete separation of the wall 
 from surrounding parts is often difficult. The limb is exsan- 
 guinated by elevation, and in suitable cases the aneurism is 
 removed without opening it, and the vessel secured by ligature 
 above and below, as also any branches which may arise from it. 
 When, however, a large saccule obscures the main trunk, it may 
 be necessary to open it and turn out its contents before attempting 
 its extirpation. Not unfrequently the vein will be encroached on 
 in this dissection, and it may have to be removed ; bad results are 
 not likely to follow, since probably its lumen has been already 
 diminished by the pressure of the sac, and an efficient collateral 
 venous circulation established. This method has hitherto been 
 chiefly applied to small aneurisms of the peripheral vessels, and, 
 indeed, in the majority of such cases no other plan need be con- 
 sidered ; surgeons are now, however, extending its scope to the 
 larger trunks, such as the popliteal, carotid, external iliac and 
 subclavian, from each of which aneurisms have been successfully 
 extirpated, whilst as far back as 1883 one of us removed in this 
 way a recurrent femoral aneurism, involving the vein, with a good 
 result.' 1 It is also attempted as an alternative to amputation for 
 recurrent, diffused, and suppurating aneurisms. The results of 
 this operation which have been recently recorded are most 
 encouraging : primary union of the wound is often obtained, and 
 hence the length of treatment is curtailed, whilst all chances of 
 recurrence are removed. Statistics also show that there is less 
 danger of gangrene, and this depends, as Pearce Gould has 
 pointed out, on the fact that only one set of collateral circulation 
 is called upon, viz., that required to bridge the gap made by 
 removing the aneurism, whereas in the Hunterian operation a 
 
 * Lancet, 1883, ii., p. 1082. 
 
268 A MANUAL OF SURGERY 
 
 double set is needed, viz., at the site of the ligature, and round 
 the consolidated aneurism. It is obvious that the nutrition of 
 the limb is best secured when what Gould calls the ' irreducible 
 minimum ' of operative treatment, viz., the occlusion of the vessel 
 only at the site of the aneurism, is undertaken. Secondary 
 haemorrhage is also less likely to occur. 
 
 4. Electrolysis has been occasionally employed in dealing with 
 thoracic aneurisms when a saccule has developed in an accessible 
 position. The clot thus formed is soft and liable to break up, 
 and the results have not been very satisfactory. For details of 
 the methods of employing electrolysis, see p. 309. 
 
 5. 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 seem 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. 
 
 6. The combination of the last two methods (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 electrolyses through the wire which is 
 attached to the positive electrode, whilst the negative electrode is 
 placed on the back. The 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 pushed into 
 the sac. Several most brilliant results have followed this plan 
 of treatment, including the cure of an innominate aneurism, the 
 patient living for three and a half years, and of an aneurism of 
 the abdominal aorta, dealt with by transperitoneal operation. 
 We ourselves have treated a subclavian aneurism in this way 
 with considerable temporary benefit. 
 
 7. Acupuncture has been occasionally tried for many years, but 
 without much advantage. Macewen, however, has again drawn 
 attention to the method, and suggested some modifications in the 
 technique. He passes fine needles into the interior of the sac, 
 and leaves them for a time to be played upon by the blood- 
 stream, so as to scratch and irritate the posterior wall, and thus 
 cause inflammatory thickening. The principle involved is entirely 
 at variance with all the other methods of cure ; in these an 
 attempt is made to fill the sac with blood clot, which is subse- 
 quently organized ; Macewen looks on blood clot as undesirable 
 material to work with, and directs his attention to thickening the 
 walls to such an extent as to occlude the sac or to prevent subse- 
 
 * British Medical journal, August 14, 1897 '• Philadelphia Medical Journal, 
 June 25, 1898. 
 
ANEURISM 269 
 
 quent dilatation. In his own hands excellent results have been 
 obtained ; but whilst 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. 
 
 8. Amputation may be required in the treatment of aneurisms 
 under a variety of circumstances : (a) When gangrene of the limb 
 has occurred or is imminent ; (b) 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 utility of the limb ; and, finally, 
 (/) in a few cases of subclavian aneurism amputation at the 
 shoulder-joint has been practised in order to diminish the amount 
 of blood flowing through the sac. 
 
 The Treatment of a Diffuse Aneurism varies somewhat according 
 to whether the diffusion is slow or rapid. In the leaking aneurism, 
 which increases in size somewhat slowly, the main vessel leading 
 to the swelling may be tied, if this has not already been under- 
 taken, and the influence of this measure, combined with rest, 
 elevation, and careful general treatment, observed. Should the 
 process not be stayed, the case is treated as a diffuse or ruptured 
 aneurism by laying open the sac, after exsanguinating the limb 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 evidence 
 of incipient gangrene, or if secondary haemorrhage supervenes, 
 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 
 artery above the aneurism has not been previously ligatured, it would 
 certainly be correct practice to tie it, and watch the effect produced 
 by that measure, together with rest, elevation, and the local 
 application of an icebag. If the inflammatory symptoms still 
 continue, the aneurism should be laid freely open after applying 
 an elastic tourniquet, the coagula turned out, and the main trunk 
 secured above and below. If bleeding still continues from smaller 
 branches opening into the sac, the cavity is carefully plugged with 
 strips of aseptic gauze, but a strict watch must be kept over the 
 case, for fear of a return of the bleeding. Should this happen, or 
 should gangrene threaten, amputation alone remains. // the main 
 vessel of supply has been previously tied, the sac should still be laid open 
 and cleared of coagula, all bleeding points secured if possible, and 
 the cavity stuffed ; amputation is, however, likely to be required. 
 
270 A MANUAL OF SURGERY 
 
 Special Aneurisms. 
 
 Aneurism of the Thoracic Aorta is dealt with rather in medical 
 than in surgical text-books ; it is, however, of such importance as 
 to demand a short notice here. Any part of the thoracic aorta 
 may be affected, and the symptoms arising therefrom are very 
 variable. The fusiform type is most commonly met with in the 
 early stages, a limited sacculation often supervening as the disease 
 advances. In the ascending part of the arch the swelling rarely 
 reaches a great size, especially if it is intra-pericardial, the sac 
 usually rupturing before marked pressure signs are evident. 
 When arising from the transverse part of the arch, the symptoms 
 vary with the direction taken by the enlargement. If it projects 
 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 tumour with 
 comparatively slight pressure effects, except the pain arising from 
 its erosion of the thoracic wall ; it then appears as a pulsating 
 swelling to the right of the sternum. If the enlargement takes 
 place either posteriorly or downwards within the concavity of the 
 arch, symptoms in the shape of dyspnoea and dysphagia are early 
 produced from the close contiguity of the trachea, oesophagus, 
 and pulmonary vessels. Dyspnoea may also be due to pressure 
 upon the left recurrent laryngeal nerve, causing paresis of the 
 crico-arytenoideus posticus muscle and difficulty in opening the 
 glottis ; the voice, moreover, becomes harsh and the cough hard, 
 with what has been described as a ' metallic ring ' about it, which 
 is extremely characteristic. Laryngeal or tracheal stridor may 
 be noticed in these cases, and a dragging of the trachea synchronous 
 with the heart's action (the so-called 'tracheal tug'). 
 
 Aneurisms of the descending arch and thoracic aorta often attain 
 considerable dimensions, and may project posteriorly to the left 
 of the vertebral column, causing a pulsating swelling. The only 
 prominent symptoms are pain due to erosion of ribs or vertebrae 
 and interference with deglutition, which may be so great as to 
 suggest the presence of an oesophageal constriction ; in fact, before 
 a bougie is passed in any case of dysphagia, it is always advisable 
 to make certain, if possible, that an aneurism is not present. 
 Auscultation in the left vertebral groove may 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. Where the tumour could be felt 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 acupunc- 
 ture have been used with some benefit for supposed cases of 
 
ANEURISM 271 
 
 sacculated aneurism. Dyspnoea may be at times severe, but 
 tracheotomy should never be undertaken, death seldom resulting 
 from this cause. 
 
 Surgical treatment, such as ligature of the right carotid and 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 has followed some of the operations, but 
 of eleven cases reported by Kiister five died within the first ten 
 days. The principles underlying such proceedings are certainly 
 at variance with those guiding our usual treatment of an aneurism, 
 and it is quite possible that the improvement 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 aneuiismal 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 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 
 frequently 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 clavicle forwards. 
 The effects produced by its pressure are very variable. 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 commonly similar changes on the left 
 side may follow compression of the left vein or of the superior vena 
 cava ; pain shooting into the neck and arm is often a marked 
 symptom, arising from implication of the cervical and brachial 
 nerves, whilst hyperemia of the right side of the face and dilata- 
 tion of the right pupil may result from irritation of the sympathetic 
 trunk. Dyspnoea is induced by direct pressure on the trachea, 
 which may be displaced or flattened, or by irritation of the right 
 recurrent laryngeal nerve, causing partial or complete paralysis 
 of the right vocal cord. Dysphagia 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 administration 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 
 — viz., the carotid, subclavian, and vertebral — with safety to the 
 
 * British Medical Journal, December 3, 1898. 
 
272 
 
 A MANUAL OF SURGERY 
 
 patient (Fig. 70). Ligature of any one of these alone offers but 
 little prospect of improvement ; thus, the only case benefited by 
 
 ligature of the subclavian was 
 one treated by Wardrop, in 
 which the carotid also had been 
 independently and by accident 
 blocked ; whilst the only cure 
 recorded after tying the carotid 
 was probably due to subse- 
 quent suppuration within the 
 sac (Evans). Ligature of both 
 carotid and subclavian, with an 
 interval of more than a week 
 between the two operations, 
 has practically the same effect 
 as a single ligature, for by that 
 time the collateral circulation 
 
 Fig. 7 o-Application of Ligatures ™ U have , be f„ established. 
 
 for Innominate Aneurism. (After 1 he _ results following such 
 
 Erichsen.) practice are better than those 
 
 IA, innominate aneurism; S, sub- gained by ligating a single 
 
 clavian artery ; C, carotid ; V, vertebral vessel, but not SO good as those 
 
 artei 7- from tying both vessels at the 
 
 same time. Simultaneous liga- 
 ture 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 tying the third part of the subclavian 
 does not materially add to the risk of the operation, which is 
 mainly due to the effect on the cerebral circulation. Should 
 operative measures seem undesirable, recourse must be had to 
 Stewart's or Macewen's methods. 
 
 Aneurism of the Common Carotid is usually situated at the 
 upper part of the trunk near the bifurcation, and more often on 
 the right than on the left side. The root of the right carotid as it 
 springs from the innominate is also not unfrequently dilated, but 
 the intra-thoracic portion of the left carotid is rarely affected, 
 except in conjunction with aneurism of the aorta. No other 
 external vessel is so 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 sympathetic trunk, 
 or to pressure upon the larynx, pharynx, or trachea. The progress 
 of these cases is usually slow. 
 
 Diagnosis. — (1) From similar disease at the root of the neck the dis- 
 tinction is often made with difficulty, since either an aortic, 
 innominate, or subclavian aneurism may push upwards so as 
 to simulate it somewhat closely. Percussion and auscultation of 
 the upper part of the chest, together with a careful investigation 
 
ANEURISM 273 
 
 into the history of the case, and a digital examination of the limits 
 of the pulsating mass, may suffice to determine the point. Holmes 
 suggests trying the effect of carefully applied distal pressure for a 
 few hours ; in a carotid aneurism the tension becomes distinctly 
 less as the collateral circulation commences to enlarge, whilst 
 in an aortic aneurism no difference is observed. 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 innom- 
 inate vein indicates aortic aneurism rather than innominate ; com- 
 pression of the internal jugular or subclavian vein only points to 
 carotid or subclavian aneurism. A " tracheal tug " indicates an 
 aneurism of the aorta' (P. Gould). The differences in the peri- 
 pheral pulses may also give useful information. The two radial 
 pulses should be first examined ; if they are equally affected, an 
 aneurism of the aorta on the cardiac side of the innominate is 
 indicated ; if they are equal and normal, an aneurism on the distal 
 side of the origin of the left subclavian. If the left radial pulse is 
 alone aneurismal, the root of the left subclavian is diseased, whilst 
 if the left temporal is also affected, it suggests an aneurism of the 
 transverse part of the arch beyond the innominate. When both 
 radial and temporal vessels on the right side show signs of inter- 
 ference with the pulse, innominate aneurism is probably present, 
 whilst an affection of only one of 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 with- 
 out being dilated, and hence the quality of the pulse must be 
 taken into consideration rather than its actual volume, and to this 
 end the sphygmograph 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. 261). (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 remaining fixed. (4) An aneurism close to the bifurca- 
 tion may be simulated by an abnormal arrangement 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 
 symmetrica], 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, proximal 
 
 18 
 
274 A MANUAL OF SURGERY 
 
 ligature becomes impracticable, and 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 
 hypoglossal nerve, aphonia, or dysphagia. In suitable cases, the 
 sac may be dissected out after securing the branches arising from 
 it, as recently recommended by Walsham.* Failing this, the 
 common trunk must be tied. 
 
 Aneurism of the Internal Carotid (extracranial portion). — There 
 is but little difference between the symptoms arising from this 
 condition and those caused by an aneurism of the bifurcation or 
 of the external carotid, except that the swelling 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 danger- 
 ously like an abscess of the tonsil. The Treatment consists in 
 tying the common carotid. 
 
 Intracranial Aneurism. — Any of the arteries within the skull 
 may become the site of an aneurism, but this condition 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 
 extremely obscure, a blow or fall being sometimes adduced to 
 explain them ; in children they are stated to result from the 
 lodgment of septic emboli. They sometimes grow to a con- 
 siderable size before causing obvious symptoms ; the patient may, 
 in fact, have continued without any manifestation of the disease, 
 until suddenly seized with a rapidly fatal apoplexy from rupture 
 of the sac. If there are any symptoms, they are due rather to 
 compression of the brain than to erosion of the more resistant 
 bony structures. 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 interfered with, but 
 physical changes in the eyes, such as optic neuritis or atrophy, are 
 not induced, unless there is direct pressure on some part of the 
 optic tract. Occasionally a loud whizzing bruit may be heard 
 on auscultating the skull. The only Treatment possible, if a 
 diagnosis can be established, is ligature of the common carotid 
 artery, and even this will be of little use if the basilar is affected. 
 
 * Trans. Med Chiv. Soc, February 28, 1899. 
 
ANEURISM 275 
 
 An Intra-orbital Aneurism is recognised by the existence of a 
 pulsating swelling of the orbit, causing protrusion of the eyeball 
 (exophthalmos) and congestion of the conjunctival and deeper 
 vessels. A feeling of pain or tension in the orbit may exist, 
 and gradually vision is impaired, whilst the cornea may become 
 opaque from exposure, due to the inability of the lids to cover 
 it ; finally, the whole globe may be disorganized. The symptoms 
 sometimes commence with a definite snap or crack, as though 
 something had given way in the orbit ; or they may follow a 
 penetrating injury or a blow. Occasionally the condition is con- 
 genital, or arises soon after birth. 
 
 Several pathological lesions are included under the title ' intra- 
 orbital aneurism': (a) If congenital, it is probably a case of 
 aneurism by anastomosis ; this, however, is not common, being 
 present only in two out of seventy-three cases collected by 
 Rivington ; (b) if traumatic in origin, whether due to a pene- 
 trating injury or not, the case is probably an aneurismal varix 
 between the internal carotid and cavernous sinus, or a genuine 
 traumatic aneurism of the ophthalmic artery ; (c) if idiopathic, it 
 is possibly due to thrombosis of the cavernous sinus, or to spon- 
 taneous aneurism of the internal carotid or ophthalmic arteries. 
 
 Diagnosis. — To determine the precise cause of a pulsating 
 tumour of the orbit is by no means an easy matter, inasmuch as 
 sarcomata are occasionally met with exhibiting many of the 
 characters of intra-orbital aneurism. Careful palpation will, how- 
 ever, generally demonstrate the existence of a more definite 
 tumour, and a less-marked expansile pulsation in the sarcoma, 
 whilst the bruit is less distinct. The distortion of the eyeball 
 and ocular axis is often considerable in malignant tumours, but 
 vision is not so early aftected. 
 
 Treatment. — Electrolysis and ligature of the common carotid 
 are the only means which hold out any prospect of success, 
 and of these the former should always be first tried. In the 
 congenital cases its application has been very successful, but in 
 those due to trauma it is very likely to fail. 
 
 Subclavian Aneurism is most frequently seen in men, and 
 particularly those who use their arms much in lifting, such as 
 soldiers and sailors ; 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 reach 
 above the clavicle, but chiefly extends backwards, outwards, and 
 downwards, causing pressure effects upon the veins and nerves 
 of the arm, and also hiccough by irritation 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 
 
 18—2 
 
276 A MANUAL OF SURGERY 
 
 dense unyielding structures, and never compresses the trachea or 
 oesophagus. 
 
 No 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. A pulsating sarcoma growing from 
 any of the neighbouring structures may also resemble it some- 
 what closely, but the pulsation is then rarely so limited in extent 
 as in an aneurism, and a definite tumour can usually be felt. 
 
 The Treatment of subclavian aneurism is surrounded with 
 difficulties, and the results hitherto obtained have been most 
 unsatisfactory. Extirpation has been undertaken in one case" 
 with success after turning up the middle third of the clavicle, but 
 the aneurism is seldom sufficiently limited to allow of the applica- 
 tion of this ideal proceeding. Should any undilated portion of 
 the artery be available outside the thorax, digital compression on the 
 cardiac side may be attempted. Direct pressure, manipulation, 
 galvano-puncture and needling the sac according to Macewen's 
 method, have been adopted with occasional success, but cannot 
 be relied on. Stewart's method proved of benefit in a case we 
 recently had under treatment, the aneurism becoming much firmer, 
 and the patient being freed from pain and able to return home. 
 Unfortunately he died three months later from haemorrhage, but no 
 post-mortem examination was obtainable. About 10 feet of gold 
 wire were introduced. Ligature of the innominate trunk suggests itself 
 as the operation to be adopted for cure by the Hunterian method, 
 and recent records would certainly encourage one to repeat it in any 
 suitable case, since most of the fatal results occurred prior to the 
 introduction of antiseptic surgery, death resulting from sepsis or 
 secondary haemorrhage. It would appear that the simultaneous 
 ligature of the carotid or vertebral trunks with the innominate is 
 essential to success, in order to prevent the rapid backflow on the 
 distal side of the ligature which otherwise occurs ; in addition, 
 the coats of the vessel must be approximated by a broad animal 
 ligature, e.g., of gold-beater's skin, and not divided. 
 
 Ligature of the first part of the subclavian has also been attempted 
 for the cure of aneurisms involving the lower part of the vessel, 
 but until recently it was so uniformly fatal that it was con- 
 sidered quite an unjustifiable proceeding, the first nineteen cases 
 all dying. Clutton,t however, has reported a successful case, 
 the ligature being applied (without dividing the coats) on the 
 proximal side of the thyroid axis and internal mammary vessels, 
 which were also secured. The first part of the axillary and the 
 superior intercostal had also to be tied before pulsation in the 
 aneurism ceased. Halsted| has since reported a second successful 
 case of this operation. Ligature of the second part of the subclavian 
 
 * Moynihan, Annals of Surgery , July, 1898. 
 
 t Trans. Med. Chir. Soc, vol. lxxx., p. 391. J Annals of Surgery, May, 1900. 
 
ANEURISM 277 
 
 has been advantageously employed in suitable cases where the 
 aneurism was situated below it. Distal ligature of the third part 
 has also been attempted, but without much success. 
 
 As a last resource, where the above measures are impracticable 
 or have failed, the plan suggested by the late Sir William Fer- 
 gusson may be followed, viz., amputation at the shoulder-joint and 
 distal ligature as near the sac as possible. Distal ligature alone is 
 usually unsuccessful, owing to the fact that 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 limb. A few successful results of such heroic treatment 
 have been reported. 
 
 Axillary Aneurisms is usually the result of falls on the out- 
 stretched arm. or injuries to the shoulder, such as fractures or 
 dislocations, or of attempts to reduce them. The Symptoms are 
 merely those due to the presence of a pulsating tumour and its 
 pressure, which may cause pain, local and neuralgic, or oedema 
 of the arm. When the upper part of the vessel is affected, a 
 pulsating swelling is felt immediately below the clavicle, whilst 
 if placed lower down it projects more into the axilla, and may 
 totally fill up the hollow. Occasionally the clavicle is displaced 
 upwards, or the aneurism may extend beneath it into the neck, 
 conditions of serious import as regards treatment. 
 
 Treatment. — Compression (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 cceliac axis, 
 or at the bifurcation ; in the former case, some of the branches 
 arising at that spot are also usually involved, and the disease is of 
 the sacculated type. Occasionally aneurisms form independently 
 on the splenic or mesenteric vessels. A pulsating tumour is 
 observed, usually near the middle line, and either close to the 
 umbilicus or in the epigastric notch ; the pulsation is expansile in 
 type, and remains the same in character whatever the position of 
 the patient. Pressure signs are mainly confined to pain, localized 
 in the back from erosion of the vertebrae, or neuralgic from 
 pressure on the solar plexus or lumbar nerves, whilst oedema 
 of the lower extremities may arise from compression of the vena 
 cava. There may be some concurrent derangement of the intes- 
 tinal functions. 
 
278 A MANUAL OF SURGERY 
 
 Diagnosis. — Many conditions give rise to epigastric pulsation, 
 but the majority of them can be readily distinguished from 
 abdominal aneurism by careful examination, if necessary, under 
 an anaesthetic. Cardiac pulsations may be felt in the epigastrium 
 when the heart is dilated, but should be easily recognised ; as also 
 an impulse transmitted from the aorta through a collection of 
 fasces, or a cancerous growth. The examination of such a case 
 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 become 
 much diminished. A large accumulation of abdominal fat will 
 seriously interfere with any satisfactory investigation. 
 
 Treatment. — Ligature of the aorta even on the distal side has 
 has never yet been attempted for this condition, and hence, 
 failing medical treatment by rest and diet, compression was formerly 
 relied on, being applied either on the distal or proximal sides of 
 the sac. The method is, however, clumsy and liable to cause 
 serious mischief to the abdominal viscera. More recently treat- 
 ment by needling the sac has been employed, and certainly in 
 Macewen's hands at least one case has been brilliantly success- 
 ful. There is also one instance on record where the introduction 
 of wire into the sac, combined with electrolysis through the wire 
 by Stewart's method, cured an aneurism as large as an orange ; 
 the abdomen was opened, and electrolysis was maintained for 
 thirty-seven minutes. 
 
 Iliac or Inguinal Aneurism arises from either the common or 
 external iliac, or from the common femoral, and usually tends to 
 spread upwards towards the abdominal cavity. It is frequently 
 sacculated in type, and is certain sooner or later to become diffuse. 
 Its shape is determined by the unequal pressure exercised by 
 fascial or other structures, sometimes leading to lobulation. The 
 symptoms are very typical, and pressure effects are mainly ex- 
 perienced in the veins and nerves of the leg. The Diagnosis 
 cannot be well mistaken in the early stages, but later on, and 
 specially when situated high in the iliac fossa, it may be difficult 
 to distinguish from a pulsating sarcoma. 
 
 Treatment. — Medical treatment alone is of little avail in curing 
 inguinal aneurisms; but proximal compression of the aorta or 
 common iliac, where the situation of the swelling and the thickness 
 of the abdominal parietes permitted it, has had a certain amount 
 of success. It is carried out by means of a tourniquet, shot-bag, 
 or the fingers, and may be advantageously combined with distal 
 pressure. Ligature of the external iliac has been frequently per- 
 formed for inguinal aneurism, and with such success as to warrant 
 its being employed in all suitable cases. Ligature of the common 
 iliac is sometimes needed for aneurisms in the iliac fossa. The 
 results of the retro-peritoneal operation were by no means satisfac- 
 
ANEURISM 279 
 
 tory, but the introduction of the trans-peritoneal method of ligature 
 and the recognition of the importance of not dividing the inner and 
 middle coats in such a large vessel, combined with the use of 
 aseptic animal ligatures, are certain to lead to better results. In 
 ten instances ligature of the abdominal aorta has been undertaken for 
 iliac or inguinal aneurism, and in all a fatal issue followed, seven of 
 the patients dying within forty-eight hours ; one survived as long as 
 the tenth day, and two lived for forty-eight and thirty-nine days 
 respectively. Of course, wherever practicable, extirpation should 
 be resorted to, and at least one most successful case has been 
 published. 
 
 Aneurisms of the Gluteal and Sciatic Arteries are usually 
 traumatic in origin, and present as pulsating swellings of variable 
 size 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. Pulsation is well marked, and murmurs are 
 heard on auscultation. Pain in the limb from pressure on the 
 sciatic nerve is a prominent sympton, especially in the sciatic 
 variety. The Diagnosis is by no means simple, especially from a 
 pulsating sarcoma, and many instances of mistakes have occurred 
 even in the practice of eminent surgeons. Treatment. — The best 
 results hitherto obtained have followed the laying open of the sac, 
 turning out the clot, and tying the affected trunk — a proceeding 
 requiring operative dexterity and skill of the highest order. 
 Ligature of the internal iliac has also been performed, and with 
 a creditable degree of success, even where the old extra-peritoneal 
 method was employed. The use of the trans-peritoneal route 
 greatly simplifies the operation, and the more recent records of 
 this proceeding are most satisfactory. At the present time it 
 should certainly be undertaken in preference to the plan of laying 
 open the sac. 
 
 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, and as often on one side of 
 the body as the other. The Diagnosis needs no discussion, as the 
 disease runs a typical course, and the Treatment consists either in 
 extirpation, compression at the groin, or ligature of the common 
 or superficial femoral trunk. 
 
 Aneurism of the Profunda Femoris Artery is a very rare con- 
 dition, presenting the ordinary features of a pulsating tumour 
 situated amongst the muscles on the inner side of the thigh, but 
 causing no diminution of the pulse in the popliteal or tibial 
 vessels. The superficial femoral may be felt coursing over it, 
 but quite distinct. Compression by a shot bag in the groin, 
 or by a tourniquet, may be sufficient to effect a cure, whilst 
 
2SO 
 
 A MANUAL OF SURGERY 
 
 ligature of the common femoral or external iliac may be resorted 
 to, if neceessary. 
 
 Popliteal Aneurism (Fig. 71) occurs almost invariably in men, 
 constituting a pulsating tumour in the ham, rendering the knee 
 painful and stiff, and so much do the symp- 
 toms resemble those of chronic rheumatism 
 that in every such case the popliteal space 
 should be examined. The limb is usually 
 semiflexed, and the aneurism, which is of a 
 sacculated type, often increases rapidly in 
 size. If the main swelling is situated to the 
 front of the 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 circula- 
 tion. The diagnosis has to be made from 
 chronic enlargement and abscess of the 
 glands in the ham, 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, from 
 which it can be recognised 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 is eminently successful in many of 
 these cases, whether applied in the groin or by Reid's method. 
 Ligature of the femoral artery at the apex of Scarpa's triangle is, 
 however, the plan most commonly adopted, and with 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. 
 
 Fig. 
 
 71. — Popliteal 
 
 Aneurism. 
 
 Ligature of Vessels. 
 
 Ligation in continuity is an operation performed to arrest the 
 flow of blood to the periphery, in order either to check haemor- 
 rhage, or to promote the cure of an aneurism, or to diminish the 
 rate of growth of some tumour, or to beneficially influence some 
 peripheral organ by reducing its blood-supply (as in tying the 
 internal iliac for enlarged prostate), or as a preliminary to remov- 
 ing some vascular structure, such as the tongue. 
 
LIGATURE OF VESSELS 281 
 
 The Instruments needed are as follows : scalpels, dissecting 
 forceps, director or blunt dissector, forcipressure or artery forceps, 
 blunt hooks, retractors for deep wounds, aneurism needle, ligature, 
 needles, and sutures. 
 
 The Material to be employed for the ligature has been discussed 
 elsewhere (p. 18). Sulphuro-chromicised catgut is that most 
 commonly employed for all but the largest trunks, and for its 
 application to an artery in its continuity the following plan may 
 be adopted : A fine loop of catgut having been passed under the 
 vessel by means of an aneurism needle, a prepared ligature, con- 
 sisting of three strands of catgut about 10 inches long, knotted 
 together at each end, is threaded through the loop, which is then 
 withdrawn, carrying the ligature under the vessel. The advan- 
 tages of this method are, that the aneurism needle, being threaded 
 with such fine gut, passes easily and without friction, whilst the 
 use of the loop to draw the ligature back obviates the difficulty, 
 where the artery is deeply placed, of threading the needle if 
 passed unarmed, as is sometimes advised. The substitution of 
 three strands for a single ligature distributes the pressure over a 
 larger area, and is considered more certainly to effect occlusion. 
 
 As to the Operation itself, the strictest asepsis must be main- 
 tained, the skin and instruments being thoroughly purified pre- 
 viously. The artery is examined, as far as is possible, so that a 
 healthy portion may be selected for applying the ligature. The 
 various structures met with on the way to the artery are recog- 
 nised, and drawn, if need be, to one or the other side, so as to lay 
 bare the sheath of the vessel. It is most important that these 
 anatomical landmarks or rallying points should each be seen or felt 
 in order, so that the operator may not be led astray or miss the 
 vessel. Naturally it is easier to find the artery in the living 
 subject than in the dead, the pulsation being of the greatest 
 assistance. The sheath, having been exposed, must now be 
 opened over the situation of the artery by a few delicate strokes 
 of the knife ; a portion of the sheath should be picked up between 
 the blades of the forceps, incised along the longitudinal axis, and 
 stripped off the artery, taking care to keep the back of the knife 
 towards the vessel. This incision should be about f inch in 
 length, and should open not only the general, but also the special, 
 sheath of the artery, if such exist. The sheath is then steadied 
 with forceps, whilst 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 sufficiently 
 opened, and the actual arterial wall fairly exposed. The ligature 
 may then be passed through the eye of the needle, and carried 
 round the vessel. It is tied in a direction exactly at right angles 
 to the longitudinal axis, and 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. A reef-knot is all that 
 
282 A MANUAL OF SURGERY 
 
 is necessary for security in the smaller vessels, but in the largest 
 trunks it may be advisable to employ what has been termed the 
 stay-knot. Two strands of ligature material are passed round the 
 vessel side and half knotted ; the two ends on each side are then 
 taken up together and tied across in one knot. 
 
 The rule usually followed is to pass the needle from important struc- 
 tures, such as the vein, but really this is a matter of little importance 
 when the above directions have been carefully carried out, and 
 especially in superficial vessels. Should the vein be accidentally 
 punctured, the needle must be at once withdrawn, and the punc- 
 ture 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 venae comites are in close contact with the 
 artery, no harm will attend their inclusion in the ligature. 
 
 After - Treatment. — The ordinary antiseptic precautions are 
 taken in regard to the wound, which should be healed and all 
 stitches removed in eight days ; but the patient must be kept at 
 rest for some time longer to allow the tissues to consolidate, 
 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 cotton-wool and slightly raised. If 
 there is any likelihood of gangrene, as in the lower limbs of 
 elderly people, the extremity should be thoroughly purified, and 
 wrapped in aseptic wool immediately after the operation, in order 
 to avoid septic complications. 
 
 There are two great dangers liable to follow the ligation of an 
 artery in its continuity : 
 
 i. Secondary Haemorrhage (vide p. 239). 
 
 2. Gangrene, which may arise from a variety of causes : 
 (a) From simple loss of vitality, the maximum amount of blood 
 transmitted by the collateral circulation being insufficient to 
 maintain in life the whole of the part supplied by the artery 
 ligated. This is particularly the case when the peripheral vessels 
 are in a condition of calcareous degeneration. 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, is 
 also sufficient in some cases to determine tissue necrosis. Under 
 such circumstances it always takes on the dry form if involving 
 the terminal joints of a limb, but in more fleshy parts it may be 
 moist, (b) Interference with the venous return, as by injury to 
 the vein during operation, such as inclusion in the ligature, or 
 thrombosis induced subsequently by septic periphlebitis, is very 
 likely to cause gangrene, and then it is of the moist type ; the in- 
 jurious pressure of a tight bandage, obstructing the venous circula- 
 tion, will have a similar effect, (c) Injudicious after-treatment, 
 such as too great elevation of the limb, the application of cold 
 lotions, an icebag, or fomentations during the period of diminished 
 
LIGATURE OF VESSELS 283 
 
 vitality immediately following the operation, or even an attack of 
 erysipelas, may also bring about the death of some of the tissues 
 involved. 
 
 Every precaution must be taken to prevent the occurrence of 
 gangrene, as indicated above, and as soon as there is any sus- 
 picion of its onset the whole limb must be thoroughly purified, 
 and subsequently maintained aseptic. The Treatment of aseptic 
 gangrene following ligature is expectant in character, the parts 
 being allowed to separate naturally. But if there is much pain, 
 or any tendency to spread, or if septic mischief is present, giving 
 rise to fever and general disturbance, it is wiser to remove the 
 limb well above the line of demarcation. 
 
 The Innominate Artery has now been tied with success on six separate 
 occasions 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 
 downwards to sweep over the upper edge of the episternal notch. The 
 platysma, the superficial and deep fasciae are divided, and the anterior jugular 
 vein secured if necessary between two ligatures ; the sterno-mastoid is drawn 
 outwards, 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 following 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 
 vessel, but if much engorged may project over the artery, and must then be 
 drawn aside by retractors, whilst the inferior thyroid plexus may course 
 directly in front of the vessel, and even need to be ligatured. To the outer 
 or right side 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 divided. 
 
 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 at one of two places, either above or below 
 the level at which it is crossed by the anterior belly of the omo-hyoid. The 
 line of the vessel is indicated by that drawn from the sterno-clavicular articula- 
 tion to a point midway between the angle of the jaw and the tip of the mastoid 
 process, the bifurcation being situated on a level with the upper border of the 
 thyroid cartilage. 
 
 Ligature above the Omo-hyoid. — This operation is usually chosen, if practicable, 
 since the vessel is here more superficial, the ligature being applied on a level with 
 the cricoid cartilage. The patient lies upon the back, with the chin raised and 
 the head turned a little 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. 72, A). The 
 skin, platysma, and fasciae are divided, and the anterior edge of the sterno- 
 mastoid defined as the first rallying-point. The deep fascia is incised along its 
 inner border, so that it may be drawn aside by a retractor ; the sterno-mastoid 
 
284 
 
 A MANUAL OF SURGERY 
 
 branch of the superior thyroid artery may be divided at this stage, and a vein 
 passing between the facial and anterior jugular may also need to be ligatured. 
 ( )n the inner side of the wound the omo-hyoid muscle must now be looked for, 
 trending forwards and upwards from under cover of the sterno-mastoid. In 
 the angle formed by 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 run no risk of being included. 
 
 Ligature below the Omo-hyoid. — The incision is made in a similar direction to 
 the above, but lower in the neck, reaching from the cricoid cartilage nearly to 
 
 Fig. 72. — Incisions for Various Operations on Head and Neck. 
 
 For ligature of carotid ; V, for ligature of vertebral artery ; B, for ligature 
 of subclavian ; C, for ligature of the first part of the axillary ; M, for the 
 internal mammary ; H, for the lingual ; E, flap incision used in trephining 
 for meningeal haemorrhage ; F, flap incision for operations on the roots of 
 the fifth nerve. 
 
 the sterno-clavicular joint. The sterno-mastoid is drawn outwards, and per- 
 haps 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 
 
LIGATURE OF VESSELS 285 
 
 of the artery. The inferior thyroid 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 go to prove that in about 25 per cent, of the patients 
 operated on cerebral symptoms manifest themselves, either immediately in the 
 form of syncope from cerebral anaemia, or in the course of a few days from 
 cerebral softening, causing paralysis on the opposite side of the body, and 
 even death. A fatal issue is likely to result in about half the cases thus 
 affected. Occasionally a somewhat acute form of congestion of the lungs 
 follows ligature of the carotid within a few hours, possibly due to interference 
 with the circulation in the medulla, or to irritation or injury to the vagus or 
 sympathetics ; it may run on to subacute inflammation, and is best remedied 
 by free stimulation, or venesection. 
 
 Collateral Circulation. — Intracranial : Circle of Willis. 
 
 Extracranial : Communications across the middle line of branches of the 
 external carotids and vertebrals ; inferior thyroid with the superior thyroid ; 
 profunda cervicis with princeps cervicis of occipital ; superficial cervical with 
 branches of occipital and vertebral. 
 
 Ligature of the Internal Carotid is rarely needed, but has been employed for 
 haemorrhage and traumatic aneurisms. Any part of the vessel may be tied, 
 but the ligature is usually placed just above the bifurcation. The operation 
 is practically the same as for securing the common carotid, only at a higher 
 level. 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 well backwards, and the posterior belly of the digastric is now seen and 
 drawn up. The external carotid presents itself, and is carefully 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 
 for applying the ligature 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 for above, the hypoglossal nerve lying just below 
 it. The sheath is now opened below the tip of the great cornu of the hyoid bone, 
 and the needle passed from without inwards. The operation may be rendered 
 exceedingly difficult by the presence of enlarged glands or veins, especially the 
 lingual, facial and superior thyroid, which often lie directly in front of the 
 vessel. The superior laryngeal nerve is placed immediately behind it, and 
 must necessarily be avoided. 
 
 Collateral Circulation. — Vide ligature of common carotid (extracranial 
 portion). 
 
 Ligature of the Lingual Artery is chiefly needed as a preliminary to removal 
 of the organ for malignant disease ; it is also occasionally employed in traumatic 
 cases. The vessel can be secured either close to its origin from the external 
 carotid, or in the submaxillary triangle under cover of the hyoglossus muscle. 
 
 In the Submaxillary Triangle. — The patient lies on his back, with the 
 shoulders raised, and the head extended backwards and turned to the 
 opposite side. A crescentic incision commencing about 1 inch below and 
 external to the symphysis menti, and skirting the angle of the jaw, is made, 
 the centre opposite the great cornu of the hyoid bone (Fig. 72, H). The 
 integument and platysma are divided, the lower border of the submaxillary 
 gland is defined, and along it the deep fascia is incised. The gland is now 
 drawn upwards, and held over the margin of the jaw with a retractor 
 (Fig. 73, Gs). On thoroughly opening up the wound the two bellies of the 
 digastric muscle (.1/ biv) are seen converging to the hyoid bone (Z), the 
 
286 
 
 A MANUAL OF SURGERY 
 
 anterior belly passing superficial to the fibres of the mylohyoid muscle 
 (M myho), which course nearly transversely to the mandible, and of which the 
 posterior fibres may be divided with advantage. The digastric tendon is drawn 
 down with a blunt hook, and in the space thus cleared the hyoglossus muscle 
 (M hyogl) becomes evident, with its fibres passing vertically upwards, and 
 resting upon it the hypoglossal nerve (5), coursing forwards to get under cover 
 of the mylohyoid, and either above or below it the ranine vein. The fibres of 
 the hyoglossus are now divided transversely midway between the nerve and 
 the hyoid bone, and in the opening made by their retraction is seen the artery 
 (3), lying on the middle 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. 
 
 Fig. 73. — Ligature of Lingual Artery. (Tillmanns.) 
 
 The submaxillary gland (Gs) has been drawn over the side of the jaw with a 
 hook ; Z , hyoid bone ; i, external carotid ; 2, internal jugular ; 3, lingual 
 artery ; 4, ranine branch of facial ; 5, hypoglossal nerve ; M biv, digastric ; 
 M styl, stylohyoid; M myho, mylohyoid ; M hyogl, hyoglossus. The place 
 where the artery is tied is indicated by a window in the hyoglossus, 
 through which it can be seen. 
 
 The muscle is drawn backwards, and the great cornu of the hyoid bone defined. 
 The small space is now cleared between that bony process and 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, 
 1 inch in length, made directly over the vessel as it crosses the lower border of 
 the jaw immediately in front of the masseter. The platysma will need division, 
 as well as the skin and fascia. 
 
 The Temporal Artery is reached in front of the auditory meatus, and as it 
 crosses the zygoma, through a vertical incision. It is merely covered by skin 
 and fascia, but 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 
 
LIGATURE OF VESSELS 287 
 
 trachelo-mastoid are divided so as to expose the artery as it emerges from the 
 groove 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 text-books for descriptions. 
 
 Ligature of the third part is performed for axillary aneurism, for haemorrhage, 
 as a distal operation for aortic or innominate aneurism, and sometimes as a 
 preliminary to amputation of the upper extremity. The patient is placed on 
 the back, close to the edge of the table ; the arm is well depressed, and the 
 head turned to the opposite side. The skin is now drawn down by the left 
 hand, and an incision 3 or 4 inches long made over the clavicle (Fig. 72, B). 
 On releasing the skin it retracts upwards, so that the wound comes to be 
 situated about J inch above the clavicle, and thus the external jugular vein is 
 more efficiently protected. The incision should be placed with its centre about 
 1 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 abnormally encroach upon the bone. 
 The skin, superficial fascia and nerves, with the platysma, are divided along 
 the whole length of the incision, as also the deep fascia. The external jugular 
 and other veins now come into view, often constituting a plexus, which may 
 give the surgeon much trouble ; when possible, they should be gently drawn 
 out of the way by means of blunt hooks, but if necessary they must be divided 
 between ligatures. The cellular tissue is then further 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, and should not appear. The posterior 
 belly of the omohyoid, 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 including the lowest cord of the plexus. 
 The operation in a thin patient may be easy, but in a stout subject, with a 
 short thick neck and high clavicle, the greatest difficulty may be experienced 
 in finding the vessel. The chief dangers arise from wounding the aneurismal 
 sac, the pleural cavity, or the superficial veins, whilst the proximity of the 
 cords of the brachial plexus must not be forgotten. 
 
 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 : Suprascapular with acromio-thoracic. 
 
 The Internal Mammary Artery (Fig. 72, M) 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 margin it is distant about ^ inch. 
 If the vessel has been divided, and the ends have retracted, it may be necessary 
 to excise a portion of costal cartilage in order to secure both ends — a most 
 necessary proceeding, owing to the freedom of the collateral circulation and 
 the consequent liability to continued haemorrhage. 
 
 Ligature of the Vertebral Artery has been undertaken for wounds, for 
 secondary haemorrhage after ligature of the innominate and in the treatment 
 of epilepsy, but without much permanent benefit in the last case. The opera- 
 tion, though by no means easy, is usually successful as far as the immediate 
 
288 A MANUAL OF SURGERY 
 
 surgical procedure is concerned. An incision is made along the lower half o 
 the posterior border of the sterno-mastoid (Fig. 72, V), the platysma and deep 
 fascia divided, a few of the posterior fibres of the muscle itself incised if need 
 be, and its belly drawn well forwards. The scalenus anticus muscle is clearly 
 defined, together with the phrenic nerve. The interval between it and the 
 longus colli muscle can now be demonstrated, with the ascending cervical 
 artery lying upon it The anterior transverse process of the sixth cervical 
 vertebra must be made out. Just below this the vertebral vessels are found 
 entering the canal in the transverse process, 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 included in the ligature, and the 
 resulting contraction of the pupil may (according to MacCormac) be looked 
 upon as satisfactory evidence that the vertebral has been in reality secured. 
 
 Ligature of the Thyroid Vessels is sometimes used as a means of arresting 
 the growth of a goitre. 
 
 The superior thyroid artery is tied by an operation similar to that for the 
 external carotid. The incision along the anterior margin of the sterno- 
 mastoid has its centre opposite the upper border of the thyroid cartilage ; 
 the external carotid is defined, and the superior thyroid secured as it rises 
 from it. 
 
 The inferior thyroid artery is reached by an incision 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 nerve as possible. 
 
 The Axillary Artery is tied for punctured wounds of the axilla, as a distal 
 operation for subclavian aneurism, occasionally for wounds of the palmar 
 arch, and possibly for secondary haemorrhage from the brachial. For aneurism 
 of the brachial, one would nowadays prefer extirpation of the sac if compres- 
 sion fails. Two classical operations are described and practised in classes on 
 operative surgery. 
 
 1. Ligature of the first part of the vessel is usually undertaken through a curved 
 incision, with its concavity upwards, extending from the coracoid process to 
 within 1 inch of the sterno-clavicular joint, and i, inch below the clavicle 
 (Fig. 72, C). The clavicular origin of the pectoralis major is divided, and the 
 costo-coracoid membrane exposed, and divided along the lower border of the 
 subclavius muscle. Branches of the acromio-thoracic axis are displaced 
 downwards, and the main trunk is exposed by a blunt dissector and forceps. 
 The vein lies within and below, and the cords of the brachial plexus above 
 and to the outer side. The needle is passed from below upwards. 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 lie over the interspace between the pectoralis major and deltoid muscles. 
 This intersection is opened up and the outermost fibres of origin from the 
 clavicle of the pectoralis 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 at the junction of the anterior and 
 middle thirds of the space between the axillary folds (Fig. 74, A). The inner 
 border of the coraco-brachialis muscle is clearly defined, and forms the first 
 rallying-point ; it is drawn slightly outwards, and the median nerve, together 
 with the musculo-cutaneous trunk , at once comes into view. On drawing these 
 
LIGATURE OF VESSELS 
 
 inwards, the artery itself is seen, with the vein to the inner side, together with 
 the internal cutaneous nerve. The needle is passed from the vein. 
 
 Collateral Circulation. — If above the acromio-thoracic, the same as for the 
 third part of the subclavian (q.v.). 
 
 If above the subscapular and circumflex : Long thoracic and intercostals 
 with thoracic branches of subscapular ; suprascapular and posterior scapular 
 with scapular branches of subscapular ; suprascapular and acromio-thoracic 
 with posterior circumflex in the deltoid. 
 
 If below the circumflex, same as for ligature of brachial above the superior 
 profunda — i.e., posterior circumflex with superior profunda in the deltoid. 
 
 The Brachial Artery may need to be ligatured for haemorrhage from the 
 palmar arches, or from a wound in the forearm or about the elbow, for 
 aneurisms, or for arterio-venous wounds at the bend of the elbow. It may be 
 tied in one of two places : 
 
 i. At the Middle of the Arm. — The arm is held away from the side at a right 
 angle, with the hand supine, but with no support beneath it, for fear of 
 pushing forwards the triceps and displacing the vessel. The surgeon stands 
 between the arm and the trunk. An incision 2 inches long is made in the line 
 of the vessel along the inner border of the biceps muscle (Fig. 74, B), and the 
 thin fascial investment of the limb divided. The inner edge of the muscle is 
 clearly exposed, and by drawing it slightly forwards the median nerve is 
 brought into view, and perhaps the basilic vein. The nerve, which is at this 
 spot crossing the artery from without inwards, is drawn inwards, and the 
 
 sss^^^j^^WII^K 
 
 Fig. 74. — Incisions for tying the Arteries of the Arm. 
 
 A, Third part of the axillary ; B, brachial ; C, brachial at the bend of the 
 elbow ; D, middle third of radial ; G, middle third of ulnar ; E and F, 
 lower thirds of radial and ulnar. 
 
 sheath of the vessel found beneath it. The artery is separated from its venae 
 comites, and the ligature passed and tied. 
 
 The operation is by no means always an easy one, as there are many traps 
 into which the beginner may fall. Thus the median nerve may cross behind 
 the vessel instead of in front of it ; the basilic vein may lie over its situation, 
 and be mistaken for it ; or there may be a high division, and two trunks, 
 usually lying close together, must then be sought for instead of one. The most 
 common mistake consists in not defining the biceps muscle, and in seeking for 
 the artery behind its proper situation. 
 
 2. At the Bend of the Elbon*. — An oblique incision is made, about 2 inches 
 long, parallel to the inner border of the biceps tendon, its lower end cor- 
 responding to the crease of the elbow (Fig. 74, C). The wound should be 
 placed at about an angle of forty-five degrees to the axis of the limb, and to 
 the outside of, and nearly parallel to, the median basilic vein, which, if seen, 
 must be drawn inwards. The bicipital fascia is now incised, and the artery 
 with its venae comites exposed in the loose fat, the median nerve being well 
 away on the inner side. The needle is passed from within outwards. 
 
 Collateral Circulation.— If above the origin of the superior profunda, pos- 
 terior circumflex in deltoid with ascending branches of superior profunda. 
 
 19 
 
290 
 
 A MANUAL OF SURGERY 
 
 If below the origin of the inferior profunda, the anastomoses around the 
 elbow-joint. 
 
 The Ulnar Artery rarely needs ligature except for palmar haemorrhage or 
 direct wounds In the former case the artery can easily be secured just above 
 the wrist, in the latter case by enlarging the original wound. The following 
 stereotyped operations are described, but are more often seen in the examina- 
 tion room or dead-house than in the operating theatre. It should be borne in 
 mind that the artery curves inwards from the centre of the bend of the elbow 
 to the radial side of the pisiform bone. The lower two-thirds of its course is 
 indicated by a line drawn from the internal condyle of the humerus to the 
 same spot below. 
 
 1. At the Wrist. — An incision about 1 inch in length is made directly upwards 
 from the flexure of the wrist in the line of the vessel (Fig. 74, 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. If possible, the venae comites should be separated, 
 and not included in the ligature. 
 
 2. In 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 pisi- 
 form bone (Fig. 74, 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 ulnar, and readily finds the vessels under cover of the flexor carpi 
 ulnaris, with the nerve lying a little way to the inner side. The most common 
 mistake consists in getting too far tr. the radial side, and in separating various 
 portions of the flexor sublimis, or in passing between it and the palmaris 
 longus. Occasionally, even when the correct interspace has been entered, a 
 beginner may pass beyond the vessels, and find himself between the flexor 
 carpi ulnaris and the flexor profundus. 
 
 The extreme upper limit of the ulnar artery can also be reached through 
 an oblique incision extending 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 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. An oblique incision is 
 made between the tendons, extending from the back of the styloid process of 
 the radius to the base of the first metacarpal bone. The superficial radial 
 vein is found beneath the skin, and a few twigs of the radial nerve. A deeper 
 layer of fascia is then divided, passing between the tendons, and beneath it 
 the artery is exposed, crossing the incision obliquely. The synovial sheaths 
 accompanying the tendons should not be opened, or some limitation of the 
 movements of the thumb may result. 
 
 2. Above the Wrist an incision is made in the line of the vessel (Fig. 74, E), 
 which is found after division of the fascia between the supinator longus and 
 flexor carpi radialis. The radial nerve has passed to the dorsum ere this, and 
 if any nerve filaments are seen they are derived from the external cutaneous. 
 A small superficial vein usually lies over the artery. 
 
 3. In the Middle or Upper Third of the Forearm an incision is made in the line 
 of the vessel (Fig. 74, D), and the inner border of the supinator longus sought 
 
LIGATURE OF VESSELS 
 
 291 
 
 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, though one patient operated on by Monteiro in South 
 America survived till the tenth day, whilst Keen's and Tillaux's lived forty- 
 eight and thirty-nine days respectively. The fatal issue was in most instances 
 due to septic contamination of the wound and secondary haemorrhage, and 
 as the operation has certainly been successful in animals, it is possible that 
 we may vet be able to chronicle a satisfactory result as a triumph of modern 
 surgery. 
 
 Two distinct plans of operation have been followed, viz., the trans-peritoneal, 
 and the extra- or retro-peritoneal, but no one would attempt the latter nowa- 
 days. The trans-peritoneal 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 on either side, and the 
 posterior layer of the serous membrane covering the aorta carefully divided ; 
 there is then no difficulty in passing a ligature around the vessel. Possibly 
 the same precaution to prevent excessive backflow of blood would be advisable 
 as in tying the innominate, viz., to secure one or both of the common iliac 
 trunks in addition ; such would in no way interfere with the establishment of 
 the collateral circulation. 
 
 The Common Iliac Artery extends for a distance of 2 inches from the bifur- 
 cation 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, as 
 the aorta, by two methods, the trans- and the retro-peritoneal. 
 
 In the retro-peritoneal operation a curved incision (Fig. 75, A or B) is made 
 through the abdominal parietes, somewhat similar to that for ligaturing the 
 external iliac, but extending higher. The muscles and fascia transversalis are 
 carefully divided, and the peritoneum, together with its contents, stripped up 
 and held out of the way with a broad retractor. The ureter which crosses 
 the artery is usually carried forwards with the peritoneum. The vessel is now 
 sought for, carefully cleaned, and a ligature passed from right to left (of the 
 patient) on both sides of the body, the vein lying behind the artery on the 
 right side, and behind and internal to it on the left. 
 
 The trans-peritoneal plan has already been undertaken with success, and will 
 doubtless henceforth supersede all other methods. An incision is made in 
 the median line with its centre a little below the umbilicus, the peritoneum 
 opened, the intestines retracted, the vessel sought for and exposed bv 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 bifurca- 
 tion must be carefully avoided. 
 
 Collateral Circulation after Ligature of Common Iliac Artery. — Blood 
 reaches the external iliac and its branches by means of the anastomoses 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-lumbar ; (b) the middle sacral with the lateral sacral ; 
 (c) the retro-pubic anastomosis of the two obturator arteries ; and (</) 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- 
 
 * See Tillaux and Riche, ' Revue de Chirurgie,' January, Februarv, and 
 March, 1901. 
 
 1 9 — 2 
 
292 
 
 A MANUAL OF SURGERY 
 
 rhage from, or aneurism of, one of its branches, the gluteal being that most 
 commonly affected, and lately has been recommended as a means of diminish- 
 ing the size of an enlarged prostate. The trunk is a chort one, at most 
 i.V inches in length, and is best reached by opening the abdomen in the 
 middle line below the umbilicus (Fig. 75, C), pushing aside the intestines, and 
 searching for the bifurcation of the common iliac. The posterior layer of 
 the peritoneum is then carefully incised, the ureter avoided, and an armed 
 aneurism needle passed without wounding the vein. 
 
 The Collateral Circulation is the same as that given for the internal iliac 
 division of the common iliac. 
 
 The Gluteal Artery occasionally needs to be secured at its point of emergence 
 from the pelvis through the upper part of the great sacro-sciatic foramen. 
 This spot is indicated by the junction of the inner and middle thirds of a line 
 
 Fig. 75. — Incisions for Operations on Lower Part of Abdomen 
 and Thighs. 
 
 A, Mott's incision for tying common iliac artery ; B, Marcellin Duval's incision 
 for the same; C, incision for trans-peritoneal ligature of internal 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, ligature of femoral artery in Hunter's canal. 
 
 drawn from the posterior superior iliac spine to the top of the great trochanter. 
 An incision is made in the direction of this line, i.e., along the fibres of the 
 gluteus maximus, which are separated and held apart. The deep fascia 
 beneath this muscle is then opened up, and the space between the gluteus 
 medius and pyriformis defined. Through this the upper margin of the sacro- 
 sciatic notch can be detected, as also the pulsation of the artery. The vessel 
 must be secured as deeply as possible on account of its early division. It is 
 always a troublesome dissection, and possibly in most cases it would be wiser 
 to deal with the trunk of the internal iliac from the front. 
 
 The Sciatic and Pudic Arteries seldom require to be tied, but may be 
 reached opposite the ischial spine, at the junction of the middle and lower 
 thirds of a line drawn from the posterior superior iliac spine to the tuber 
 
LIGATURE OF VESSELS 293 
 
 ischii. An incision about 4 inches in length is made over this spot, cor- 
 responding in direction to the fibres of the gluteus maximus, which are 
 separated. The spine of the ischium and lower border of the pvriformis 
 should now be defined, and the vessels and nerves seen emerging from the 
 foramen. The pudic vessel lies to the inner side of the sciatic ; the ligature is 
 passed as high as possible. 
 
 The External Iliac Artery is easily accessible in any part of its course, which 
 measures from 3^ 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 unnecessary to open 
 the peritoneum. There are two chief forms of extra-peritoneal 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 1 inch internal 
 to the anterior superior spine (Fig. 75, G). The external oblique aponeurosis 
 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 retractors. The transversalis fascia and loose subperitoneal fat 
 are now opened with forceps and director, and the vessel is felt pulsating 
 immediately under the finger. It is very important not to damage either the 
 epigastric or circumflex iliac arteries during this manipulation, since they 
 are most essential factors in establishing the collateral circulation, whilst the 
 circumflex iliac vein crossing the main trunk must also be avoided. The 
 needle is passed from within outwards, the ligature tied, and the divided 
 muscular and aponeurotic structures brought accurately together by buried 
 sutures. 
 
 Abernethy's Modified Operation is more commonly utilized. The incision, 
 about 4 inches in length, extends from a point 1^ inches within and above the 
 anterior superior iliac spine to just external to, and | inch above, the middle 
 of Poupart's ligament (Fig. 75, F). Through this the aponeurosis of the 
 external oblique is divided along the course of its fibres, as also the internal 
 oblique and transversalis. The transversalis fascia is now carefully incised ; 
 it varies considerably in thickness, being sometimes well developed, but is 
 occasionally so attenuated as to be scarcely recognisable, and in such cases 
 the peritoneum may unintentionally be opened. In the present day this is an 
 accident of slight importance, the wound being readily closed by a continuous 
 suture, and no harm resulting. The 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 properlv opened, it is quite 
 possible to strip it up together with the peritoneum, and carry the vessels 
 forwards with it, when they may be found under cover of the spatula. 
 
 On comparing the two operations, we are very distinctly in favour of the 
 latter plan. 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 that is diseased and unsuitable for the application of a ligature, no further 
 choice is possible. In Abernethy's, on the other hand, the vessel is tied well 
 
294 • A MANUAL OF SURGERY 
 
 away from collateral branches, and if the exposed portion of the trunk is 
 diseased, the common iliac can be reached and secured without much difficulty 
 bj extending the incision upwards. As to the greater tendency to hernia 
 stated to exist in this method, this may have been the case in pre-antiseptic 
 days, when the muscles were not sutured for fear of retaining septic discharges ; 
 but careful asepsis, the use of buried sutures, and the possibility of doing 
 without drainage tubes should render such a sequela impossible. 
 
 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 may be reached by 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 liga- 
 ture passed from the inner side. 
 
 Collateral Circulation — Interna! 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 ischiadici with perforating of the profunda and 
 muscular of popliteal. 
 
 The Superficial Femoral Artery is indicated by a line drawn from midway 
 between the anterior superior spine and the symphysis pubis to the tuberosity 
 of the internal condyle, the limb being flexed, abducted, and a little 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. 75, H). The integument and fascia; are divided, the 
 inner border of the sartorius exposed, and the sheath found immediately behind 
 it, the muscle being drawn slightly outwards; the middle cutaneous nerve is 
 perhaps brought into view. A muscular branch to the sartorius may be met 
 with at this spot, and should be separately ligatured. The vein is placed 
 behind the artery, so that the needle may be passed either way, special care 
 being taken to keep it close to the vessel. 
 
 Collateral Circulation. — External circumflex with lower muscular of femoral, 
 anastomotica magna, and superior articular of popliteal. 
 
 • Profunda femoris by its perforating and terminal branches with the muscular 
 and articular branches of femoral and popliteal. 
 
 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 (Fig. 75, K). The sartorius 
 is exposed by division of the fascia lata, its fibres running downwards 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 and vastus internus ; it is incised, and the sheath of the 
 vessel found below it, with the nerve to the vastus internus lying to its outer 
 side, the long saphenous nerve crossing it from without inwards, and the vein 
 passing behind it, to become external lower down. The needle maybe passed 
 
LIGATURE OF VESSELS 295 
 
 in either direction, and the ligature should not be placed too low on account 
 of the contiguity of the anastomotica magna. A common mistake made by 
 students in tying this artery on the dead subject is to burrow down along 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 trans- 
 verse 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 limb is fully abducted and everted so as to enable 
 the adductor tubercle and tendon of the adductor magnus to be clearly defined. 
 
 Fig. 76 — 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 Tibialis Posticus ; 
 F, Ditto for Tendo Achillis. 
 
 An incision, 4 inches in length, is then made from the tubercle upwards 
 (Fig. 76, 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 
 wdth the sartorius, gracilis, and semi-membranosus. 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 a good deal of loose connective tissue. The vein is usually seen on the 
 outer side, and is here very thick and dense, so that in the dead subject it can 
 be readily mistaken for the artery. 
 
 The lower part is tied through an incision in the middle line of the popliteal 
 space, dividing the deep fascia, and drawing out of the way the heads of the 
 
296 
 
 A MANUAL OF SURGERY 
 
 gastrocnemius muscle, and the internal popliteal nerve. The vein is superficial 
 to the artery, and is found by following the short saphenous trunk. The 
 needle is passed from the inner side. 
 
 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, 
 
 Fig. 77. — Incisions for Liga- 
 ture of Anterior Tibial 
 (A and B) and Peroneal 
 (C) Arteries. D, Site for 
 Introduction of Knife in 
 Tenotomy of Peronei. 
 
 Fig. 78. — Incisions for 
 Ligature of Lower 
 Part of Anterior 
 Tibial (A) and Dorsalis 
 Pedis (B ; Arteries. C, 
 Site for performing 
 Tenotomy of Tibialis 
 Anticus. 
 
 and an incision 4 inches long is made a finger's breadth behind the inner 
 border of the tibia (Fig. 76, 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. The venae comites are 
 separated, if possible, and the ligature passed from the nerve. Sometimes the 
 above-mentioned aponeurosis is in the substance of the soleus, and a thin layer 
 of muscular fibres exists on its deeper aspect. 
 
LIGATURE OF VESSELS 297 
 
 2. In the Lower Third of the Leg. — An incision is made midway between the 
 tendo Achillis and inner border of the tibia (Fig. 76, 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. 76, 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 readily 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 
 midway between the outer tuberosity of the tibia and the head of the fibula 
 above,, to the central point between the two malleoli below. 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 artery (Fig. 77, 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. 77, B). — The same intermuscular space is 
 opened, being indicated here by a definite white line, due to a slight sub- 
 fascial 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 78, A). 
 The deep fascia and upper part of the annular ligament are divided, and the 
 vessel is found between the tendons of the tibialis anticus and of the extensor 
 proprius hallucis, the nerve lying to the outer side. 
 
 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. 78, 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 slip of 
 the extensor brevis digitorum. It is by no means 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. 77, 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 XL 
 SURGERY OF THE VEINS. 
 
 Thrombosis. 
 
 By Thrombosis is meant intravascular coagulation in any part of 
 the circulatory system. Normally the blood remains in a fluid 
 condition, owing to some interaction between it and the vessel 
 walls. Any factor producing a disturbance of this normal 
 equilibrium may determine thrombosis, and any part of the 
 vascular tract may be affected by it, whether the heart, arteries, 
 veins, or capillaries. We have already discussed some of the 
 conditions associated with capillary or arterial thrombosis ; that 
 which follows, whilst referring primarily to venous thrombosis, is 
 also in a measure true of the other forms. 
 
 Causes. — (i) Changes in the vessel walls, as a result of which the 
 integrity of the endothelium is disturbed — e.g., injury (either 
 division, rupture, puncture, compression, or contusion), inflamma- 
 tion or degeneration (as in varicose veins). 
 
 (2) Changes in I he constitution of the blood, whereby its coagula- 
 bility is increased. Excess of excretives, as after pregnancy 
 during involution of the uterine walls, may have this effect, or the 
 presence of toxins arising from bacterial activity ; hence septic 
 diseases are commonly associated with thrombosis. Great loss 
 of blood up to a half of the whole amount in the body also 
 increases its coagulability, but excess of leucocytes, as in leukaemia, 
 has the opposite effect. A. E. Wright has shown that the per- 
 centage of calcium chloride in the blood is an important factor. 
 If o*6 per cent, of this salt is present, coagulation is hastened, 
 and he has proposed to reduce the loss of blood during opera- 
 tions to a minimum by injecting into the rectum half an hour 
 previously a pint of warm water containing in solution 2 oz. of 
 this salt. In one or two cases in which we have seen it used, 
 it appears to have been efficacious, but its general utility is 
 doubtful, since it might lead to coagulation in unwished-for 
 localities. 
 
SURGERY OF THE VEINS 299 
 
 (3) Diminished rate of the blood stream predisposes to thrombosis 
 if some other condition is present to determine it. Lister showed 
 years ago that blood can remain fluid for a long time if confined 
 in a tube formed of a suitable length of the vein wall ; but when 
 either of the preceding factors is present, a retardation of the 
 blood stream materially assists in causing coagulation. Thus, 
 when a vein is pressed upon by a tumour, the obstruction to 
 the blood flow produces a clot at the spot where the nutrition 
 of the wall is interfered with. After fevers, such as typhoid or 
 rheumatic, where the character of the blood is somewhat altered 
 and the action of the heart weakened by changes in the muscular 
 fibres, the defective vis-a-tevgo causes a retardation of the flow 
 in the veins, as a result of which the intravenous pressure is 
 diminished, and the valves are only partially pushed back, spaces 
 being left behind them in which the blood stagnates. Coagulation 
 is probably determined by some slight injury or pressure which is 
 not noticed by the patient, or by some lessened vitality of the w r all 
 of the vein, or by disintegration of the leucocytes and setting free 
 of fibrin ferment owing to the defective circulation. The clots 
 thus formed behind the valves gradually increase in size until 
 the whole lumen of the vessel is obstructed. The white leg of the 
 puerperal woman is sometimes induced in the same way, although 
 it is probable that in most cases the coagulum extends to the 
 femoral vein from the uterine plexuses. A similar condition 
 occurs during or after appendicitis, and is then probably due 
 to the direct action of inflammatory phenomena around the iliac 
 vein. 
 
 The Character of the clot varies according to whether it is 
 deposited slowly or is due to a rapid coagulation of the blood. 
 In the former case the so-called White Thrombus is met with, 
 which is formed upon, and adheres to, the vessel wall, and 
 gradually increases by fresh deposits of fibrin until it entirely 
 blocks the channel. If a certain number of red corpuscles are 
 entangled in the meshes of the clot, it is termed a Mixed 
 Thrombus ; the more rapid its formation, the greater the number 
 of red corpuscles present. Should the blood coagulate en masse in 
 a vein, as after its total division or ligature, an ordinary Red 
 Thrombus is produced, which at first is not adherent to the wall, 
 but becomes so later on, especially at its base. A similar type of 
 clot is usually found post-mortem capping any white clot which has 
 formed previously. 
 
 The Effects of thrombosis may be considered under the follow- 
 ing headings : local, distal, and proximal. 
 
 Locally, the following conditions may obtain : (a) The clot 
 may be organized into connective tissue, a fibrous cord replacing 
 the vessel in the same way as was described for arterial throm- 
 bosis in a previous chapter (p. 227). (b) The lumen of the 
 vein may be re-established by cleavage and shrinking of the 
 
3°o 
 
 A MANUAL OF SURGERY 
 
 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 soften, dis- 
 integrate, and be washed away in 
 minute particles into the circulation. If 
 this is unattended with sepsis, no harm 
 need follow ; but if septic in origin, 
 local abscesses, or even diffuse suppura- 
 tion, may occur along the vein, together 
 with general pyaemia, (d) The clot may 
 shrink or become loosened in an ampulla 
 of a varicose vein, forming a fibrinous 
 mass which is subsequently infiltrated 
 with calcareous particles, constituting a 
 vein stone or Phlebolith. 
 
 Distally, congestion of the terminal 
 veins is caused by the obstruction to 
 the circulation, and if a main trunk is 
 affected, oedema of the limb follows, 
 and possibly ulceration or gangrene. In 
 favourable cases the collateral circula- 
 tion is soon established by the opening 
 up and dilatation of other venous 
 channels, which after a time become 
 varicose, and if situated superficially, 
 are often very obvious. Thus, if the 
 common femoral or external iliac vein 
 is occluded above Poupart's ligament, 
 the internal saphenous and superficial 
 epigastric veins become distended and varicose, and the latter may 
 be seen coursing up the abdominal wall towards the umbilicus, and 
 uniting with the same branch on the opposite side to find its way 
 to the saphena vein of that limb. If the inferior vena cava is 
 obstructed, the mammary and epigastric veins become dilated and 
 tortuous, standing out prominently on the anterior abdominal wall. 
 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. 79, B). If the clot is undergoing 
 molecular disintegration and only minute portions are set free, 
 they are filtered off by the lungs or kidneys, and no symptoms 
 need be caused. If, however, a large portion is detached, urgent 
 dyspnoea and even death occur from obstruction to the pulmonary 
 vessels and subsequent arrest of the circulation. If the clot 
 becomes septic and fragments conveying organisms are carried 
 into the circulation, pyaemia is the result, preceded, however, in 
 the portal area by pylephlebitis — i.e., suppurative phlebitis of the 
 portal trunks in the liver. 
 
 Fig. 79. — Thrombus and 
 Embolus. (Keen and 
 White.) 
 
 A, Thrombus in situ ; B, 
 bolus detached from 
 same. 
 
 em- 
 the 
 
SURGERY OF THE VEINS 
 
 301 
 
 The Clinical Signs and Treatment of venous thrombosis are the 
 same as for phlebitis (q.v.). 
 
 Embolism. 
 
 An Embolus is the term applied to any foreign body which travels for a 
 greater or less distance in the bloodvessels until it becomes lodged within 
 them and causes obstruction. There are four main varieties of embolus : 
 (a) Simple Emboli, e.g., blood-clot, granulations or fibrinous vegetations from 
 the cardiac valves after acute endocarditis, atheromatous plates, air-bubbles, 
 fat globules, etc. (6) Infective Emboli consist of either zooglcea masses of 
 bacteria or disintegrated portions of blood-clot carrying micro-organisms and 
 originating a pysemic abscess wherever they lodge, (c) Malignant Emboli 
 are formed by portions of some malignant growth, from which the various 
 secondary deposits originate ; such are met with more frequently in the 
 sarcomata than in the carcinomata. (d) Parasitic Emboli also occur, such 
 as the ova and scolices of the Tania echinococcus, and the Filaria sanguinis 
 I10 111 in is. 
 
 Emboli may be detached from the heart, veins, or arteries, although neces- 
 sarily 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 symp- 
 toms depends 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 
 impacted 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 obstruc- 
 tion complete ; organization of the thrombus usually follows, although occa- 
 sionally it may disintegrate and disappear. Under these circumstances a 
 weak spot mav be left in the arterial wall, from which an aneurism is subse- 
 quently developed. 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. 
 
 (1) 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 anaemia 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 Cohnheim called a ' terminal artery ' 
 (i.e., one with no anastomosis between the embolus and the terminal capil- 
 laries), 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 white or yeilow 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 what is known as 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 firm, solid patch of a dark red colour results, known as a 
 haemorrhagic 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, 
 
302 A MANUAL OF SURGERY 
 
 perhaps, a few haematoidin crystals. The conditions necessary for the pro- 
 duction 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. 
 
 Effects of the Lodgment of Emboli in Various Organs. — In the Brain, the 
 middle cerebral artery is most commonly blocked, resulting in 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 affected vessel occasionally follows. In the 
 Central Artery of the Retina, sudden, total and irremediable blindness is pro- 
 duced ; the branches of the vessel are seen to be almost empty, the retina 
 becomes cedematous, the macula alone retaining its normal colour, appear- 
 ing as a cherry-red spot, contrasting markedly with the pallid cedematous 
 tissues around. In the Lung, fatal results supervene from obstruction to a 
 large vessel ; whilst, if a smaller one is blocked, a certain amount of pain and 
 dyspnoea is produced, followed by the formation of an infarct, as indicated by 
 dulness, bronchial breathing, and bronchophony. In the Liver, an embolus of 
 the hepatic artery causes sudden hypochondriac pain, and perhaps a passing 
 glycosuria. The portal vein and its branches are not unfrequently obstructed 
 by emboli, which, being usually of a septic nature, give rise to pysemic 
 symptoms (pvlephlebitis). In the Spleen, a sudden pain in the left hvpo- 
 chondrium is experienced, the organ becomes enlarged, and a considerable 
 rise of temperature may follow In the Kidney, sudden pain in the loin 
 and a temporary haematuria constitute the main symptoms. In the Intestine, 
 localized ulceration or extensive gangrene is likely to follow, according to the 
 size of the vessel obstructed. In the Limbs, the emboli usually lodge at the 
 hi furcations 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. 73). 
 
 Phlebitis. 
 
 Phlebitis, or inflammation of the vein wall, arises from a 
 variety of causes, and is not uncommon in surgical practice. The 
 following forms may be described : 
 
 1. Simple Phlebitis, in which a more or less localized inflam- 
 mation of the wall of a vein is attended by thrombosis ; it extends 
 for a variable distance up and down the vessel, but usually not 
 further than the next patent branches, (a) It may arise from 
 injury, either subcutaneous or open, or from the continued pressure 
 and irritation of a tumour or aneurism ; (b) it may be idiopathic 
 in nature, attacking the larger veins of the lower extremity, or 
 vessels which have been long subject to varix, especially in gouty 
 individuals, (c) It may follow primary thrombosis, the blood 
 usually clotting first in one of the pouches or ampullae of a vari- 
 cose vein ; or (d) it may be induced by inflammation of the tissues 
 around the vein (periphlebitis), usually of septic origin. 
 
 2. Infective Phlebitis is a much more serious condition, inas- 
 much as the thrombus resulting therefrom is always invaded by 
 micro-organisms, and the disease is often of a spreading type. It 
 was this form of phlebitis which in the old days so commonly 
 followed operations, and made surgeons fear any interference 
 with veins ; it has now been almost banished as a sequela of 
 surgical operations by antisepsis, and there is no more fear of 
 
SURGERY OF THE VEINS 
 
 dealing with veins than with any other tissue of the body. It 
 may, however, arise (a) in traumatic cases where asepsis has not 
 been attended to or has failed, the organisms invading the clot 
 which lies in the open mouth of the vein ; or (b) as a result of 
 septic periphlebitis in wounds, or in septic inflammation of bones, 
 such as when a septic mastoiditis leads to disease of the mastoid 
 emissary vein and of the lateral sinus. The usual results are 
 localized or spreading suppuration in the course of and around 
 the vein, and general pyaemia, (c) It may possibly be induced 
 by auto-infection of the clot present in simple phlebitis. 
 
 The Morbid Anatomy of phlebitis shows nothing unusual ; the 
 walls of the vein are congested and thickened, and the endo- 
 thelial lining is hypertrophied ; the thrombus contained in the 
 vessel varies in its characters. If infected, it becomes soft and 
 pultaceous, resembling dirty-looking pus; a localized abscess may 
 form, or the suppuration may extend for some distance along and 
 around the vein. In the more 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 suffi- 
 ciently 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 congested, and there may be some oedema of the 
 region from which the blood flowing in the vein is gathered ; 
 this, however, rarely amounts to much, since the collateral cir- 
 culation is always abundant. If suppuration occurs, the signs of 
 a localized abscess are noted ; on opening this, care must be 
 devoted to maintaining the part aseptic in order to prevent, as 
 far as possible, the extension of the inflammation. 
 
 When the deeper veins are involved, it may be impossible to 
 detect them on palpation, although a blocked common femoral is 
 easily felt ; but acute deeply-seated pain over the vein and well- 
 marked fever are characteristic evidences of what has occurred. 
 (Edema of a more or less solid character develops, although 
 if the limb is maintained 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 under thrombosis 
 (p. 299) may result. 
 
 The onset of Septic Spreading Phlebitis is marked by fever and 
 perhaps rigors, whilst the local signs are due to the 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 
 suppuration follows. The development of pyaemia would be indi- 
 cated by a repetition of the rigors. 
 
 Treatment of Simple Phlebitis. — The limb must be kept abso- 
 lutely at rest to limit the inflammation and to prevent the 
 detachment of emboli, and also elevated to assist venous return. 
 
304 A MANUAL OF SURGERY 
 
 Locally, belladonna fomentations may be applied, or the parts 
 may be painted with 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 
 (six to eight weeks), massage may be commenced, to assist in 
 the removal of oedema 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 (p. 307), but not when the deeper veins are involved. 
 If abscesses form, however, they must be opened antiseptically. 
 
 Spreading Infective Phlebitis is treated by following up the sup- 
 purative process with the knife, laying open the tissues around the 
 involved veins. The wounds thus made should be treated with 
 peroxide of hydrogen and lightly stuffed ; at the same time, the 
 limb is raised and kept absolutely quiet. Should pyaemic phe- 
 nomena develop, it may be possible to place a ligature between 
 the disintegrating clot and the heart, and to scrape or wash away 
 the septic mass ; thus in septic 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 affects the veins of a limb, 
 and cannot be stopped by either of these plans of treatment, the 
 question of amputation may even have to be raised. 
 
 Varicose Veins, or Varix. 
 
 A vein is said to be varicose, or 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 varicocele, whilst piles are primarily due to 
 varicosity of the hemorrhoidal plexus. We shall here only deal 
 with the first of these three manifestations. 
 
 Causes. — Varix is induced by any condition which leads to a 
 frequently repeated or more or less permanent distension of a vein, 
 such as prolonged standing, as in those serving behind counters ; 
 the pressure of tight garters, especially if worn below the knee ; 
 prolonged or forcible exertion of the limb, as possibly in cyclists, 
 whereby the blood is driven from the deeper into the more super- 
 ficial veins ; the pressure of a pregnant or displaced uterus, or of 
 a pelvic tumour. Obstruction to and occlusion of the deeper 
 veins is another well -recognised cause of varix, and we have 
 already drawn attention to the effect produced by blocking of the 
 
SURGERY OF THE VEINS 
 
 305 
 
 common femoral vein and inferior vena cava. A less known 
 instance is the varix of the internal saphena or some of its 
 branches below the knee, which follows thrombosis of the 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 varix persists and usually 
 extends to just below the knee. Any abnormal communication 
 between an artery and a vein also causes varicosity, from the 
 inability of the latter to withstand arterial blood pressure (vide 
 Aneurismal Varix, p. 249). Inherited weakness, or the relaxation 
 of system due to sedentary habits, must be looked on as pre- 
 disposing causes. The tendency to varix increases with age till 
 the middle period of life is reached. When a vein is varicose 
 and its walls are thin and expanded, the valves become incompe- 
 tent, and the superincumbent weight of the 
 blood tends to still further increase 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 
 functionally useless. After a time the walls 
 become further stretched and irregularly ex- 
 panded, forming pouch-like dilatations, which 
 are very obvious under the attenuated skin, to 
 which they are often adherent. Micro- 
 scopically, the change consists in a transforma- 
 tion of the normal structures of the vein wall 
 into fibro- cicatricial 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 middle coat is atrophied, 
 and, indeed, is often completely absent. 
 
 Clinical History. — The enlarged veins are 
 seen ramifying under the skin with a more or 
 less tortuous and serpentine course (Fig. So), 
 
 and they often feel thickened. One or more fig. 80. Varix of 
 
 veins may be affected, and the tortuosity may Internal Saphena. 
 be at parts so marked as to constitute large (From a Photo- 
 clusters of dilated vessels, which look bluish GRAPH ) 
 under the attenuated skin. 
 
 The Effects of this condition are very varied. The circulation 
 in the lower parts of the leg may be impaired, especially that of 
 the skin. The limb feels heavy and painful ; forcible exertion 
 may cause a sensation of tension, and after standing or exercise 
 
 20 
 
306 A MANUAL OF SURGERY 
 
 there is usually a little cedema of the ankle. The capillaries in 
 the papillae often become dilated, appearing 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 spontaneous cure, 
 but coagulation sometimes occurs idiopathically in the pouches, 
 and the clot may subsequently shrink and form a small fibrinous 
 or calcareous mass, known as a ' phlebolith.' Gouty persons 
 with varicose veins are especially prone to attacks of phlebitis. 
 If these are limited in extent, no serious harm results ; but 
 sometimes the thrombosis spreads into deeper or larger veins, 
 whilst fragments of clot may be detached as emboli. Occasionally 
 the dilated pouch of a varicose vein gives way, and an alarming 
 gush of blood results ; the same may follow the extension of 
 ulceration through the vein wall. The blood under these circum- 
 stances is derived, not only from the lower, but also from the 
 upper end, inasmuch as the valves have become incompetent ; a 
 column of blood extending from the right auricle is thus tapped 
 near its lower end, and, unless prompt precautions are taken, the 
 patient's life may be lost. 
 
 The Treatment of varicose veins may be described as palliative 
 and radical. 
 
 Palliative Treatment consists in removing any source of obstruc- 
 tion in the shape of tight garters, in limiting the amount of stand- 
 ing, in moderate massage, together with the application of either 
 an elastic stocking or an indiarubber bandage. The bowels 
 should be kept well open, and the general health attended to. 
 Eczema may be treated by the application of soothing and 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). Varicose ulcers are treated on ordinary prin- 
 ciples, or by Unna's method (p. 62) ; but repair is often delayed 
 till the veins have been dealt with by operation. 
 
 Radical Treatment consists in the excision of the distended veins. 
 Before operating it is important to make certain that the con- 
 dition is not due to thrombosis of the deep trunks, as interference 
 would then do more harm than good, and the varix would be 
 certain to recur in neighbouring collateral veins. Operation is 
 specially indicated when thin, dilated pouches exist ; when elastic 
 stockings cannot be comfortably worn, as in the tropics ; when 
 ulcers exist which refuse to heal ; 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, indicating that the valves which protect the veins of 
 
SURGERY OF THE VEINS 307 
 
 the leg are defective. It may not be practicable to remove all, 
 but if the largest and most prominent are taken away, the others 
 will probably shrink and disappear. There are two chief plans of 
 doing this : (a) Small portions are removed at several different 
 situations. The skin is pinched up over the vein, and incised by 
 transfixion ; the vessel is usually bared by this means, but may 
 need a little cleaning. An aneurism needle is passed beneath it, 
 and the vein isolated sufficiently to allow of its being grasped by 
 two pairs of forceps, and divided between. Each end is now 
 freed, and drawn out of the wound as far as possible ; it is then 
 ligatured and removed. Probably i\ inches of vein may be taken 
 away through a i-inch incision. The wound is sutured without 
 drainage and dressed, (b) Long incisions are made, perhaps 6 
 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 unhealthy, but 
 should be curved so as to include as much sound skin as possible, 
 whilst crossing the vessels once or twice. All collateral branches, 
 especially the deep ones, must be secured, and this, in fact, con- 
 stitutes the great advantage of the operation, viz., that so many 
 anastomosing channels are obliterated. A simpler procedure has 
 been advocated by Trendelenburg, viz., the removal of a portion 
 of the internal saphena high up, so as to break the weight of the 
 superjacent column of blood. In cases where there is an impulse 
 on coughing, it is a most valuable measure, but the enlarged veins 
 should also be excised. 
 
 Inflamed Varicose Veins are not unfrequent, and may result in 
 a natural cure of the condition. The symptoms are those of a 
 superficial 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 
 to first secure by ligature the vein above the clot, so as to prevent 
 any risk of embolic detachment. Operation of a similar type is 
 also required when thrombosis is gradually spreading upwards, 
 and threatening to affect the deep trunks, e.g., in the neighbour- 
 hood of the saphenous opening ; or when portions of clot are 
 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. 
 
 Nsevus. 
 A naevus is a vascular tumour developing in the skin and in 
 subcutaneous or submucous tissues, and consists of a congeries of 
 vessels held together by connective tissue. Nsevi are of con- 
 genital origin, or develop soon after birth. Left to themselves, 
 
 20 — 2 
 
3 o8 A MANUAL OF SURGERY 
 
 they may shrink and disappear, but more often they increase in 
 size more or less rapidly, whilst sometimes they remain passive 
 and persist through life. Two chief varieties are described : 
 
 The Capillary Nsevus (or mother's mark) 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. It 
 consists merely of a mass of capillaries lined with endothelium 
 communicating with a few arterioles and venules, and held 
 together by loose connective tissue. Several such growths may 
 be present in the same individual, and they are usually quite 
 small, not exceeding an inch or two in diameter, though some- 
 times they extend widely over the face and neck, and are then 
 very superficial in character, and somewhat dusky in colour, con- 
 stituting the ' port-wine stain.' If cut into, they bleed freely, but 
 the haemorrhage is easily stopped by pressure. 
 
 Occasionally a naevoid development may be observed involving 
 half the body, and limited almost exactly by the middle line ; this 
 condition is known as ncevus unius latevis. It may consist of a 
 purely vascular manifestation, or the skin may be hypertrophied 
 and covered with small soft papillary excrescences. In a case 
 under our observation recently, the trunk, head, and limbs were 
 distinctly asymmetrical, the naevoid half being larger and better 
 developed, except in the case of the leg. 
 
 Treatment is usually simple in the extreme. Small superficial 
 naevi can be completely cured by some form of cauterization, such 
 as the application of the electric or actual cautery, ethylate of soda, 
 or nitric acid ; in applying fluid caustics, the surrounding skin 
 must be protected by a thick layer of vaseline. In exposed 
 situations electrolysis (vide infra) is the best plan to adopt in order 
 to prevent the formation of a scar, but excision will often give an 
 equally good result. 
 
 The Cavernous or Venous Nsevus most commonly involves both 
 skin and subcutaneous tissues, but is sometimes purely sub- 
 cutaneous. It consists of a more or less prominent swelling, 
 soft to the touch, and easily compressible, but refilling when 
 the pressure is removed. There is no pulsation or bruit, and the 
 mass may be lobulated. If subcutaneous, the skin over it is 
 somewhat bluish in colour, but the mixed forms are dusky red. 
 Occasionally it may undergo spontaneous cure from inflammation 
 and thrombosis, and cysts are sometimes found in the centre of a 
 naevoid mass, indicating that a partial attempt at this process has 
 occurred. Venous naevi consist of a collection of vascular spaces 
 lined with endothelium, some tubular-like veins or capillaries, 
 others mere pouches, held together by fibrous tissue. The arterial 
 supply is not very great, but the arteries usually open directly into 
 the venous spaces without the intervention of capillaries (p. 170). 
 
SURGERY OF THE VEINS 309 
 
 The Treatment is by no means as simple as in the former 
 varieties. The following plans may be mentioned : 
 
 1. Excision of the growth should always be adopted where 
 practicable. Cases which formerly were dealt with by strangula- 
 tion are now treated by this means. The bleeding is never great, 
 even if the naevoid tissue is encroached upon by the knife, and 
 only a few vessels will need to be tied. Circular growths should 
 be removed by crescentic incisions, and a little undercutting will 
 usually enable the edges to be easily approximated. 
 
 2. The Injection of coagulating and irritating fluids, such as 
 perchloride of iron or pure liquefied carbolic acid, has been 
 employed, but has no advantages over electrolysis, and is more 
 risky and less certain in its results. 
 
 3. Where excision is impossible, or where it is important to 
 leave no scars or only minute ones, Electrolysis should be em- 
 ployed. It consists in the passage of a current of high electro- 
 motive force through the mass, producing chemical and physical 
 changes in the contained blood. A Stohrer's battery can be used, 
 or any suitable collection of cells, connected in series. Both 
 needles may be inserted into the mass, but it is sometimes wiser 
 only to use one or more needles connected with the positive 
 pole, whilst the negative pole is attached to a large electrode 
 moistened and placed on some indifferent part of the body, such 
 as the arm, back, or thigh. The needle is often with advantage 
 made of iron or steel, since it is usually corroded, and the chloride 
 of iron thus formed acts beneficially in determining coagulation 
 of the blood ; it must be carefully and thoroughly insulated when 
 deep naevi are treated, so as to protect the skin and prevent the 
 current passing through it. The use of the negative pole is more 
 likely to produce scarring, since a caustic sodium compound is 
 formed around it, and this may lead to sloughing of the tissues ; 
 the clot, moreover, is loose and spongy, whilst a much firmer 
 coagulum occurs around the positive pole. If the positive pole 
 alone is introduced, a current equal to about 200 milliamperes, as 
 measured by a galvanometer, may be passed for 10 or 15 minutes; 
 if both poles are used, a current half this strength is sufficient. 
 An anaesthetic is needed, and the immediate effect should be to 
 make the mass feel hard and firm by the coagulation of the blood ; 
 the tumour is subsequently disintegrated and absorbed. The 
 application may require to be repeated several times, and the 
 needles should be freely worked about through the mass. Not 
 uncommonly the child becomes pale and faint if the naevus is 
 on the head, probably as an effect of the strong current upon the 
 cerebral centres. For the treatment of superficial naevi, there is 
 no necessity to have the needle coated ; it is introduced into the 
 mass in a number of places, especially where any definite vessels 
 are seen, and of course does not penetrate deeply. A very short 
 application of the current usually suffices at each puncture ; the 
 
3io A MANUAL OF SURGERY 
 
 naevoid tissue turns white, and there is a little bubbling of gas 
 around the needle. It is best to deal first with the periphery of 
 a naevus, and then, when its extension is arrested, the central 
 parts can be treated. Of course some scarring cannot be avoided, 
 and hence it is wise not to do too much at one sitting, and to 
 make the intervals sufficiently long to allow cicatrization to take 
 place. 
 
 A Nsevo-Lipoma is the name given to a somewhat rare tumour, 
 in which a fatty element is blended with naevoid tissue. It is 
 usually of congenital origin, or, at any rate, appears early in life, 
 and is probably due to the undifferentiated formative cells of the 
 "embryo developing in a twofold direction so as to produce not 
 only fatty connective tissue, but also vessels. It gives rise to 
 a swelling, 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 
 capillaries are often seen on the surface. The only treatment is 
 excision. 
 
 Venesection. 
 
 Venesection or phlebotomy is a means of treatment which has 
 largely fallen into disuse of late years, but is still occasionally 
 employed with benefit. When a patient is becoming cyanosed, 
 and asphyxia is threatening either (a) as a result of pulmonary 
 engorgement 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 inflam- 
 mation of the brain is pending, and the pulse is hard and full ; 
 or (<f) in many inflammatory states in strong, full-blooded indi- 
 viduals where the pulse tension is high — in any of these conditions 
 venesection may be used with advantage. 
 
 The median basilic vein at the bend of the elbow is that usually 
 opened, since it is larger than the median cephalic, though placed 
 more directly over the brachial artery, from which it is separated 
 by the bicipital fascia. 
 
 Requisites. — A pad of antiseptic wool or gauze ; a strip of 
 bandage about 4 feet long ; a lancet ; a graduated bleeding-bowl ; 
 and finally a stick or bandage to be grasped by the hand, so as to 
 cause contraction of the muscles, thus pressing the blood from the 
 deep into the superficial veins along the communicating branch 
 which enters the median just below its bifurcation. 
 
 Operation. — The patient should be seated in a chair ; standing 
 would produce syncope too rapidly, whilst the recumbent posture 
 
SURGERY OF THE VEINS 
 
 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 fingers of the surgeon and 
 the lancet, the pad is placed on the front of the arm, and the 
 bandage tied firmly over it, so that the venous circulation may be 
 arrested whilst the arterial supply is unimpeded. Grasping the 
 stick firmly causes the veins to become prominent. The median 
 basilic is now steadied by the left thumb, and an oblique incision 
 made into it in the axis of the limb (Fig. 81). Blood will flow 
 
 Fig. 8i. — Venesection. 
 
 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, the surgeon's thumb is placed over the bleeding 
 spot, the bandage above is relaxed, the pad placed over the 
 wound and firmly bandaged in position ; the arm is kept at 
 rest for a few days to allow the small incision to heal. Occa- 
 sionally neuralgic pain is caused by the implication 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. 
 
CHAPTER XII. 
 DISEASES OF THE LYMPHATICS. 
 
 Affections of Lymphatic Vessels. 
 
 Acute Lymphangitis, or Inflammation of the Lymphatic Vessels. 
 —The Cause is almost invariably the absorption from an impure 
 wound of septic material, with or without bacteria. In either 
 case the toxins diffuse themselves along the lymphatics, and give 
 rise to irritation and inflammation of the surrounding tissues, 
 which may run on to suppuration, especially if pyogenic organisms 
 have also been taken up from the wound. The process is usually 
 limited by the nearest lymphatic glands, which filter off the toxic 
 products, but occasionally it spreads beyond them, and may give 
 rise to general infection of the system. Dissecting or post-mortem 
 wounds are not unfrequently of this nature. 
 
 Morbid Anatomy. — The walls of the lymphatics become hyper- 
 aemic and infiltrated, and the tissues around are inflamed. The 
 lymph is said to coagulate in the vessels, forming a pinkish clot. 
 
 Clinical Signs. — The characteristic 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 
 cedematous. If the mischief is limited to the main trunks (tubular 
 lymphangitis), these red lines remain isolated from each other; but 
 if all the smaller lymphatic channels of a part are affected (retiform 
 lymphangitis), the redness merges into a generalized blush, and the 
 condition is practically identical with cellulitis. Localized foci of 
 suppuration often follow, the redness increasing, and the parts 
 becoming dusky and brawny, until finally the centres soften and 
 fluctuate. These phenomena are associated with the general signs 
 of fever and malaise, the temperature rising to 102 or 103 , pos- 
 sibly attended by rigors, vomiting, and diarrhoea. 
 
 The Diagnosis of acute lymphangitis from erysipelas turns on 
 the more localized and patchy or streaky character of the redness, 
 whilst the margin is by no means so sharply limited or defined as 
 in the latter disease. 
 
DISEASES OF THE LYMPHATICS 
 
 Under suitable treatment resolution rapidly follows, but sup- 
 puration 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 lym- 
 phatic oedema results. In a few cases the patient dies from general 
 septicaemia, or from exhaustion following diffuse suppuration. 
 
 Treatment is first of all directed to the septic wound, which 
 must be thoroughly purified, so as to cut off the supply of 
 irritating toxins to the lymphatics. The limb itself is kept at 
 rest in a slightly elevated position, and either irrigated with cold 
 lotions, or treated with belladonna fomentations. Abscesses are 
 opened as soon as they develop. Any subsequent oedema of the 
 limb is remedied by massage and firm bandaging, provided no 
 venous complications are present. 
 
 Constitutional treatment consists in the administration of a 
 purge, followed by quinine and tonics, care being taken that 
 constipation is not thereby produced. A light and nutritious diet 
 is ordered, together with stimulants, if necessary. 
 
 Chronic Lymphangitis either results as a sequela of an acute 
 attack, or is met with as a separate condition. It is most fre- 
 quently seen in connection with venereal disease, the dorsal lym- 
 phatics of the penis becoming enlarged, hard, and cord-like, 
 especially in cases of primary syphilis. This is usually accom- 
 panied by a solid ©edematous condition of the prepuce, and en- 
 largement of the inguinal glands. Under appropriate anti-syphilitic 
 treatment, the swelling subsides in a few weeks. 
 
 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 dis- 
 semination. The treatment consists in the excision, if possible, of 
 each focus. 
 
 Rupture or Division of the Thoracic Duct during operations on 
 the neck is manifested by an escape of chylous fluid, which 
 coagulates on standing ; if the flow continues, exhaustion quickly 
 follows. Cases, however, have been published showing that the 
 condition is not necessarily fatal, and that if the wounded vessel 
 can be secured, as by ligature or forcipressure, recovery may 
 ensue. In such instances the thoracic duct probably opens by 
 several mouths into the subclavian vein, and only one of the 
 branches has been injured. 
 
 Lymphatics, like bloodvessels, are liable to distension and 
 dilatation which may be either congenital or acquired, and are 
 
3 r4 A MANUAL OF SURGERY 
 
 known as Lymphangioma or Lymphangiectasis. It is impossible 
 to draw an absolute line of distinction between the two conditions, 
 but the latter term is applied mainly 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. Of course, the two conditions may 
 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 markedly fatty nature. They may be 
 congenital or acquired, but even in the latter case there is pro- 
 bably some underlying congenital element, which was only awaiting 
 some irritation or localized injury to determine its development. 
 Two varieties may be described, 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. It is often termed a lymphatic 
 nawus, 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 warty in appearance, but on examination with a 
 lens each projecting point contains a vesicle. This type of growth 
 is sometimes very extensive, and may be associated with tumours 
 of the underlying connective tissues. We recently removed a 
 large fatty mass 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 con- 
 dition is excision or destruction by a caustic. 
 
 (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 often small and not larger than a split pea, 
 and this type may coexist with the capillary variety. Any part 
 of the body may be affected, and the lesion manifests itself as a 
 series 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 (lymphorrhcea) may result, lasting for some time. 
 They have been observed most frequently on the inner side of 
 the thigh and on the prepuce. Treatment consists in excision or 
 in laying them open and cauterizing the base. 
 
 In the deeper structures large multilocular cystic swellings may 
 be produced ; these are most frequently seen in the neck, and the 
 condition is often termed a Cystic Hygroma. The description 
 given in Chapter XXIX. would apply equally well to a tumour 
 of this nature in any other part of the body. Removal by dis- 
 section is often very difficult, especially in old-standing neglected 
 cases ; the limitations of the mass are sometimes very indefinite, 
 
DISEASES OF THE LYMPHATICS 315 
 
 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 asso- 
 ciated overgrowth of the connective tissues of the parts. (See 
 Chapter XXIV.) 
 
 In a few cases the opening of the thoracic duct has been obstructed 
 or compressed, leading to such backward tension that the recep- 
 taculum 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 enor- 
 mously distended, especially those of the small intestine. 
 
 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. 
 
 Chronic forms of lymphatic obstruction arise from the deposit 
 of tuberculous or cancerous material in the lymphatic glands, 
 from repeated attacks of subacute lymphangitis, due to the 
 continuous irritation of a large ulcer or extensive eczema of 
 the leg, or from the growth within the lymphatics of living 
 organisms, e.g., the Filaria sanguinis hominis. The latter con- 
 dition is the cause of the disease known as Elephantiasis Arabum, 
 whilst the former may give rise to a spurious form of this 
 affection, known as Pseud-elephantiasis. 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 cedema ; (b) hyperplasia 
 follows, affecting not only the subcutaneous tissues, which are 
 markedly thickened and increased in amount, but also the skin, 
 which becomes coarse and wart-like in appearance, and is very 
 prone to ulcerate ; and (c) lymphatic fistula are liable to develop, 
 from which a large amount of fluid exudes (lymphorrhaa). 
 
 Solid oedema of the prepuce is a not very unfrequent com- 
 plication of suppurative balanitis, and occurs most usually in 
 cases of syphilis. The dorsal lymphatics can be felt enlarged, 
 and the prepuce becomes swollen and indurated to such a degree 
 that retraction is impossible. In cases of hypospadias, where 
 the prepuce is voluminous and hangs like a hood over the glans, 
 the occurrence of solid cedema renders it so prominent as almost 
 to resemble the glans in colour and size. 
 
316 
 
 A MANUAL OF SURGERY 
 
 The removal of tuberculous glands from the neck maybe followed 
 by a puffy condition of the lower half of the face, which remains 
 enlarged for some time, but after a while regains its usual size. 
 The cheeks are occasionally involved in a solid cedematous process 
 spreading from either side of the nose, and due to attacks of 
 chronic lymphangitis, caused by the absorption of toxins from sores 
 or ulcers within the nostril. The thick lips occurring in tuberculous 
 children are of a similar nature, and due to the constant irritation 
 of cracks along the margins. 
 
 The pseud-elephantiasis arising from chronic ulcers, or from 
 disease of the lymphatic glands, can usually be dealt with by the 
 pressure of an elastic bandage ; but the limb is very likely to 
 remain permanently enlarged, and in some cases where intract- 
 able ulceration and lymph fistulae exist amputation is the best 
 treatment. 
 
 Elephantiasis Arabum (syn.: Barbadoes leg) requires but little 
 
 A B 
 
 Fig. 82. — Elephantiasis of Feet. 
 
 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 fre- 
 quently attacked, but the face or breast may also be affected. It 
 manifests itself as a hyperplasia of variable size of the sub- 
 cutaneous tissues, whilst the skin becomes thickened and wart- 
 like (Fig. 82, A and B), and from it a copious discharge of 
 lymph may escape. The parts sometimes attain enormous 
 dimensions, the scrotum even reaching to the ground when the 
 patient is sitting. The disease persists for many years, and is 
 not directly fatal. 
 
 The condition is due, as already mentioned, to the obstruction 
 caused by the development of the Filavia sanguinis hominis in the 
 lymphatics. These are spread (according to Manson) by the 
 agency of mosquitoes, in whose bodies the intermediate stage is 
 passed. The dead mosquito, with its parasitic contents, falls 
 upon the water, and in this way the ova find an entrance into the 
 human stomach, where the young worm is set free, bores through 
 
DISEASES OF THE LYMPHATICS 317 
 
 the gastric mucous membrane, and finally becomes lodged in the 
 lymphatics, especially those of the extremities. Not more than two 
 or three pairs of mature filariae 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 filariae 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 their way into 
 the blood stream, usually at night, and can be readily seen under 
 the microscope. Manson claims that they are taken into the 
 body of the mosquito with the blood which it abstracts, and thus 
 a fresh generation is developed. 
 
 The Treatment is extremely unsatisfactory. Of course, if one 
 can localize the situation of the parent filariae, as has been 
 possible in a few cases, they should be excised ; but more fre- 
 quently one has to depend on less satisfactory measures. When 
 the face or trunk is involved, but little can be done. When the 
 scrotum is affected, the morbid tissue can be freely dissected 
 away, sufficient skin 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. In 
 the leg elastic bandages, elevation, and possibly scarification, may 
 be useful in the slighter cases ; but where the limb is enormously 
 enlarged the greatest measure of success seems to have followed 
 ligature of the main artery, so as to diminish the blood supply, and 
 so check the growth by a process of starvation. Failing this, 
 amputation is the only resource. 
 
 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. 
 When a part becomes inflamed, there is always an increased flow 
 through the efferent lymph channels, owing to the exudation ; 
 the result of this is an increase in size of the glands to which the 
 lymph is carried, which quickly subsides when the inflammatory 
 process is at an end. If, however, irritating toxins are produced 
 in the inflamed area, they give rise to a more prolonged and 
 serious affection, whether accompanied or not by a similar con- 
 dition of the lymphatic vessels. When pyogenic organisms are 
 also absorbed, suppuration almost invariably results. In fact, the 
 lymphatic glands must be looked on as the filters by means of 
 which Nature eliminates many sources of disease. It is curious 
 that certain peripheral infective conditions are not at all liable to 
 produce enlargement of the glands, e.g., spreading gangrene, and 
 many forms of cellulitis ; possibly the acuteness of the process 
 
3 i8 A MANUAL OF SURGERY 
 
 causes lymphatic thrombosis in the efferent trunks, and thus 
 hinders the absorption of the noxious material. 
 
 Pathologically, the condition is characterized by hyperaemia of, 
 and exudation into, the gland, which becomes redder, firmer, and 
 larger than usual. Suppuration usually starts in more than one 
 spot. A certain amount of peri-adenitis, or inflammation of the 
 surrounding tissues, is always associated with it, even in the early 
 stages ; the latter may be of little importance, but when the 
 capsule has given way it may become so extensive as to constitute 
 a diffuse suppurative cellulitis. 
 
 Clinically, the glands can be felt as enlarged, tender, and 
 rounded masses, the skin over them being red and cedematous ; 
 when pus has formed, the swelling, which is at first hard and 
 brawny, becomes soft and fluctuating. They early contract 
 adhesions to neighbouring tissues, and suppuration may extend 
 widely beyond the glands, especially where there is much loose 
 areolar tissue, as in the axilla. Fever, malaise, and all the 
 general phenomena associated with an acute inflammation, are 
 usually well marked. 
 
 The Treatment consists, in the first place, in the removal of all 
 sources of irritation, both physical and physiological. The part 
 must be kept at rest and protected from injury, and the offending 
 wound or causative lesion dealt with by such antiseptic measures 
 as may be needed to hasten its restoration to a healthy state. 
 Fomentations are applied over 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 should be let out by an 
 incision, and the wound dressed antiseptically. Linseed-meal 
 poultices, whilst useful in encouraging the formation of pus, are 
 most undesirable after the abscess has been opened (vide Treat- 
 ment of Acute Abscess, p. 48). 
 
 Special Forms of Acute Lymphadenitis. 
 
 The 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 supra-condyloid, just above the internal condyle. Boils in the axilla and 
 excoriations or septic wounds of the breast may also cause an axillary abscess. 
 In this region a suppurative periadenitis is often superadded, extending widely 
 under and between the pectoral muscles, reaching even up to the clavicle. 
 Care must be taken in opening such an abscess to avoid the main vessels by 
 cutting from above downwards, midway 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 : (1) 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 saphenous vein, and receiving 
 lymph from all the superficial parts of the limb, except perhaps those from 
 which the blood is returned by the external saphenous vein, the popliteal 
 glands receiving the lymph from this region ; and (3) the deep vertical set, 
 receiving the deep lymphatics of the limb. Abscess in the groin is opened by 
 
DISEASES OF THE LYMPHATICS 319 
 
 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 (otorrhcea or 
 eczema), throat, or lips. As to the exact distribution of the lymphatics we 
 must refer students to anatomical text-books. 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 varieties of chronic inflamma- 
 tion of lymphatic glands are met with, viz., the simple, syphilitic, 
 and tuberculous. 
 
 1. Chronic Simple Lymphadenitis is a condition resulting from 
 some peripheral irritation, which is insufficient to cause an acute 
 attack. It also occasionally results from blows and strains, as in 
 over-walking, being in such cases possibly due to obstruction to 
 the lymphatic flow, owing to compression or rupture of the efferent 
 vessels. The glands become enlarged, tender, and painful, but 
 as a rule they do not become 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 Treat- 
 ment consists in keeping the part at rest, removing if possible all 
 sources of local irritation, combined perhaps with the local appli- 
 cation of iodine paint, or friction with iodide of potassium or iodide 
 of mercury ointment. The general health should also be attended 
 to, especially in children predisposed to the development of tuber- 
 culous disease. 
 
 2. Chronic Syphilitic Lymphadenitis. — The lymphatic glands 
 are involved in several ways in the course of syphilitic disease : 
 (a) The primary lesion is associated with the development of an 
 indolent bubo in the nearest lymphatic glands, which become 
 hard, somewhat like almonds or bullets beneath the skin. But 
 little pain is noticed unless suppuration is taking place ; this is 
 never due to the syphilitic virus alone, but to the absorption of 
 some septic matter from the primary lesion. There is usually 
 much more infiltration and enlargement of glands in extra genital 
 chancres than in those occurring about the genital organs, (b) In 
 the second stage, when general infection has occurred, the glands 
 in many parts of the body are affected in the same indolent fashion. 
 (c) In the tertiary period the lymphatic glands may undergo a 
 true gummatous change, or become enlarged and tender owing to 
 the absorption of septic material from a broken-down gumma. 
 For further particulars and Treatment, see p. 125. 
 
 3. Chronic Tuberculous Lymphadenitis occurs most commonly in 
 children or young adults, who have inherited a predisposition to 
 the development of tuberculous disease, and more especially in 
 those whose surroundings are unhealthy, and whose general 
 condition is deteriorated by insufficient or bad food and want of 
 
3 2o A MANUAL OF SURGERY 
 
 fresh air. Some local focus of irritation is usually present in the 
 form of pediculosis capitis, decayed teeth, chronic otorrhaea, 
 adenoids, or eczema of the face. As a result of this, neighbour- 
 ing glands become chronically inflamed, and, as Sir T. Burdon 
 Sanderson says, ' 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 perhaps 
 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, a situation in which tubercle is 
 often unexpectedly found. Any lymphoid tissue in the body may 
 become the seat of tuberculous disease ; but the glands of the 
 neck, especially the submaxillary and the concatenate, are much 
 more commonly involved than any others. The axillary and 
 inguinal glands are also not unfrequently affected, whilst tuber- 
 culous disease of those in the mesentery gives rise to the affection 
 known as 'tabes mesenterica.' 
 
 The course of the case may be described under the following 
 headings, although it must be remembered that the stages do not 
 necessarily follow one another in exact sequence : (i.) The earliest 
 manifestation of the disease consists in a fleshy enlargement of the 
 glands which cannot at first be distinguished, either clinically or 
 pathologically, 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. Microscopic- 
 ally, all that is noticed is a great increase in the lymphoid 
 corpuscles, together with some overgrowth and thickening of the 
 fibrous capsule and trabecular. When tuberculous infection has 
 occurred, the characteristic nodules can be seen under the micro- 
 scope, but there is at first no change in the naked-eye appearances, 
 (ii.) Caseation follows sooner or later, and since the tuberculous 
 nodules are often disseminated widely through the gland, many 
 caseating foci will be found, (iii.) Calcification of the caseous 
 detritus sometimes occurs in those cases which are tending to 
 recovery. Such is accompanied by a fibroid thickening of the 
 gland, resulting from overgrowth of the capsular and trabecular 
 connective tissue. This change is most frequently observed in 
 the mediastinal and mesenteric glands, and is not very uncommon 
 in the neck, (iv.) More frequently suppuration ensues, sometimes 
 from a simple emulsification of the caseating material, sometimes 
 from infection with pyogenic organisms from without. Foci of pus 
 develop at various spots in the glandular parenchyma, and when 
 once formed, these tend to amalgamate and cause the destruction 
 of the rest of the glandular tissue, the fibrous trabecular remaining 
 longest unaffected, so that finally the gland is represented by a 
 single abscess cavity surrounded by a pyogenic membrane of the 
 ordinary tuberculous type, in which traces of the capsule can be 
 observed. Several of these abscesses may merge into one another, 
 
DISEASES OF THE LYMPHATICS 321 
 
 and thus a large multiloculated cavity, containing pus mixed with 
 curdy debris, is formed, (v.) A certain amount of peri-adenitis is 
 almost always present, though not to any great extent in the early 
 stages ; when, however, suppuration has occurred, or if the glands 
 are exposed to pressure or friction, they become adherent not only 
 to neighbouring glands, but also to surrounding structures. In 
 the more chronic cases the fibro-cicatricial tissue thus formed may 
 be so extensive as to firmly fix the mass to the deeper parts, such 
 as the main vessels and nerves, rendering removal by enuclea- 
 tion dangerous and almost impracticable. Important vessels are 
 occasionally eroded by an extension of the suppurative process, 
 and this may lead to fatal haemorrhage, (vi.) Sooner or later the 
 abscess, if left to itself, bursts either at one or several spots, 
 leaving ulcerated openings, through which is seen cedematous 
 granulation tissue mixed with caseating material. The edges are 
 undermined, thin, and purplish, and the granulations sometimes 
 sufficiently prominent to protrude through the openings as 
 fungating masses. A variable amount of pus escapes from these, 
 and the condition may persist for many years if radical treatment 
 is not undertaken, (vii.) Under suitable local and constitutional 
 measures these sores may, and usually do, heal after a time, 
 giving rise to a pulpy spongy cicatrix, which is often puckered and 
 more or less keloidal, and may retain its vascularity for a much 
 longer period than would a healthy scar. Lymphatic oedema in 
 the region drained by the affected glands is sometimes observed 
 as a late consequence of this affection. 
 
 The usual complications met with in the course of all tuberculous 
 diseases may also manifest themselves (p. 144). 
 
 The Treatment of tuberculous glands is palliative or radical. 
 
 Palliative Treatment 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 situation, especially at the seaside, as, for 
 instance, at Margate. All sources of local irritation must be 
 removed so as, if possible, to prevent infection with pyogenic 
 organisms, and counter-irritants, such as iodine paint, are best 
 avoided. Rest of the affected part should be enforced as much as 
 possible ; in some cases the application of splints to restrict move- 
 ment is advisable. 
 
 Radical Treatment. — Wherever practicable, glands evidently 
 tuberculous should be completely removed by dissection, and 
 even amongst the wealthy 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 with 
 surrounding tissues. In the later stages, so far may this process 
 have gone that removal by dissection is hopeless. In such cases 
 a free opening is made down to the diseased tissues, and as large 
 a portion removed as possible, whilst the remaining deeper parts 
 
 21 
 
322 A MANUAL OF SURGERY 
 
 axe scraped with a Volkmann's spoon. The wound can rarely be 
 entirely closed, and must be packed with gauze soaked in an 
 iodoform emulsion (10 per cent), and allowed to heal by granula- 
 tion. In septic cases the same line of treatment must necessarily 
 be adopted. 
 
 In the neck very extensive operations may have to be under- 
 taken for the removal of tuberculous glands. The incision varies 
 with the situation of the mass, but where feasible it is kept well 
 behind the sterno-mastoid. When, however, enlarged glands 
 exist both in front of, behind, and beneath the muscle, it is well 
 to make the incision parallel to the course of the external jugular 
 vein, entirely dividing the sterno-mastoid, which may subsequently 
 be stitched together. Special care must be taken of the chief 
 vessels and nerves, particularly of the internal jugular vein, to 
 which the glands are frequently adherent ; in some cases, however, 
 it is necessary to divide the vein or excise a segment of it, a 
 comparatively unimportant proceeding in children. The situation 
 of the spinal accessory nerve as it crosses the posterior triangle 
 must also be remembered. Naturally, adherent glands may be 
 dealt with very much more freely in the posterior than in the 
 anterior portion of the neck. 
 
 The pYe-auriculnr gland, lying 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 with 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. 
 
 In the groin, tuberculous glands are often mistaken for some 
 condition due to venereal disease. The history of onset and the 
 extreme chronicity should suffice to establish a diagnosis. The 
 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 implication in the cicatrix. 
 
 Tumours of Lymphatic Glands. 
 
 The Primary New Growths occurring in lymphatic glands are 
 lymphadenoma" and lympho-sarcoma. A few instances of appar- 
 ently primary epithelioma have been recorded. Amongst others, 
 Sir James Paget mentions some cases of epithelioma of the inguinal 
 glands, following eczema of the scrotum, caused by soot, tar, or 
 paraffin, in which, on the most careful examination, no primary 
 scrotal growth was discovered ; possibly it had disappeared. 
 
 * The term Lymphoma is sometimes applied to these conditions, but is 
 obviously inaccurate, as etymologically it should mean ' a tumour consisting 
 of lymph.' 
 
DISEASES OF THE LYMPHATICS 
 
 523 
 
 Lymphadenoma is the term given to a new. growth occurring 
 in lymphatic glands, corresponding in structure with normal 
 lymphoid tissue — that is to say, it consists of a stroma, more or 
 less delicate according to the consistency of the mass, in the 
 meshes of which are packed a great number of small round cells 
 resembling leucocytes. 
 
 There has been much discussion as to the nature of this growth, 
 and also as to the relation it bears to leukaemia. Nothing final 
 has as yet been made out, but there seems every probability in 
 favour of the view that it is to be looked on as an infective disease, 
 due to some specific micro-organism, and therefore to be placed 
 midway between tubercle and cancer. Occasionally it develops 
 as a strictly local affection, and can then be readily eradicated ; 
 sometimes it involves a whole series of lymphatic glands, but is 
 limited to one region of the body, both the above types being 
 included below under the term ' benign ' lymphadenoma. On the 
 other hand, it is sometimes disseminated widely throughout the 
 system, affecting not only the external lymphoid tissues, but also 
 the spleen and other internal tissues of a lymphatic nature ; it is 
 then known as Hodgkin's disease, or pseudo-leukaemia. Leuk- 
 aemia (or leucocythaemia) is an affection with special and peculiar 
 blood features, dependent on changes occurring in the spleen, 
 lymphatic glands, or marrow of bones. The spleno-medullary 
 type is the commonest ; lymphatic leukaemia is much rarer, and 
 the glands are even then seldom larger than walnuts. 
 
 Benign or Localized Lymphadenoma is usually met with in young 
 adults, affecting either one gland or a large number. It is most 
 often seen in the neck, and though the patient may be slightly 
 anaemic, he never presents any leukaemic blood changes. 
 
 When a single gland is affected it becomes slowly enlarged, and 
 shows no tendency to caseate or suppurate ; it remains free from 
 adhesions to adjacent structures, and is hence moveable and pain- 
 less. It is quite possible that many glands thought to be of this 
 nature are in reality tuberculous, in the early stages of fleshy 
 enlargement. The Treatment of such is by removal. 
 
 When many glands are affected, the disease may be limited to 
 one region, or several groups may be enlarged in different parts 
 of the body; the neck is a favourite situation, both sides being 
 often involved, and the disease may here be so extensive as to 
 render the wearing of a collar impossible. The special character- 
 istics of this condition are : that many glands are enlarged, that 
 they have no tendency to suppurate, caseate, or ulcerate, and 
 that there is but little peri-adenitis ; hence they are freely move- 
 able one on another and on surrounding tissues, and are neither 
 painful nor tender. 
 
 On removal, the glands vary somewhat in consistency, being 
 sometimes firm and elastic, presenting on section with the knite 
 a pink and fleshy cortical portion, whilst the central part is 
 
324 A MANUAL OF SURGERY 
 
 grayish and somewhat indurated ; but in other cases they are soft 
 and more friable, and on scraping the cut surface with the knife a 
 milky juice is obtained, the cells of which, however, are leucocytes 
 and not epithelial, as in the juice obtained by scraping a can- 
 cerous tumour. This difference in texture depends mainly on 
 the rate of growth, the soft growing rapidly, and the firm slowly. 
 Microscopically, no changes in structure from ordinary lymphoid 
 tissue are observed. Constitutionally, there is usually a good 
 deal of anaemia present, but no leukaemia. 
 
 This affection is sometimes markedly amenable to Treatment, 
 especially to the administration of arsenic. Small doses of liquor 
 arsenicalis combined with iron are at first given, but these are 
 gradually increased, and as the patient comes under the influence 
 of the drug, retrogression of the glands may be observed. If, 
 however, they persist in spite of medicinal treatment, their re- 
 moval should not be delayed. Where many glands are affected, 
 this may involve extensive and repeated operations. 
 
 Hodgkin's Disease (syn. : General Lymphadenosis or Pseudo- 
 leukaemia) is a condition usually met with in adults, and is 
 characterized by an overgrowth of all, or nearly all, the lymphoid 
 tissues in the body, including glands, the spleen, the solitary 
 or agminated follicles of the intestine, etc. Marked blood changes 
 are present, consisting in a great increase in the number of leuco- 
 cytes, whilst the red corpuscles are deficient both in number and 
 in the amount of haemoglobin contained in them. In true 
 leukaemia the proportion of white corpuscles to red is enormous, 
 one to ten of the latter being a common experience ; in pseudo- 
 leukaemia the proportion rarely exceeds one to forty or fifty. The 
 character of the leucocytes and their reaction to staining reagents 
 also varies, so that a microscopical examination of the blood 
 will at once differentiate Hodgkin's disease from lymphatic 
 leukaemia, although the external swellings may be indistinguish- 
 able. 
 
 The tumours thus produced grow slowly, are painless, and, 
 when groups of glands are affected, adhere together, forming 
 lobulated masses, but with no tendency to caseate or suppurate. 
 The skin may become involved in the tumour later on, and super- 
 ficial ulceration follow, but there is no subsequent fungation. 
 
 The prognosis is exceedingly grave, the disease usually pro- 
 gressing in spite of all treatment to a fatal issue from exhaustion. 
 
 Treatment. — Arsenic combined with iron may be administered, 
 and, latterly, injection of an emulsion of bone-marrow has been 
 strongly recommended, but the results gained hitherto have not 
 been at all satisfactory. It is useless attempting to remove the 
 external growths, since they are only an evidence of a deep- 
 seated general affection. 
 
 Lympho-sarcoma. — Lymphatic glands sometimes become the 
 seat of a primary sarcomatous growth, the microscopic characters 
 
DISEASES OF THE LYMPHATICS 
 
 of which have been detailed elsewhere (p. 156). The disease 
 occurs in adults and is met with not uncommonly in the tonsil, 
 sometimes in the glands at the root of the neck, and may occa- 
 sionally originate in the mediastinum or in the testis. When com- 
 mencing in a region where its development can be followed, it is 
 seen to form a rapidly growing tumour, which is at first 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 con- 
 gested and shiny, and contains a network of dilated veins. 
 Finally, it is involved in the growth, and ulcerates, an occurrence 
 usually followed by the sprouting up of a bleeding fungating mass, 
 similar in character to that formed by any other rapidly growing 
 malignant tumour. Dissemination of the growth throughout the 
 viscera follows, death resulting from exhaustion and cachexia. 
 
 The Treatment consists in the removal of the mass, where 
 practicable, without delay. If, however, extensive adhesions 
 exist, this becomes absolutely impossible. 
 
 Secondary Growths in Lymphatic Glands are a special feature 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 XIII. 
 AFfECTIONS OF NERVES. 
 
 Injuries of Nerves. 
 
 The simplest and most common forms of injury to which nerves 
 are liable are Contusions and Strains, causing a sensation of tingling, 
 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 
 sensation may ensue, and in hysterical women more or less 
 neuralgia. In patients suffering from gout, syphilis, or rheuma- 
 tism, a chronic peripheral neuritis is readily induced, often of 
 a somewhat intractable type, and this even occurs in healthy 
 individuals. Treatment consists in gentle friction with stimu- 
 lating liniments. 
 
 Rupture of nerves without an external wound only occurs in 
 connection with severe injuries, such as dislocations or fractures, 
 and even then total division is rare, the sheath retaining its 
 integrity, although the axis cylinders may have given way. Im- 
 mediate paralysis and loss of sensation usually follow, and may 
 persist for a time, although repair not unlrequently occurs, 
 since the sheath remains intact. The doubt always existing as 
 to the condition of the sheath regulates the treatment which must 
 be followed, viz., one of expectancy. 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. 
 
 Compression of a nerve is usually due to the growth of tumours 
 or aneurisms, or to some displacement of bones, as in fractures or 
 dislocations ; or, again, the nerve may be included in the callus 
 formed in the repair of a fracture, e.g., the musculo-spiral, owing 
 to its proximity to the humerus, 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 splint pressure, as when 
 the external popliteal nerve is compressed against the neck of the 
 fibula. Those nerves also which traverse bony canals in the 
 skull are liable to pressure as a result of chronic osteitis and con- 
 
AFFECTIONS OF NERVES 
 
 327 
 
 densation of the surrounding osseous tissues. Patients who have 
 suffered from syphilis are more liable to develop chronic neuritis 
 from slight pressure than other individuals. The early symptoms 
 are those of irritation, e.g., cramp and spasm of muscles, or 
 neuralgic pain: whilst the later ones, due to more prolonged 
 compression, are those of paralysis and anaesthesia, 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, 
 electricity, and the administration of iodide of potassium or 
 nerve tonics. 
 
 Total Division of a Nerve.— The Immediate Effects are: (a) 
 Paralysis of the muscles supplied by the nerves; (b) complete 
 
 Fig. 83. — Traumatic Neuroma of Posterior Tibial Nerve after 
 Amputation of Leg. (From King's College Museum ) 
 
 anaesthesia of the parts supplied by it, which, however, is not 
 necessarily permanent, since sensation may be conveyed by col- 
 lateral trunks, the anaesthetic area passing through gradual stages 
 of partial sensation before recovery is complete, (c) Vasomotor 
 paralysis is also produced, the limb becoming hyperaemic and 
 warmer for a few days, and then subsequently colder and insuffi- 
 ciently 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 complicated than the former. We 
 must discuss them under five headings : 
 
 1. Changes in the Nerve. — Locally, the two ends retract very 
 slightly, perhaps not more than the twelfth of an inch, and the 
 
328 A MANUAL OF SURGERY 
 
 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-cicatrical tissue (traumatic neuroma), within which 
 are found spaces filled with fine nervous fibrillae coiled up in loops 
 and developed from the ' neurilemma cells which, taking on an 
 active neuroblastic function, secrete short lengths of axis cylinders 
 and of medullary sheaths ; and these, linking themselves to- 
 gether into chains, form continuous axis cylinders and medullary 
 sheaths.'* After an amputation, most of the divided nerves are 
 found to have developed these typical bulbous ends (Fig. 83), 
 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 in- 
 dicated by total and rapid restoration of function, but it is quite 
 possible that the phenomena in question were due to a trans- 
 mission of nervous stimuli by collateral nerve trunks. 
 
 Peripherally, an almost immediate invasion of leucocytes occurs 
 as the result of the traumatism, and these are followed and 
 replaced after a few days by proliferated connective-tissue cells. 
 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 kind of segmentation, 
 becoming broken up into irregular masses of myeline, which are 
 absorbed by the connective- tissue cells and disappear entirely in 
 about a month. The axis cylinders also degenerate and disappear, 
 being lost in the myeline masses. The neurilemma cells pro- 
 liferate in columns and form a fibro-cellular mass, which represents 
 the nerve, and has long lost 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 
 necessarily occurs when a motor nerve has been divided, and the 
 muscles involved slowly atrophy 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. As a result of the 
 paralysis and atrophy, deformity may ensue, owing to a disturb- 
 ance of the equilibrium normally maintained between opposing 
 groups of muscles. The electrical changes, too, are exceedingly 
 
 * See Ballance and Purves Stewart, ' The Healing of Nerves ' ; Macmillan 
 and Co., 1901. 
 
AFFECTIONS OF NERVES 329 
 
 important. The faradic current rapidly loses its power over the 
 affected muscles, and its effects totally disappear in two or three 
 weeks, whilst the galvanic excitability 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) . 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 
 stimuli, the case may be looked upon as beyond repair. 
 
 3. Various modifications of Sensation, both special, general, 
 and muscular, may be observed. 
 
 4. The blood supply to a paralyzed part is always diminished, 
 so that it looks blue and congested, owing to the weak circulation; 
 consequently the temperature falls, and the vitality of the part is 
 decreased. This, associated with anaesthesia and the loss of trophic 
 influence of the nerve centres, results in certain conditions which 
 maybe of considerable importance. Thus the skin becomes thin, 
 atrophic, bluish-red, and shiny (' glossy skin' of Weir- Mitchell), 
 or it may be rough and covered with scales, or even cedematous. 
 Chilblains are readily produced, and any exposure to cold or heat 
 may result in vesication 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. 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 
 secretion, or remaining absolutely functionless. Atrophy of the 
 smaller bones may follow, and ankylosis of the terminal joints of 
 the fingers or toes. In a growing child the development of the 
 part is always more or less impaired. The more exaggerated 
 forms of trophic trouble just described only occur in irritative 
 lesions of nerves, e.g., when a foreign body is left in contact with 
 them ; simple section results merely in simple atrophy. 
 
 5. Finally, in a few cases changes have developed in the central 
 nervous system which are of extreme 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. The median nerve was divided in the upper arm, 
 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 ensue if 
 restoration of function is obtained. Attempts at regeneration are 
 
333 
 
 A MANUAL OF SURGERY 
 
 always evident 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 cylinders grow downwards from 
 the central end to the peripheral, or whether they are developed 
 in the distal segment. The researches of Ballance and Purves 
 Stewart certainly suggest that the latter theory is correct. The 
 proliferated neurilemma cells always retain their longitudinal 
 direction, and about 3 or 4 weeks after the operation (a little 
 later, if no operation) thin beaded threads begin to show them- 
 selves along one side of such a spindle-shaped cell, and, gradually 
 growing downwards, stretch out towards their nearest neighbours. 
 The union of these small segments constitutes the new axis 
 cylinder, which is gradually covered in by a medullary sheath, 
 also apparently the product of the neurilemma cells. The process 
 takes some months to reach completion. Clinically, the earliest 
 evidence of regeneration is a slight return of sensation, which may 
 be at first abnormal, and only slowly becomes of a normal type. 
 Motion is generally much later in its restoration than sensation, 
 and may never be entirely recovered. Under very favourable 
 circumstances it is possible for an interval even as great as 
 1 \ inches to be bridged over by this process, but such an event 
 is very unusual. The use of a nerve graft under these conditions 
 may direct the energies of the neuroblastic cells, but the graft is 
 itself quite passive, being invaded by neurilemma cells from above 
 and below. 
 
 The Treatment of a divided nerve depends upon its size and 
 function. If small and of slight importance, no special treatment 
 is required ; but in any of the main nerves of the extremities it is 
 essential to deal with them at once by Primary Nerve Suture. 
 This is best accomplished by using a domestic sewing needle 
 without cutting edges, or a fine Hagedorn needle, and the finest 
 chromicized 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. 
 
 If the wound has been inflicted months before, and a bulb 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 fibrillae ; 
 the divided ends are then brought together with as little tension 
 as possible. To fill up the gap resulting from removal of the 
 bulb, traction upon each end of the nerve should be employed to 
 stretch it, and the limb subsequently put up 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 of the nerve). In 
 
AFFECTIONS OF NERVES 331 
 
 one case we removed an inch or two of the humerus to allow the 
 divided ends of the musculo-spiral nerve to be approximated. In 
 order to diminish the drag on the fine end-to-end sutures, a 
 tension stitch should be passed through the substance of the 
 nerve, about ^ to h an inch from the divided ends. 
 
 Nerve grafting, in order to bridge over a defect, has not up to 
 the present been found of much practical value, although a few 
 cases of success are reported. A nerve similar in size to that to 
 be operated on is removed from an animal just previously killed, 
 and carefully 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. 
 
 During the time that the paralysis continues the limb itself 
 must be well 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 then dipped in the water 
 till it becomes of a bright red colour. 
 
 In many cases where the original wound has been complicated 
 with spreading septic inflammation the impaired mobility is as 
 much due to the inflammatory adhesions of joints and tendons as 
 to paralysis. 
 
 Inflammation of Nerves. 
 
 Acute Neuritis is not a very common condition. It is usually 
 due to injury, gout, or rheumatism, but is occasionally observed in 
 connection with septic wounds. The nerve may sometimes be 
 felt to be swollen or tender, whilst severe pain of a neuralgic 
 type is often complained of by the patient. On microscopic 
 examination the ordinary signs of inflammation are well marked, 
 though mainly evident in the sheath. The Treatment consists of 
 rest to the limb, together with leeching or dry cupping over the 
 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 
 connective tissue of a nerve, both around it and between the 
 fasciculi, 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 syphilis, rheumatism, 
 or gout, and is met with after influenza and in various toxic 
 conditions, e.g., alcoholism, 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. 
 Occasionally it can be felt thickened and tender on pressure, 
 whilst more or less severe neuralgia is also noticed, accompanied 
 perhaps by some loss of power in the muscles supplied by it. 
 
332 A MANUAL OF SURGERY 
 
 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 with suitable liniments. If there is any paresis, 
 the muscles must be stimulated daily by the faradic current or 
 electric bath. Excessive pain is combated by administering 
 hypodermically morphia or atropine. Failing these, other means 
 should be adopted, such as acupuncture, in which needles are 
 passed into the substance of the nerve, and allowed to remain for 
 a few moments ; this probably acts by relieving the tension and 
 inflammatory exudation within the sheath. Various operative 
 measures dealt with under neuralgia may be called for in severe 
 and protracted cases. 
 
 For Tumours of nerves, see p. 167. 
 
 Neuralgia. 
 
 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 a paroxysmal or 
 intermittent pain of a darting or stabbing character, which follows 
 the course of some particular nerve or nerves, especially the 
 trigeminal. In this nerve the attack commences suddenly, and 
 the pain steadily increases, until it reaches a climax, 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 hyperaemic and cedematous (the points douloureux of Valleix). 
 Occasionally adjacent muscles become spasmodically and sym- 
 pathetically contracted during the attack, whilst excessive 
 secretion, such as from the lachrymal or sweat glands, is also 
 induced. Herpes is sometimes met with in the 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 complex 
 bodies, such as the breast, 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. The direct causes may be toxic, e.g., malaria, 
 influenza, lead, or mercury ; reflex, e.g., ovarian disease, worms, 
 
AFFECTIONS OF NERVES 
 
 333 
 
 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. 
 
 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 valerianate 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 called for. Empirical remedies, such 
 as antipyrine, phenacetin, menthol, and croton-chloral hydrate 
 will sometimes do good. 
 
 When, however, medicinal agents fail, surgical measures are 
 indicated in order to allay the patient's sufferings. The following 
 are the more usual methods adopted : 
 
 i. In purely Sensory Nerves, such as the trigeminal, simple 
 division or neurotomy has often been resorted to, but the relief 
 gained is of a most temporary nature, since sensory nerves readily 
 unite after division, and sensation is rapidly restored even when 
 union is incomplete, probably by transmission through collateral 
 branches ; hence the operation has fallen into discredit. A much 
 more satisfactory proceeding is neurectomy, or the removal of a por- 
 tion of the nerve-trunk, after which union of the divided ends is less 
 likely to occur. Many of these cases, however, are due to central 
 disease, and it is an interesting question how the trouble can be 
 benefited by such proceedings ; probably the explanation is that 
 the centre is placed in a condition of rest by the exclusion of 
 afferent stimuli. Acting on this theory, most surgeons nowadays 
 endeavour to remove as large a portion of the affected nerve 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 forcibly extracted by torsion. An outline of 
 the various methods employed on separate nerves is given below. 
 
 Finally, if all such measures have failed, the roots of the nerves 
 may be divided either within the skull or in the spinal canal. 
 
 2. In a Mixed Nerve, conveying motor as well as sensory 
 stimuli, nerue- stretching has to be mainly relied upon. The trunk 
 is laid bare, and traction exercised, both centrally and peripher- 
 ally, by means of a blunt hook if the nerve is small, or of the 
 finger 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 extensibility of the nerves 
 are considerable, and the pressure needed to cause their rupture 
 has been accurately estimated. It varies much in different indi- 
 viduals, and allowance must be made for this in all operations. 
 
334 A MANUAL OF SURGERY 
 
 Thus, the sciatic nerve will stand about as much traction as an 
 ordinary man can make with his finger and thumb ; it should be 
 applied 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 fibrillar, which are 
 naturally wavy, straightened out, thereby compressing the lym- 
 phatic spaces between the fibres, and possibly rupturing the nervi 
 nervorum. The nerve becomes hyperaemic, and the medullary 
 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, leading to sudden irre- 
 mediable blindness ; or it may be compressed by effused blood 
 or inflammatory exudation, either within or outside of its sheath, 
 causing more or less complete loss of vision preceded by optic 
 neuritis (i.e., inflammation of the intraocular termination of the 
 nerve, or papillitis) ; but if the haemorrhage has not been very 
 extensive, vision may be in measure restored. Orbital cellulitis 
 not unfrequently causes pressure on the nerve, either immediately 
 as a result of the inflammation, or subsequently by cicatricial con- 
 traction. Syphilitic disease of the sheath or the formation of a 
 gumma in its neighbourhood, or intraorbital aneurisms or tumours, 
 may likewise induce amblyopia from pressure on the trunk. 
 
 The Third Nerve (motor oculi) being entirely motor, paralytic 
 symptoms are those to be looked for. They may arise from 
 central causes, such as syphilitic or degenerative changes in the 
 floor of the third ventricle ; or from peripheral lesions, such as 
 aneurisms, tumours, 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 eyelid, from 
 loss of power in the levator palpebrae superioris ; (b) external 
 strabismus, or squint, from paralysis of the inner, upper, or lower 
 recti, the eye being also directed a little downwards from paralysis 
 of the inferior oblique ; (c) mydriasis, or dilatation of the pupil, 
 from palsy of the iris ; (d) loss of accommodation, from the ciliary 
 muscle being paralyzed ; and (e) some slight protrusion of the 
 eyeball (exophthalmos), owing to most of its muscles being 
 flaccid and relaxed. 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 
 
AFFECTIONS OF NERVES 
 
 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 
 superior oblique muscle, results in defective movement of the 
 eyeball downwards and outwards. 
 
 The Fifth or Trigeminal Nerve is occasionally torn in head 
 injuries, giving rise to anaesthesia, with perhaps ulceration of the 
 cornea; but such cases are exceedingly rare. Much more common 
 is the disease known as trigeminal neuralgia, or tic douloureux, which 
 is more frequently observed in women than in men. It is to 
 be clearly distinguished from the simpler forms of neuralgia due 
 to some local irritation or general weakness by the paroxysmal 
 character and violence of the pain ; hence the term ' epileptiform 
 tic ' has been applied to it, and not inaptly represents the terrible 
 nature of the affection. As a rule, it commences in the infra- 
 orbital or inferior dental branches, radiating thence to all the other 
 divisions of the nerve. The paroxysms are not very frequent at 
 first, but they rapidly increase both in number and severity, until 
 at last the patient becomes utterly prostrate, and may be so 
 depressed as to contemplate or even attempt suicide. The con- 
 dition is often influenced considerably by the general health, and 
 intermissions of varying length occur. The attacks are accom- 
 panied by twitching of the muscles of the face, and even of the 
 neck ; also by unilateral sweating and hyperaemia of the head, 
 and the development of such marked 'points douloureux,' that 
 possibly the patient cannot brush his hair or wash his face on 
 the affected side, which becomes dirty and is often shiny from 
 trophic changes. Lachrymation is a marked feature during the 
 attacks, and there may be a considerable increase in the salivary 
 secretion, as also in that of nasal mucus. 
 
 As to the Cause of tic douloureux, but little can be said for certain, although 
 many conditions may contribute to its production, viz.: (a) Central causes, such 
 as changes of a sclerosing type in the deep centres of the fifth nerve, or in the 
 Gasserian ganglion ; (b) radical, or those due to compression or disease of the 
 roots of the nerve, reaching from the ganglion to the cranial foramina ; 
 (c) cranial conditions, such as diminution in the size of the foramina of exit of 
 the nerves, which not only vary immensely in different skulls, being generally 
 smaller in women, but also may be encroached upon by callus, inflammatory 
 swellings, or tumours ; (d) peripheral causes, e.g., dental caries, narrowing of the 
 walls of the bony canals, etc. ; (e) toxic agents, e.g., malaria, which especially 
 tends to affect the supra-orbital nerve, constituting the so-called ' brow ague '; 
 and (/) reflex phenomena, e.g., ovarian disease, errors of refraction, etc. 
 
 In the Treatment of tic douloureux, innumerable remedies have been used, 
 with a varying degree of success, e.g., quinine, where there is a malarial history ; 
 iodides and mercury for syphilis ; iron and arsenic for anaemic patients ; and, 
 
336 
 
 A MANUAL OF SURGERY 
 
 failing these, croton-chloral, paraldehyde, etc. All sources of reflex irritation 
 should be removed or treated, such as carious teeth, errors of refraction, intra- 
 nasal trouble, ovaritis, etc. If the pain persists, Operative Measures will, 
 sooner or later, be required. Neurotomy and nerve-stretching may give 
 temporary relief, but most surgeons have been led by experience to the con- 
 clusion that the greatest measure of success follows neurectomy, and that the 
 larger the portion excised, and the nearer that portion is to the central organs, 
 the better the results attained. Hence much more extensive operations are 
 now undertaken than formerly, even extending to the Gasserian ganglion itself. 
 The operations which have been utilized in dealing with this nerve are so 
 
 Fig. 84. — a, Incision for division of supra-orbital nerve ; b, line indicating 
 position of supra-trochlecir nerve, passing from angle of mouth through 
 the inner canthus ; the short cross-line at its upper end is the incision 
 required to expose it; c, position of infra-orbital nerve and incision; 
 d, Carnochan's incision for neurectomy of the second division. 
 
 numerous and often so complicated that we can merely give the briefest 
 description here of those which we usually employ.* All purely subcutaneous 
 or submucous methods are to be condemned for their inaccuracy and in- 
 efficiency, as also on account of the bleeding which is likely to result from the 
 closely contiguous bloodvessels. 
 
 The Supra-orbital Nerve does not very commonly require division or extrac- 
 tion, since neuralgia of this trunk is certainly more amenable to therapeutic 
 
 * Owing to necessary limitations of space we must refer readers for further 
 details to Rose on ' Trigeminal Neuralgia ' (Bailliere, Tindall and Cox, 1892). 
 
AFFECTIONS OF NERVES 337 
 
 measures than other forms. The pain usually recurs about the same time 
 each day, and may be treated by giving a pill containing ferri sulph., 1 grain, 
 quiniae disulph., 2 grains, and morphinse hydrochlor., T \ grain, four hours 
 before the attack is expected, and repeating it every hour till six pills in all 
 have been taken. At the same time attention must be directed to any local 
 cause of irritation. Should the pain persist in spite of treatment, 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, and is reached by an incision following the course of the eyebrow, 
 through which the orbicularis is divided along the line of its fibres (Fig. 84, 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 Supra-trochlcar Nerve has been stretched (somewhat empirically, it is 
 true) for sundry obscure neuralgic affections of the eyeball, and occasionally 
 with considerable success. It emerges from the orbit along a line drawn from 
 the angle of the mouth through the inner canthus (Fig. 84, b). An incision is 
 made at right angles to this course just below the eyebrow, and the nerve, 
 which is found in several filaments, stretched or divided. 
 
 The Infra-orbital Nerve emerges from the foramen of the same name at a spot 
 about h 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. 84, c) ; but since such an operation is unlikely to give more than temporary 
 relief, the root of the second division should be at once attacked if operative 
 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, 
 which traverses the antrum) are objectionable, whilst they are almost certain 
 to leave ugly cicatrices (Fig. 84, d). 
 
 Thz pterygoid method, or, as it called, the Braun-Lossen operation, is without 
 doubt the best for dealing with the root of the second division. Our experience 
 of this proceeding, which is now extensive, has induced us to modify the 
 original plans considerably, and our usual method of procedure is as follows : 
 The incision commences at the external angular process of the frontal bone, 
 follows the upper border of the zygoma, and curves downwards in front of the 
 ear to reach the angle of the lower jaw (Fig. 72, F). The flap thus marked out, 
 consisting only of skin and subcutaneous fat, is dissected forwards, temporarily 
 fixed by a suture to the nose, and protected with gauze. The zygoma is 
 exposed by a horizontal incision through the periosteum, which is cleared 
 from the bone by a suitable raspatory, and drilled front and back so as to 
 carry silver wires in the subsequent suturing up (Fig. 85) ; it is then sawn 
 through and turned down, together with the masseter. The mouth is slightly 
 opened with a gag, and the temporal tendon pulled well backwards from the 
 front of the temporal fossa by retractors, exposing thereby the pterygo- 
 maxillary fissure, although the coronoid process is sometimes so large as to 
 need removal. The internal maxillary vessels are then looked for, and, if 
 possible, secured by ligatures and divided. The root of the second division 
 of the fifth nerve can then be hooked up on an aneurism needle as it emerges 
 from the foramen rotundum, and divided — a proceeding much facilitated by 
 chiselling away a bony prominence which rises from the base of the great wing 
 of the sphenoid, on the posterior aspect of the junction of the two limbs of the 
 pterygo-maxillary fissure. By also dividing the nerve 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, scarcely any scar persisting, and the 
 freedom from pain being usually prolonged and complete. 
 
 The third division of the trigeminal nerve has many branches, but the 
 
 22 
 
338 
 
 A MANUAL OF SURGERY 
 
 lingual and inferior dental are those mainly affected with neuralgia sufficiently 
 severe to call for operative interference. For purely local lesions they can 
 be divided separately in the peripheral portions of their course, but for 
 epileptiform tic it is best to deal with them at the same time close to the 
 foramen ovale. 
 
 The Lingual Nerve can be divided from within the mouth by a simple 
 incision down to the bone, as it crosses the junction of the upper and middle 
 thirds of a line drawn from the crown of the last lower molar toofh to the 
 angle of the jaw ; or it may be sought for more carefully after division of the 
 mucous membrane. Such methods, however, lack precision, and are net only 
 useless, but dangerous, owing to the necessary occurrence of sepsis. 
 
 The Inferior Dental Nerve is sometimes the seat of neuralgia, due to com- 
 pression in its bony canal as a result of dental troubles. It may then suffice 
 
 Fig. 85. — Zygoma and Lower Jaw in situ to show Position of Saw-cuts 
 and Drill-holes in the Braun-Lossen Operation, and in that for 
 Removal of the Gasserian Ganglion. 
 
 to trephine the inferior maxilla, making the necessary incision along its lower 
 border, and remove half its thickness, so as to expose the nerve in its canal. 
 
 Section of the third division of the fifth nerve at the foramen ovale is best accom- 
 plished in the following manner : A flap of skin and subcutaneous tissue is 
 reflected forwards from the parotid region, extending from the zygoma above 
 to the angle of the jaw below (Fig. 72, F), exposing thus the parotid gland 
 with the socia parotidis and the masseter muscle, covered by fascia If the 
 incision is kept strictly to the subcutaneous tissues, the facial nerve is in 
 no way endangered. The masseter is then divided transversely immediately 
 below the socia parotidis, and the vertical ramus of the inferior maxilla cleared 
 of muscle and periosteum to a sufficient extent to allow the application of a 
 j-inch trephine just below the sigmoid notch, the remaining bridge of bone 
 being subsequently removed by cutting pliers; enough bone is left in front and 
 behind to preserve the continuity of the jaw with the articuiar and coronoid 
 
AFFECTIONS OF NERVES 339 
 
 processes. The fibres of the external pterygoid muscle can now be seen cross- 
 ing the upper part of the wound horizontally, and over it the internal maxillary 
 artery sometimes courses, giving rise to considerable haemorrhage if it is 
 wounded. The lingual and dental nerves are usually found close together, 
 emerging from under the outer pterygoid muscle, and lying between the 
 internal pterygoid and the bone. The peripheral portions should be twisted 
 or pulled up, and divided below as far down as possible, whilst by drawing 
 the external pterygoid outwards with retractors, the foramen ovale can be 
 seen, if electric illumination is employed, and the nerve trunks divided at the 
 point of exit. The wound usually heals well, and leaves but little scar, 
 although some impairment in the mobility of the jaw may result, partly from 
 the cicatrization following disturbance of the muscles and tissues, but mainly 
 from paralytic atrophy of the muscles supplied by the divided nerve. 
 
 In cases where such measures have been adopted and have failed, or where 
 the pain is referred to the whole nerve, removal of the Gasserian ganglion has 
 been successfully performed, but should never be undertaken until the extra- 
 cranial proceedings have been very thoroughly carried out. The operations 
 are so elaborate and recondite that we can only give a bare outline of 
 them here. 
 
 Rose's operation approaches the ganglion through the pterygoid region, taking 
 the third division as its guide. An incision (Fig. 72, F) similar to that for 
 exposing the foramen ovale is made through the skin, and the flap thus marked 
 out is drawn forwards and stitched out of the way. The zygoma is drilled, 
 divided (Fig. 85), and turned down together with the masseter ; the coronoid 
 process is then divided or removed, and together with the temporal muscle 
 turned upwards ; the internal maxillary artery is, if possible, secured, and the 
 sphenoidal attachment of the external pterygoid scraped away so as to allow 
 of the exposure of the foramen ovale, which lies just behind the base of the 
 pterygoid processes. A ^-inch trephine is now applied immediately outside 
 the foramen ovale, and the bone around the opening thus made is also 
 removed by forceps or chisel so as to give more space. The trunk of the third 
 division is traced upwards, the sheath of the ganglion opened, the second 
 division cut through by means of a sharp cutting-hook, and the ganglion torn 
 away piecemeal, or, at any rate, broken up. There is likely to be a good deal 
 of bleeding, especially in the earlier stages of this operation, chiefly derived 
 from veins ; it can, however, be usually restrained by packing the wound for 
 a few moments with sponges wrung out of very hot lotion. Efficient electric 
 illumination is absolutely essential, since the wound is a very deep one. 
 
 A modification of and improvement upon this plan has been introduced by 
 Doyen.* The earlier steps are alike, though the incision differs somewhat. 
 The zygoma with the masseter is turned down, and the coronoid process divided 
 and together with the bulk of the temporal muscle removed. The great wing 
 of the sphenoid is cleared and a trephine applied just above the pterygoid 
 ridge. The dura mater is then detached and the bone nibbled away with a 
 rongeur from all round the opening, and downwards so as finally to reach the 
 foramen ovale. The temporo-sphenoidal lobe of the brain is held up under a 
 retractor so that the second and third divisions of the nerve can be recognised, 
 divided peripherally and cleared. The dural sheath of the ganglion (cavum 
 Meckelii) is then opened, and the greater portion of it can be removed ; the 
 innermost portion is so adherent to the cavernous sinus that it is better not to 
 attempt its removal. The zygoma is wired back into place, and the wound 
 can then be closed. 
 
 The Hartley-Krause operation was devised independently by the two surgeons 
 whose names are associated with it. An ft-shaped flap is marked out in the 
 temporal region, the base situated just above the zygoma. Through this the 
 subjacent bone is divided by chisel or electric saw, and the whole flap of skin, 
 
 * For Doyen's operation, see Practitioner, May, 1902. 
 
 22 — 2 
 
340 A MANUAL OF SURGERY 
 
 muscle, and bone is turned down en bloc, exposing the dura mater, which is 
 gently stripped up from the middle fossa of the skull as far as the cavernous 
 sinus. Profuse haemorrhage is likely to be caused by this proceeding, derived 
 mainly from the middle meningeal trunk or its branches, and must be con- 
 trolled by pressure, or possibly by plugging the foramen spinosum with puri- 
 fied sponge. The second and third divisions of the nerves are readily found 
 beneath the periosteum, and are traced back to the ganglion as it lies on the 
 apex of the petrous bone, and it is then dealt with as in the last operation. 
 
 As far as we can see, the freedom from pain is certainly more prolonged 
 than after any of the operations upon the peripheral portions of the nerve 
 trunks, and may possibly be permanent; certainly some of the cases on which 
 we have operated have remained seven or eight years without recurrence. 
 At the same time we cannot but admit that, with a mortality which amounts 
 to about 10 or 15 per cent., it is very desirable to perform the extracranial 
 operations very thoroughly before resorting to such a serious measure. 
 During the last few years we have been working along these lines, taking 
 the greatest precautions to excise very extensive portions of the nerves, and 
 have been much gratified with the results. 
 
 The Sixth Nerve may be torn or compressed, either in its intra- 
 cranial course 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) Intra-cranial lesions. — If simply cortical, as from pressure, 
 haemorrhage, degeneration, etc., a limited portion of the opposite 
 side of the face is usually involved. If sub-cortical, or in the 
 corona radiata, or corpus striatum, as from haemorrhage, or 
 softening due to carotid thrombosis or embolus, the paralysis 
 appears on the opposite side together with hemiplegia, but only 
 the lower half of the face is palsied, the associated movements 
 of the eyelids being left. If the lesion is situated in the pons, 
 the deep facial centres may be implicated, 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 wot 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, involving the petrous portion of the temporal bone, the 
 paralysis supervening either immediately after the injury from 
 laceration, a rare phenomenon, or some weeks later from implica- 
 tion in the callus, the usual cause ; or (ii.) as a complication of 
 chronic otorrhcea, and then 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 com- 
 
AFFECTIONS OF NERVES 
 
 341 
 
 munication 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) Extra-cranial lesions from injury, inflammation from exposure 
 to cold, or the pressure of a tumour, e.g., malignant disease of the 
 parotid. This variety has been called ' Bell's palsy,' and is 
 usually characterized by the whole side of the face being affected, 
 but without implication of the palate or uvula. 
 
 The general Signs of facial paralysis (Fig. 86) are as follows : 
 The side of the face is immobile and expressionless, all the natural 
 
 ■r" 
 
 -Facial Paralysis. (From Photographs.) 
 
 On the left side the face is in a position of rest ; on the right side 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 asymmetry of the 
 face becomes more manifest. 
 
 folds and wrinkles being lost ; the eye cannot be completely closed, 
 and on attempting to do so the eyeball is usually seen to roll 
 upwards and outwards ; ulceration, and even perforation, of the 
 cornea may result from this exposure. From the drooping and 
 relaxation of the lower eyelid, the apposition of the punctum 
 lachrymale to the conjunctiva is imperfect, and thus tears escape 
 over the face (epiphora), a condition aggravated by the loss of the 
 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. 
 
34 2 A MANUAL OF SURGERY 
 
 The iips 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 necessarily depends upon its 
 cause. In the majority of cases medical treatment (including the 
 administration of perchloride of mercury and iodide of potassium) 
 will suffice, together with massage and electricity ; in others, 
 surgical measures with a view to remove some obvious cause of 
 pressure may be necessary. 
 
 Facial Tic (or histrionic spasm) consists of a clonic contraction 
 of the facial muscles, due to some lesion of the centre in the pons 
 or cortex. 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 admin- 
 istration of nerve tonics or anti-spasmodics, and, failing that, 
 stretching, or even in severe cases division, of the facial nerve has 
 been employed, but is most unsatisfactory. 
 
 Operation. — The nerve is exposed immediately below the ear, its position 
 being indicated by a horizontal line drawn 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 belly 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 will 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 temporarily paralyze it, but the ultimate results have been by 
 no means encouraging, only one case out of twenty collected by Godlee being 
 successful. 
 
 The Auditory Nerve may be injured in fractures of the base of 
 the skull, either one or both sides being involved. Incurable 
 deafness usually results, often associated with facial palsy. 
 
 It is a little doubtful what effect would be produced by injury 
 of the Glosso -pharyngeal Nerve, but in one case in which it was 
 supposed to be compressed the patient suffered from difficulty in 
 swallowing and speaking, together with persistent ulceration of 
 the tongue ; death resulted from oedema of the glottis. 
 
 A severe injury to the Pneumogastric Nerve may prove rapidly 
 fatal, but less serious lesions result in palpitation, vomiting, and 
 a sense of suffocation ; such phenomena sometimes manifest 
 themselves after head injuries, especially fractures involving the 
 posterior fossa, and indicate 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 tuber- 
 culous glands. Irritation causes vomiting and temporary inhibition 
 
AFFECTIONS OF NERVES 343 
 
 of the heart's action ; one-sided division sometimes does compara- 
 tively little harm, but if both nerves are divided, death results from 
 laryngeal paralysis or from such complications as cedema or 
 congestion of the lungs. When the vagus is injured in the lower 
 part of the neck or compressed by an aneurism, or if the recurrent 
 laryngeal nerve is divided or compressed, hoarseness or partial 
 aphonia is produced, from paralysis either of all the muscles on 
 one side of the larynx, or in slighter cases only of the abductor 
 (crico-arytenoideus posticus). 
 
 The Spinal Accessory Nerve may be irritated, either at its exit 
 from the skull by a fracture running through the jugular foramen, 
 or in its peripheral course by inflamed lymphatic glands, etc. 
 Clonic spasm of the sterno-mastoid and trapezius is usually 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. — The nerve runs downwards and backwards at right angles to 
 the centre of a line passing from the angle of the jaw to the apex of the 
 mastoid process ; it enters the deep aspect of the sterno-mastoid about 
 3 inches below that spot. 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, and then below the transverse process of the atlas, 
 which can be readily felt. The operation has not given good results, since, 
 even if the twitching of the head and neck ceases, the spasmodic phenomena 
 often recur elsewhere. 
 
 The Hypoglossal Nerve may be accidentally divided in an 
 operation, or compressed by an aneurism of the external carotid, 
 or by a new growth. Unilateral paralysis or weakness of the 
 tongue results, the organ, when protruded, being directed towards 
 the paralyzed side. 
 
 The Spinal Nerves. 
 
 The nerves constituting the Cervical Plexus are exposed to 
 injury either from blows, dislocations of the cervical spine, pene- 
 trating 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 be injured from exactly similar causes, 
 paralysis or spasm of the muscles of the arm arising from 
 division or irritation of the motor branches, whilst hyperesthesia 
 or anaesthesia may follow from damage to the sensory trunks. 
 Thus a blow on the back of the neck opposite the fifth or sixth 
 vertebrae caused paralysis of the serratus magnus and rhomboids 
 (winged scapula) ; an old unreduced unilateral dislocation of the 
 seventh cervical vertebra produced intense neuralgia along the 
 
344 
 
 A MANUAL OF SURGERY 
 
 course of the ulnar nerve, and many similar instances might be 
 mentioned. 
 
 One special form of injury may be alluded to in which the roots 
 of the fifth and to a less extent of the sixth cervical nerves are 
 wrenched or torn as a result of a fall on the shoulder, which is 
 pressed downwards, whilst the head is forced over to the opposite 
 side, a type of accident which is liable to follow a spill from a high 
 dog-cart. The result is paralysis of Erb's pre-axial group of 
 muscles, including the biceps, deltoid, and supinator longus, arising 
 from the fifth nerve, whilst the extensors of the fingers and wrist 
 are involved when the sixth nerve is also injured. Sensory lesions 
 are usually slight, and recovery, though slow, ensues after a time. 
 
 The Treatment is mainly symptomatic, including the adminis- 
 tration of iodide of potassium and the local application of blisters 
 or other counter-irritants and of electricity. In cases where there 
 is severe and intractable neuralgia, not referred to any discoverable 
 lesion, or where clonic spasm of the muscles of the arm and 
 shoulder are met with, stretching of the brachial plexus may be 
 required. 
 
 Operation. — The patient lies on his back, with the head directed to the 
 opposite side, and the arm well drawn down ; a cushion is inserted under the 
 shoulder to steady it. An incision is made above the centre of the clavicle, 
 3 or 4 inches in length, parallel to the anterior border of the trapezius. The 
 platysma and deep fascia are divided, and the deep cellular tissue opened up 
 by retracting the margins of the wound. The posterior belly of the omo- 
 hyoid is thus exposed, and the posterior border of the scalenus anticus 
 defined. The cords of the plexus are found emerging between the latter 
 muscle and the medius ; they are carefully isolated by division of the sheath 
 covering them, and pulled upon by the finger or an aneurism needle passed 
 under tnero. Special care must be taken of the lowest cord of the plexus, 
 which passes behind the subclavian artery. The nerves are stretched both 
 centripetally and centrifugally. Excellent results have followed this opera- 
 tion, although in a few cases the necessary cicatrization which followed led to 
 a recurrence of the symptoms. 
 
 The Circumflex Nerve is liable to injury from its exposed posi- 
 tion, 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 some- 
 times torn or compressed in fractures of the surgical neck of the 
 humerus, or in dislocation of the shoulder, 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 posterior fold of the axilla, but this does not 
 last long. No operative treatment has been adopted, although we 
 see no reason why it should not be attempted in suitable cases. 
 
 The Musculo-Spiral Nerve is not unfrequently damaged in 
 fractures and dislocations of the upper extremity of the humerus, 
 
AFFECTIONS OF NERVES 345 
 
 but is especially exposed to injury in the musculo-spiral groove 
 where it lies close to the bone. It is implicated with or without 
 other nerves in crutch palsy (p. 433), or by lying asleep in bed 
 with the arm under the body, as so frequently occurs in drunken 
 people (commonly called ' Saturday-night paralysis '). 
 
 The Symptoms arising from its total division are as follows : 
 
 A. Anaesthesia over the front and back of the outer side of the 
 
 elbow and fore-arm (external cutaneous branches), 
 over the radial side of the dorsal aspect of the wrist 
 and hand, and over the back of the thumb, index, 
 middle, and half of the ring fingers, to a variable 
 extent (Fig. 88, B, ra). 
 
 B. Paralysis of the following groups of muscles : 
 
 (i.) Of the extensor of the forearm (triceps) ; hence the 
 
 forearm can only be extended by its own weight, 
 (ii.) Of the long and short supinators ; hence the hand is 
 pronated, the only supinator remaining being the biceps. 
 
 Fig. 87. — Wrist-drop from Paralysis of the Musculo-Sfiral Nerve. 
 
 (TlLLMANNS.) 
 
 (iii.) Of the radial and ulnar extensors of the wrist ; hence 
 wrist-drop (Fig. 87), a condition also present in certain 
 lesions of toxic or central origin, e.g., lead palsy, and 
 progressive muscular atrophy. 
 
 (iv.) Of the extensors of the fingers and thumb, which either 
 hang limp 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 
 supported and extended, the termin.il phalanges can 
 be straightened by the action of the interossei and 
 lumbricales. 
 Treatment consists in massage and electricity applied to the 
 muscles, but in some cases an operation is necessary. 
 
 Operation. — The 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 intersection the fore- 
 arm is semiflexed and pronated, and an incision made extending from the 
 centre of the crease of the elbow upwards and outwards along a line made by 
 
346 
 
 A MANUAL OF SURGERY 
 
 prolonging upwards the radial border of the forearm, which in 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. 
 Where there has been considerable loss of substance of the nerve, so that the 
 ends cannot be approximated, an inch or two may be excised from the shaft 
 of the humerus with advantage, the bone being subsequently wired, and the 
 nerve sutured. We have performed this operation with a successful result. 
 
 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. 
 
 Fig. 88. — Distribution of Sensory Nerves of Hand from Froni and 
 
 Back. (Tillmanns.) 
 
 vie, Median nerve ; u, ulnar ; ra, radial. 
 
 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 thrusting the hand and arm through a window. Paralysis 
 necessarily results in these cases with the following symptoms : 
 
 If divided just above the wrist : 
 
 A. Anaesthesia over the palmar aspect of the radial side of the 
 
 hand, over the front of the thumb, index, middle, and 
 half the ring fingers, and over varying portions of the 
 dorsum of the same (Fig. 88, A, B). 
 
 B. (i.) Paralysis of the outer group of the short muscles of the 
 
 thumb (i.e., abductor, opponens, and outer half of the 
 
AFFECTIONS OF NERVES 347 
 
 flexor brevis pollicis), so that the thenar eminence 
 wastes, and the movement of ' opposition ' is impaired, 
 the thumb remaining extended by the side of the 
 fingers (Duchenne's ' ape-hand '). 
 (ii.) Paralysis of the outer two lumbrical muscles, causing 
 loss of power of flexion at the metacarpo-phalangeal 
 joints of the index and middle fingers. 
 The great impairment of mobility in the hand and fingers so 
 often seen in these cases depends not so much on paralysis of 
 muscles as on the fact that in the majority of cases the synovial 
 sheaths of the wrist are also laid open, and involved in septic 
 inflammation, which leads to the formation of diffuse adhesions. 
 Hence the prognosis is often unsatisfactory, even when the nerve 
 has been skilfully sutured at a secondary operation. 
 
 // 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 radialis, causing defective 
 wrist flexion on the radial side, and impaired radial 
 abduction. 
 (iii.) Paralysis of the flexor longus pollicis, of the flexor 
 sublimis, 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- 
 exrension of the wrist. 
 (iv.) Paralysis of the palmaris longus. 
 
 Operations. — When the nerve has been divided, primary or secondary nerve 
 suture should always be undertaken. In the latter case incisions are made 
 through the old scars, which may be removed with advantage, the ends of the 
 nerve clearly defined, and the bulb removed. Suture is often very difficult 
 from lack of material, and to assist in the apposition of the segments the hand 
 is flexed to a right angle, and also the elbow, and maintained in that position 
 by a poroplastic or plaster of Paris splint. 
 
 In order to stretch the nerve, it may be exposed in the arm by an incision 
 similar to that for ligature of the brachial artery, or at the wrist by an incision 
 placed to the ulnar side of the flexor carpi radialis tendon, between that 
 structure and the palmaris longus or flexor sublimis tendons. 
 
 The Ulnar Nerve is exposed to injury at the wrist, as also in 
 the hollow between the olecranon and the inner condyle of the 
 humerus, and paralysis may be caused by wounds, fractures, 
 blows, implication in callus, etc. The symptoms are very charac- 
 teristic. 
 
 If divided at the elbow : 
 
 A. Anaesthesia of the ulnar side of the front of the wrist and 
 palm (palmar cutaneous branch), over the back of the hand, and 
 of the little and half the ring fingers, back and front (Fig. 88, 
 A, B). 
 
 B. (i.) Paralysis of the flexor carpi ulnaris, causing weakness 
 
 in flexion and in ulnar adduction of the wrist. 
 
348 
 
 A MANUAL OF SURGERY 
 
 (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 
 interossei ; hence, loss of adduction and abduction of 
 the fingers, with flexion of the two last phalanges in 
 each finger and hyper-extension at the metacarpo- 
 phalangeal joint (main-en-griffe or claw-hand, Fig. 89). 
 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 (ad- 
 ductor transversus, adduc- 
 tor 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, whilst the 
 paralysis merely affects the short 
 palmar muscles. Additional impair- 
 ment 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. 
 
 Fig. 89. — Claw-hand (Main- 
 en - Griffe) from Ulnar 
 Paralysis. (After Byrom 
 Bramwell.) 
 
 To expose the nerve for the purpose of 
 stretching for neuralgia, or suturing, the 
 following methods may be adopted : (a) In 
 the upper arm an incision is made similar to that for tying the brachial artery, 
 but half an inch behind it. (b) At the elbow, cut down just behind the internal 
 condyle, and find the nerve behind the internal inter-muscular septum with 
 the inferior profunda artery, (c) Just above the wrist it lies to the radial side 
 of the flexor carpi ulnaris between the tendon and the ulnar vessels ; the skin 
 and deep fascia alone need division. 
 
 The Intercostal Nerves are frequently the seat of severe neuralgia, 
 either 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. Herpes zoster or shingles is a very frequent 
 sequela to such pain, and may be followed by some amount of 
 anaesthesia. 
 
 Sciatica, or neuralgia of the great sciatic nerve, is a most 
 painful affection, and often exceedingly intractable. It may arise 
 
AFFECTIONS OF NERVES 349 
 
 from the following Causes : (a) Inflammation of the neurilemma 
 (acute or chronic), the result of cold, injury, gout, rheumatism, 
 syphilis, and many toxic agents ; (b) pressure upon the extra- 
 pelvic 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 evident, the pain shooting down the 
 back of the thigh and 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 line 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 often kept slightly flexed, 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. 
 
 The Treatment necessarily varies with the cause. If due to 
 neuritis or perineuritis, general anti-syphilitic or anti-rheumatic 
 measures may be adopted, and blisters or sedative remedies in the 
 more acute cases applied to the back of the thigh. Hypodermic 
 injections of morphia and atropine may also be useful ; but if all 
 the usual anti-neuralgic remedies have been exhausted without 
 benefit, stretching of the nerve may be employed. 
 
 Stretching of the sciatic nerve may be required for : (i.) neuralgia 
 of an intractable type ; (ii.) paralysis or spasm of muscles supplied 
 by it, owing to adhesions contracted between it and surrounding 
 parts, the result of injury, cellulitis, or perineuritis ; (iii.) in 
 paralysis or spasm due to some forms of tabes. The nerve may 
 also be exposed in order to suture it after it has been divided. 
 Nerve-stretching may be accomplished without operation by 
 flexing 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 further measures. 
 
 The nerve is best exposed for stretching at the point where it emerges from 
 under cover of the gluteus maximus, midway between the tuber ischii and the 
 great trochanter. The patient lies in the prone position with the limb slightly 
 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 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 peripherally and proximally. 
 
350 A MANUAL OF SURGERY 
 
 The Anterior Crural Nerve may be paralyzed as a result of 
 injury or pressure, and may be the seat of neuralgia or spasm. 
 Its division causes paralysis of the quadriceps extensor, pectineus, 
 and sartorius, and the most marked effect will be secondary 
 flexion of the knee-joint from the unopposed action of the ham- 
 strings ; anaesthesia extends over the front of the thigh and along 
 the inner side of the leg and foot as far as the ball of the great 
 toe. The nerve may be exposed on the outer side of the femoral 
 vessels, just below Poupart's ligament, by a vertical incision half 
 an inch outside the line of the artery. 
 
 The External Popliteal Nerve may be divided during a sub- 
 cutaneous tenotomy of the biceps, to which it lies immediately 
 internal ; 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 over the dorsum of the foot, together with paralysis 
 of the extensor and peroneal groups of muscles ; and from the 
 contraction of the unbalanced opposing groups, the paralytic 
 form of talipes equino-varus results. The nerve may be ex- 
 posed by making an incision i| 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 anaes- 
 thesia of the back of the calf and sole of the foot, and in paralysis 
 of the calf muscles, flexors of the foot and toes, and of the short 
 muscles of the sole. Paralytic talipes calcaneo-valgus is very 
 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 
 paralysis of the short and long flexors of the foot and of the inter- 
 ossei, with resulting talipes calcaneo-valgus, follow lesions of the 
 posterior tibial. The nerves may be exposed in the same way as 
 the accompanying arteries (p. 296). 
 
 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 are produced ; but, if divided, the pupil is contracted 
 from unbalanced action of the third nerve. It has also been 
 intentionally divided and portions excised in the treatment of 
 Graves' disease, glaucoma, and epilepsy ; but such practice is still 
 onlv in the experimental stage. 
 
CHAPTER XIV. 
 
 SURGICAL DISEASES OF THE SKIN AND OF THE 
 CUTANEOUS APPENDAGES. 
 
 A Boil or Furuncle is a limited form of infective gangrene involving 
 merely a small portion of skin and subcutaneous tissue, usually 
 round a hair follicle. Experimentally, a plentiful crop of boils can 
 be produced by rubbing a culture of staphylococci into the skin, 
 and clinically it is supposed that a similar infection through the 
 hair follicles is the most common cause of this condition. The 
 secondary boils around a primary one are without doubt due to 
 the friction upon the healthy integument of dressings, covered 
 with pus and microbes. 
 
 People with a coarse skin and a tendency to comedones are 
 specially liable to the occurrence of boils. A gangrenous inflam- 
 mation ensues after infection, resulting in the death of the hair 
 follicle, or of the sweat or sebaceous gland involved, 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. Although infection from without is the local 
 exciting cause, there is frequently present some depression of the 
 vital powers, which may lead to crops of boils recurring again 
 and again. 
 
 Signs. — A boil commences as a small red irritable pimple, from 
 which a hair may often be seen to protrude, which 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 subsequently the core or slough comes away. The 
 process is then at an end, and the wound rapidly heals by granu- 
 lation. Occasionally the inflammation extends more deeply into 
 the subcutaneous tissues, constituting a ' carbuncular boil.' The 
 neighbouring lymphatic glands become sympathetically enlarged 
 and painful, but rarely suppurate. A boil sometimes subsides 
 
352 A MANUAL OF SURGERY 
 
 without suppuration, leaving the parts thickened and infiltrated, 
 the condition then being known as a ' blind boil.' 
 
 Treatment. — Locally, many boils may be left to burst naturally, 
 though possibly the process may be checked by surrounding 
 them with a piece of ordinary adhesive plaster, with a hole over 
 the apex of the swelling. Poultices are generally applied, and 
 the boil is incised when mature. The pus should be received 
 on portions 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 applied. Constitutionally, tonics, such 
 as iron and quinine, are usually required, except in plethoric indi- 
 viduals, 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 
 from time to time for weeks or months. 
 
 A Carbuncle is a more extensive infective gangrene of the subcu- 
 taneous 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-infection, 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 even a diameter of six or more inches is reached. As it ex- 
 tends peripherally, 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-grey sloughs and purulent discharge accumulated 
 below. Fresh openings gradually develop, leading to a cribriform 
 condition of the cutis, due probably to the passage of the pus 
 along the lines of least resistance, viz., the perforations of the 
 cutis at the sites of the sebaceous glands and hair follicles. 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, 
 
SURGICAL DISEASES OE THE SKIN 353 
 
 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 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 a painful 
 enlargement of the nearest lymphatic glands. 
 
 There is often considerable constitutional disturbance of an 
 asthenic type, although the temperature is not necessarily much 
 raised. Sometimes the gravest symptoms of blood-poisoning 
 (pyaemia or septicaemia) may supervene. 
 
 Diagnosis. — 1. From Boils. — Pathologically, a boil is an infective 
 gangrene of a small portion of the skin. A carbuncle affects the 
 subcutaneous tissues primarily, and the skin secondarily. Clini- 
 cally, boils are multiple, conical in shape, more localized, and 
 when suppuration has occurred the process is terminated by the 
 discharge of the pus and slough through a single opening. 
 Carbuncles, on the other hand, are usually single, much larger, 
 flatter, and the sloughing process may continue peripherally, 
 whilst the central part is discharging its sloughs through several 
 openings. 2. From Gummata. — Cutaneous gummata are frequently 
 multiple, occurring in patients with a distinct syphilitic history. 
 They are not very painful, and do not as a rule attain any 
 great size. They usually ulcerate early, leaving circular sores, 
 or if multiple and confluent, sores with serpiginous outlines ; 
 there is generally but little definite sloughing. The deeper 
 gummata are also less painful, have but one opening, and leave 
 excavated sores, in the bases of which are yellowish sloughs like 
 wet wash-leather. The discharge is not distinctly purulent, but 
 more like bloodstained gum, unless the sore becomes septic. 
 
 The Prognosis of a carbuncle mainly depends upon the condition 
 of the internal organs. If the patient is a confirmed sufferer from 
 diabetes or albuminuria, there is always considerable risk of his 
 sinking from exhaustion. The vascularity of the parts also influ- 
 ences the result, as although there is more reparative power about 
 a vascular region like the face, yet the implication of large veins 
 may lead to embolic pyaemia. 
 
 Treatment must always be of a tonic, supporting character. 
 Good food, iron, quinine, and alcohol according to judgment, 
 must be administered, whilst appropriate medicine (e.g., codeia or 
 opium) and limitation of diet are necessary in diabetic patients. 
 Locally, many different forms of treatment have been suggested. 
 The most thorough and satisfactory is to lay the carbuncle freely 
 open under an anaesthetic, and scrape with a sharp spoon or cut 
 away all sloughs until healthy tissue is reached, and then to 
 thoroughly disinfect the cavity with pure carbolic acid or peroxide 
 of hydrogen (10 volumes). The hollow thus formed is stuffed 
 with antiseptic dressings, such as gauze soaked in an iodoform 
 
 2 3 
 
354 A MANUAL OF SURGERY 
 
 emulsion (10 per cent.), and the case will then probably do well. 
 Another less radical proceeding is to make a free crucial incision, 
 and allow the sloughs to separate naturally, assisting matters by 
 antiseptic poultices. 
 
 In the early stages, it has been proposed to inject the surround- 
 ing tissues with pure carbolic acid in the hope of destroying the 
 organisms, and thus preventing suppuration. In a certain number 
 of cases this object will be successfully accomplished, but where 
 the organisms are at all virulent, it will probably fail. 
 
 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 under- 
 lying papillae, constituting a cup-shaped hollow, whilst the 
 surrounding papillae are hypertrophied. It is the presence of 
 this central plug that constitutes 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 sufficiently 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 de- 
 scribed, viz., the hard and the soft. 
 
 The hard corn usually occurs on the little 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. Treatment consists in 
 paring the corn down, after softening with hot water or treating 
 with salicylic acid plaster (10 or 20 per cent.), or painting with a 
 solution of salicylic acid in collodion.* A circular ring of felt 
 plaster may subsequently be worn, but attention must be directed 
 to the boots, and the cause of the trouble removed. Occasionally, 
 where the toe is deformed, it is necessary to perform amputation. 
 
 A soft corn occurs between the toes, and owing to the absorp- 
 tion 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 care- 
 fully cleansed night and morning, and spirits of camphor painted 
 
 * The following is a useful formula : 
 
 ]£. Acidi salicylici, gr. xv. 
 Ext. cannabis ind., gr. viii. 
 Sp. vini rect., tilxv. 
 jEtheris, ttixl. 
 Collodion flexile, nilxxv. 
 M. Ft. pigm. 
 Sig. : ' To be painted on with a brush three times a day for 
 a week.' — R. Crocker. 
 
SURGICAL DISEASES OF THE SKIN 355 
 
 on at night, whilst cotton-wool is worn between the toes during 
 the day. 
 
 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., anesthesia 
 of the soles, 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: (1) In certain central nervous diseases, e.g., 
 tabes dorsalis, syringomyelia, spina bifida, 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 down- 
 wards. Thus, a short time back one of us amputated a foot 
 which was painful and deformed as the result of a healed per- 
 forating ulcer which had involved bones and joints, and was due 
 to a severe lesion of the lower lumbar region, involving the 
 cauda equina, received thirty years previously. (4) Perforating 
 ulcer is occasionally due to pure plantar lesions, apart from any 
 nervous influence, e.g., a suppurating wart or corn, 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 uncommonly 
 several such sores may be seen on the same foot. A corn or 
 callosity first forms, and under this a bursa, in which suppuration 
 takes place, the pus tending to travel not only to the surface, but 
 also deeply, so as to involve bones and joints. A typical per- 
 forating ulcer presents the appearance of a sinus passing down 
 to the deeper parts of the foot, the orifice of which is surrounded 
 by heaped-up and thickened cuticle. There is usually but little 
 discharge and often no pain. If allowed to progress without 
 treatment, the bones and joints of the foot may be extensively 
 destroyed, or may be welded together into a solid painful mass, 
 in either case necessitating amputation ; but if taken in hand 
 early, a cure can in some cases be established by carefully paring 
 away the thickened mass of cuticle, purifying the sinus, and pro- 
 tecting the parts from pressure. 
 
 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 
 
356 A MANUAL OF SURGERY 
 
 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. 
 Verruca Necrogenica (see p. 206). 
 
 Tuberculous Affections of the Skin. — Lupus. — Although the term 
 1 lupus ' is usually and correctly applied to a tuberculous affection 
 of the skin, yet it is also sometimes employed to indicate any 
 chronic inflammation of the skin which tends to spread, and 
 results in replacement of the cutaneous structures by fibro- 
 cicatricial tissue with or without ulceration. In this place we 
 shall deal with the ordinary Lupus Vulgaris, which is universally 
 acknowledged at the present day to be 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, 
 usually 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 in such 
 cases the disease usually spreads to it from the skin. It is rarely 
 symmetrical, except when commencing on the nose. 
 
 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 hyperemia 
 and infiltration. These nodules are not particularly hard to the 
 touch, but when of any size can be demonstrated to be of a 
 brownish-yellow tint, especially if they are compressed by a 
 glass slide, appearing then somewhat of the colour 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 
 epithelium, and owing either to degeneration of the tuberculous 
 nodules, or to a lack of vitality, arising from compression of 
 the vessels by the contraction of this new formation, ulceration is 
 very liable to follow. In the extremities the lupoid growth not 
 unfrequently takes on a warty aspect, somewhat similar to the 
 ' anatomical wart ' occasionally seen- on the knuckles of post- 
 mortem porters, (p. 206). 
 
 A Lupoid Ulcer usually spreads at one margin as it heals at 
 the other, and hence under typical circumstances is more or less 
 crescentic in shape, although this is frequently interfered with 
 by various causes. The surface is covered with granulations, 
 often of a protuberant nature. The edges are raised and infil- 
 trated, and scattered lupoid tubercles are readily distinguishable, 
 extending into the healthy tissues, which are usually red and con- 
 gested. A considerable amount of sero-pus is often secreted, and 
 this by drying forms thick scabs. Any cicatrix which results from 
 
SURGICAL DISEASES OF THE SKIN 
 
 357 
 
 natural processes of cure is thin and vascular, easily breaking 
 down from any slight irritation. The process extends gradually, 
 with or without intermissions, from the seat of its first appearance, 
 being, as a rule, distinctly limited to the cutaneous tissues ; but 
 when it attacks the nose, the cartilages are often involved and 
 destroyed, whilst if it extends to the palate or septum nasi, 
 perforation is very likely to ensue. The disease is practically 
 painless, and does not at first affect the general health. Neigh- 
 bouring lymphatic glands may become inflamed, and in some few 
 instances are the seat of a tuberculous deposit. Even if left to 
 itself, it tends sooner or later to come to an end, the ulcerated 
 parts cicatrizing, but leaving indelible traces of its ravages in the 
 shape of obvious scars, with often considerable loss of substance. 
 
 ;■ • r, 
 
 Fig. 90. — Spreading Margin of a Patch of Lupus. (Ziegler.) 
 
 a, Normal epidermis ; b, normal corium with sweat gland (/) ; c, focus oi 
 lupoid tissue ; A, vascular nodule surrounded by diffuse cellular infiltra- 
 tion ; e, non-vascular nodule ; /, strings of cells in course of lymphatics ; 
 g, lupoid ulcer; h, proliferating epithelium. 
 
 Occasionally 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. 
 
 Pathological Anatomy. — The characteristic microscopical feature 
 of lupus lies in the formation of nodules around the smaller vessels 
 of the skin, consisting chiefly of a mass of round cells, within 
 which may perhaps be observed a giant cell and epithelioid cells, 
 arranged in the same way as in tubercle. The structures around 
 are infiltrated and hyperaemic, and as the disease progresses, the 
 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 (Fig. go). 
 
358 A MANUAL OF SURGERY 
 
 The Diagnosis of lupus from syphilitic and other destructive 
 affections of the skin turns on the presence of outlying nodules 
 beyond the spreading edge of the lesion, together with the apple- 
 jelly-like granulations, and the thin, congested character of any 
 cicatricial tissue present, whilst the slow, though continuous, 
 progress, and the tendency to heal at one part as it spreads at 
 another, are also suggestive of its presence. The age and con- 
 stitution of the individual, and the persistence of the disease in 
 spite of treatment, must also be taken into account. 
 
 The Treatment of lupus is often a matter of considerable 
 difficulty. Theoretically, it consists in the free removal of all 
 the diseased tissue, either by the knife, sharp spoon, or caustics. 
 Wherever possible, excision of the whole mass should be per- 
 formed, the wound being either closed by sutures, or allowed to 
 heal by granulation, or covered by skin-grafts. The last is the 
 best plan to adopt, if practicable, when dealing with the face. 
 More commonly one has to depend on scraping and the use of 
 caustics. This must be undertaken with a free hand if the whole 
 disease is to be eradicated, since the growth extends beneath the 
 layer of fibro-cicatricial tissue exposed by the spoon. Hence 
 scraping should always be accompanied by the subsequent appli- 
 cation of caustics, e.g., solid nitrate of silver, a paste composed 
 of chloride of zinc, pyrogallic acid (5 to 10 per cent.), or even 
 the actual cautery. The wound thus produced should be dressed 
 with an ointment containing iodoform, and allowed to heal by 
 granulation. Outlying nodules may be removed with a sharp 
 lupus-spoon, and the little cavity formed in this way covered with 
 chloride of zinc paste; or they may be dug out with the sharpened 
 end of a match dipped in acid nitrate of mercury. 
 
 Recently excellent results have been obtained by exposing lupus 
 patients to concentrated electric- or sun-light from which the 
 heat rays have been eliminated by being passed through a glass 
 chamber full of cold running water (Finsen light cure). The rays 
 are passed through what is practically a telescope focussed on the 
 patient's skin. Each sitting lasts for an hour or more, and the 
 constant attention of an assistant is required to slightly shift the 
 lens so as to bring all parts of an area about the size of a shilling 
 under treatment. Inflammatory phenomena supervene, and the 
 lupoid tissue disappears. The process, though satisfactory, is very 
 slow, owing to the limited surface that can be exposed to the light 
 at any sitting. 
 
 Lupus Erythematosus is a disease the nature of which is not yet 
 satisfactorily determined. The appearance of the affection is 
 tolerably 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, correspoding in appearance to a 
 butterfly with outspread wings. There is a considerable tendency 
 for it to evade the forehead, ears, and scalp, and it occasionally 
 
SURGICAL DISEASES OF THE SKIN 359 
 
 appears on the trunk, and may then be unilateral. It appears 
 as a smooth hyperaemic surface, covered with a branny desquama- 
 tion ; 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 cicatrical 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 ex- 
 ceedingly slow, and ulceration uncommon, except when the ears 
 
 «/ 
 
 M 
 
 LlViitif / 1 mmwzmm 
 
 91. — Tuberculous Ulceration of Large Intestine. 
 (Ziegler.) 
 
 a, Mucosa ; b, submucosa ; c, inner transverse muscular coat ; d, outer longi- 
 tudinal muscular coat ; e, serosa ; /, tuberculous focus in solitary gland ; 
 g, mucosa infiltrated with cells ; h, tuberculous ulcer ; h u focus of soften- 
 ing or tuberculous abscess ; i, early tubercle, with giant cell in centre ; 
 i v caseous tubercle. 
 
 or scalp are involved ; 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 light-cure acts rapidly, but must be used with caution, since 
 the inflammatory disturbance caused by it is considerable. 
 
 The so-called Tuberculous Ulcers differ from the lupoid in the 
 fact that they always result from the breaking down of a sub- 
 cutaneous focus, and hence may be connected with diseases of 
 bones, joints, lymphatic glands, or simply of the connective 
 tissues. A similar condition is found in connection with mucous 
 
360 A MANUAL OF SURGERY 
 
 membranes, the tuberculous foci starting in the submucosa, and 
 subsequently bursting through the mucous membrane (Fig. 91). 
 Whatever their location, the ulcers are characterized by the same 
 features, viz., an irregular and ragged margin with undermined 
 and congested edges ; the base is formed by pulpy granulation 
 tissue containing caseous masses of tubercle (z' x ). 
 
 The Treatment necessarily consists in the removal both of the 
 unhealthy and undermined skin, and of the tuberculous granula- 
 tion tissue beneath it, the wound being purified by some strong 
 antiseptic, and then dressed with gauze covered with iodoform. 
 
 Other cutaneous manifestations of tubercle are recognized, but 
 need scarcely be mentioned here. 
 
 Affections of the Nails. 
 
 Onychia is almost always due to the infection with pyogenic or 
 other organisms of the matrix, starting at the side or base of the 
 nail under the semilunar fold. Two varieties are described : 
 
 1. Onychia Purulenta (Peri-onychia, or Ungual Whitlow) is an 
 affection of the matrix commonly seen in surgeons and nurses, in 
 which suppuration occurs beneath the nail, which is thereby 
 loosened ; the individual attacked is generally out of health. The 
 condition usually starts on one side, and gradually extends round 
 the semilunar fold and beneath the nail, until the whole matrix 
 may be affected. When the loosened nail is cut away, it is found 
 that the diseased portion of the matrix is converted into granula- 
 tion tissue. The process is extremely painful and somewhat 
 tedious. The only hope of checking its progress lies in removing 
 with fine scissors, possibly under an anaesthetic, all the loosened 
 portion of the nail, and then touching the exposed granulations 
 with nitrate of silver, whilst the most comforting applications are 
 without doubt linseed-meal poultices, possibly made with hot 
 carbolic lotion (1 in 40), and frequently repeated. At the same 
 time the general health must be attended to. 
 
 2. Onychia Maligna is the term applied to a somewhat similar 
 condition met with in badly nourished children, w ho are perhaps 
 syphilitic. The whole matrix is transformed into granulation 
 tissue, whilst the digit becomes swollen and club-shaped. Treat- 
 ment consists in avulsion of the nail from its bed, and the applica- 
 tion of antiseptic fomentations or poultices, together with iodoform. 
 
 Ingrowing Toenail is an ulcerative condition of the soft parts 
 curling 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. The 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 cuts away the projecting angle of the 
 nail, but leaves a deep corner which still further irritates the soft 
 
SURGICAL DISEASES OF THE SKIN 361 
 
 parts. Ulceration ensues, accompanied 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. When ulceration is 
 actually present, the best plan to adopt is the removal of the 
 affected half of the nail under local or general anaesthesia, giving 
 special attention to the extraction of the projecting angle. If 
 there is much discharge, it is also wise to cut away the over- 
 hanging fold of skin with scissors, and scrape away any granula- 
 tions 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 condi- 
 tion of the nails, which become distorted and bent, or twisted up, 
 perhaps 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. 
 
 Affections 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 sebaceous 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 contained within is of a cheesy, 
 pultaceous consistency, with a peculiar stale odour, yellowish- 
 white in colour, and under the microscope is seen to be composed 
 of fatty and granular debris, epithelial cells, and cholesterine. 
 Sometimes a distinctly adenomatous element is present, so that 
 the cyst walls are thick and firm. Left to themselves, the cysts 
 may attain considerable dimensions, whilst the walls and contents 
 sometimes become calcified. Occasionally the exudation oozes 
 through the duct, and dries on the surface, with just sufficient 
 cohesion to prevent it from falling off; layer after layer of this 
 desiccated material is deposited from below, finally giving rise to 
 what is known as a Sebaceous Horn. These become dark in 
 colour from admixture with dirt, and are always more or less 
 
362 A MANUAL OF SURGERY 
 
 fibiillated in texture ; the base to which they are firmly adherent is 
 infiltrated and hyperaemic. Sebaceous cysts sometimes inflame 
 and suppurate. When the skin has given way over them, the 
 contents are only partly discharged, and the remainder undergoes 
 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 Tumour. True malig- 
 nant 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 fatty tumour it is recognised by 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 
 existence of 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 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 below rather than from above. Horns and fungating 
 ulcers should be excised with the surrounding skin. 
 
 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 umbilicated. The depression in the centre may be 
 occupied by dry debris, and from the larger ones a waxy mass 
 may 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. The cause 
 of the contagion is by no means certain, whilst the exact nature 
 of the affection is also more or less in dispute, since, although 
 some authorities consider it sebaceous in origin, others are equally 
 insistent that it commences in the hair follicles or deep layers of 
 the rete. Pathologically, the tumours consist of numerous wedge- 
 shaped lobules of polygonal, nucleated, epithelial cells, supported 
 by a fibrous stroma. The cells towards the centre undergo a 
 waxy or hyaline degeneration, and in them are seen numerous 
 rounded bodies, which have been supposed to resemble psoro- 
 sperms. Treatment consists in cutting or pulling them away, or 
 in cutting them across, and squeezing the contents out from the 
 well-defined capsule. 
 
CHAPTER XV. 
 
 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 contraction gives rise to pain ; passive movement, however, 
 is tolerated, if the injured fibres are not thereby put on the stretch. 
 Fomentations and rest may be needed for a few days ; but friction, 
 with stimulating embrocations and liniments, and regular massage 
 of the parts, 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 friction 
 with liniments and passive movements 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 biceps cubiti or rectus femoris. The 
 belly of the muscle, when contracted, protrudes through the open- 
 ing 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 
 fascia to heal. In old-standing cases it is justifiable to cut down 
 and expose the opening in the muscular sheath, the edges of which 
 are sutured together. 
 
 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 popu- 
 larly known as a ' rick.' In superficial parts the displaced tendon 
 can sometimes be distinctly felt in an abnormal position, and this 
 becomes more evident on attempting to move it. Thus the long 
 
364 A MANUAL OF SURGERY 
 
 tendon of the biceps may be dislocated from the bicipital groove ; 
 and various tendons about the wrist or ankle, especially that 
 of the peroneus longus, may similarly suffer. If left alone, the 
 parts settle down more or less comfortably, but some permanent 
 weakness may persist ; whilst 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 
 immobilized and well supported, as by a plaster of Paris splint or 
 strapping, and this should be maintained for six or eight weeks. 
 If the displacement recurs, as is commonly the case where such 
 treatment has not been adopted, it is sometimes advisable to cut 
 down, expose the tendon, and stitch it back into position, using 
 early passive movement to prevent the formation of troublesome 
 adhesions. This is required most frequently in the case ot 
 the peroneus longus tendon, which slips forwards from its groove 
 behind the external malleolus. The external annular ligament is 
 thereby ruptured, 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. 
 
 Eupture of Muscles and Tendons is by no means an uncommon 
 accident, resulting from any 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 experiences 
 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 bruising, which is more 
 evident if the muscular fibres have been torn across than if the 
 tendon has alone 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 already described (p. 209), 
 viz., a cellulo-plastic effusion is first poured out, taking the place 
 of the blood-clot, which is absorbed ; this becomes vascularized 
 into granulation tissue, and finally cicatricial tissue is developed. 
 Where a muscular belly is involved and the ends are much 
 separated, a lon<^ and weak bond of union is likely to form ; but 
 when they are closely apposed, the cicatrix is a short one, and may 
 
AFFECTIONS OF MUSCLES, TENDONS, AND BURS& 365 
 
 sooner or later be replaced by true muscular tissue. When a 
 tendon has been divided or torn, the connecting medium is at 
 first attached to the sheath, and if this adhesion persists, it may 
 lead to much pain and weakness. It is an exceedingly interest- 
 ing fact to note how rapidly this tissue attains a considerable 
 degree of strength ; 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 fully so as to 
 prevent separation of the divided ends, and to maintain them in 
 this position for two or three weeks. Any resulting stiffness is 
 combated by passive movements and mas- 
 sage, whilst, if need be, adhesions are 
 broken down under an anaesthetic. Tendons 
 accidentally divided in open wounds should 
 be sutured together by catgut, special anti- 
 septic precautions being adopted to prevent 
 suppuration along the tendon sheaths. 
 Where there has been actual loss of sub- 
 stance in a tendon, it is possible to remedy 
 the defect by grafting a portion of tendon 
 from another patient, or from an animal, 
 between the two ends ; or, again, one end 
 may be split longitudinally in such a way as 
 to leave a thin flap attached peripherally, so 
 that the free end (a) can be turned down and 
 united to the other segment (Fig. 92). Care 
 must be exercised to prevent opposing mus- 
 cles from dragging on and stretching the new 
 bond of union, as thereby considerable func- 
 tional 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 Avere 
 stretched, and hence the most vigorous contractions had no effect 
 in raising the toes, which dragged along the ground. A second 
 operation to shorten all these structures was required. 
 
 When muscular bellies have been divided, it is not difficult to 
 secure them, if the fibres have been severed longitudinally or 
 obliquely ; but when the section is transverse, there is a great 
 tendency for the stitches to cut out. 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 
 
 Fig. 92.. — Method of 
 Uniting Tendon 
 after Loss of 
 Tissue by Turning 
 Down a Portion of 
 it as a Flap. 
 
3 66 A MANUAL OF SURGERY 
 
 resembling a lipoma, No special treatment is needed beyond 
 keeping the forearm flexed for a time. If the tendo A chillis 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 passed round the knee above. A better 
 result, however, would follow an aseptic incision and suture. 
 Similarly, if the ligamentum patella gives way, suture through an 
 open wound is more satisfactory than mere elevation of the leg 
 and rest. The inner head of the gastrocnemius is sometimes torn in 
 wrenches or slips, as at lawn tennis, and the plantaris is similarly 
 affected. Cooling lotions are applied for a few days, and the parts 
 are kept at rest until the tenderness and swelling have subsided 
 in part, and then regular massage is undertaken. 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 application of a firm spica bandage. 
 
 Diseases of Muscles. 
 
 Inflammation of Muscles (Myositis) may arise from a variety of 
 circumstances, but the chief results are alike, whatever the cause, 
 viz., a more or less painful infiltration of the muscle, with in- 
 creased discomfort on attempting movement. The part feels 
 hard and rigid, and may be tender to the touch. If suppura- 
 tion 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 replaced by fibrous tissue (M. fibrosa), and this fibrosis may 
 extend beyond the limits of the original lesion. The induration 
 of the sterno-mastoid muscle met with in children is of this type, 
 and may lead to torticollis. In other cases ossification of a limited 
 portion of the muscle or tendon may occur from long-continued 
 and frequently-repeated irritation ; thus, in riders the upper 
 portion of the adductor tendons may in this way become bony, 
 constituting the so-called ' riders' bone.' 
 
 2. Rheumatic Myositis usually results from exposure to cold, 
 e.g., wry neck from sitting in a draught. It is treated by fomenta- 
 tions, and ordinary saline anti-rheumatic remedies, whilst later 
 on friction with stimulating embrocations is needed. 
 
 3. Acute Suppurative Myositis is the outcome of infection with 
 pyogenic organisms, either from without, as after operation 
 wounds, punctures, gun-shot injuries, gangrene, etc., the pus in 
 such cases spreading widely up and down the muscular planes ; 
 
AFFECTIONS OF MUSCLES, TENDONS, AND BURSA? 367 
 
 or from within the body, as in pyaemia ; or by extension from 
 neighbouring suppurative foci, as from sub-periosteal abscesses ; 
 it may also arise after a contusion or sprain by auto-infection. 
 Great cicatricial deformity is likely 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 syphilitic 
 history, the slow growth, the hardness with subsequent central 
 softening, and the rapid disappearance after the administration 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 
 longitudinally, which are painless and apparently attached to 
 the fascial sheath. They react readily to iodide of potassium. 
 
 6. Parasitic Myositis, arising from the presence of either 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 recently under observa- 
 tion the arms were immobilized by ossification of the Latissimus 
 dorsi muscles on either side, whilst the Pectoralis major was also 
 ossified on the right side. The Erector spinas was involved, the 
 back being thus rendered rigid, and the right Trapezius was 
 undergoing the same change. This disease is not unusually asso- 
 ciated with a congenital deformity of the great toes in which the 
 proximal phalanx is absent or stunted. No treatment has proved 
 of any value. 
 
 Tumours of Muscles are not very common. Primary growths 
 consist of angioma, fibroma, chondroma, myxoma, or sarcoma, 
 and of these the majority start in the fibrous sheaths or the inter- 
 fibrillar connective tissue. Secondary deposits of both carcinoma 
 and sarcoma occur, but there is nothing special to be noted about 
 them. 
 
 Treatment must be determined on ordinary surgical principles. 
 If sarcomatous, the whole thickness of the muscle should, if 
 possible, be excised for some distance from the growth, the sheath 
 forming a natural limit not early overstepped. Amputation of 
 the limb may, however, be required. 
 
3 68 A MANUAL OF SURGERY 
 
 Diseases of Sheaths of Tendons. 
 
 The synovial membranes which line the sheaths of tendons 
 may become inflamed as a result of injury or infection. 
 
 1. Acute Simple Teno Synovitis often follows sprains and 
 stiains, and is most commonly seen in connection with the 
 extensor muscles of the thumb. A puffy swelling 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. All that is needed for its Treatment is to immobilize 
 the limb for a few days, and apply fomentations. As soon as the 
 more acute symptoms have disappeared, friction with stimulating 
 embrocations and pressure are employed to hasten the absorption 
 of the fluid : whilst active and passive movements are undertaken 
 to prevent the formation of adhesions. 
 
 2. Acute Suppurative Teno-Synovitis may result from a punc- 
 tured wound of the synovial sheath, or the inflammation may 
 spread to it from neighbouring tissues. The thecal variety of 
 whitlow (p. 208) is of this nature. Suppuration may extend both 
 up and down the sheath, and gives rise to both local and con- 
 stitutional symptoms. Unless promptly treated by incision, the 
 tendon will slough, or may contract extensive adhesions to 
 neighbouring parts ; in either case considerable impairment of 
 function follows. The suppuration may extend to 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 egg. It may be 
 limited in extent, constituting one of the varieties of ganglion, or 
 diffuse. An elastic fluctuating swelling forms in the course of a 
 tendon, usually associated with creaking. There is no pain or 
 tenderness, but the affected part feels weak. Treatment consists 
 in counter-irritation and pressure, as by Scott's dressing ; failing 
 this, the part may be freely incised, the synovia removed, and, if 
 need be, the cavity washed out. In the more localized 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 fe lined by cedematous granulation tissue of 
 some thickness, containing tuberculous foci, giving rise to a soft 
 elastic swelling along the course of a tendon, which increases 
 slowly in size, and is but slightly painful or tender. Suppura- 
 tion may follow, and subjacent bones or joints be involved. 
 Treatment consists in immobilizing the part, pressure, and im- 
 provement of the general health. If a cure is not quickly 
 
AFFECTIONS OF MUSCLES, TENDONS, AND BURSJE 369 
 
 established, a free incision should be made and the diseased 
 tissue removed. 
 
 The other form of tuberculous disease consists in a passive 
 effusion into the synovial space, the lining membrane of which 
 becomes thickened by the deposit thereon of fibrinous material. 
 At the same time there is usually a large development ot the so- 
 called melon-seed bodies, which are laminated masses of fibrin, 
 perhaps containing traces of tuberculous giant-cell systems. When 
 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 spores or bacilli contained 
 therein are not, however, in a very active state. 
 
 If Treatment by immobilization and pressure (as by the appli- 
 cation of Scott's dressing) fails, the part should be laid open, 
 and the effused fibrin and melon-seed bodies removed, together 
 with as much of the thickened membrane as possible. 
 
 A Ganglion is the term given to a localized cyst-like swelling 
 forming in connection with a tendon sheath. It is most commonly 
 met with at the back of the wrist, arising from the tendons of the 
 thumb or index-finger, but it sometimes occurs on the front of the 
 wrist or in the foot. It varies in size considerably, and contains 
 a clear, transparent gelatinous or colloid substance, like white- 
 currant jelly. A rounded firm elastic swelling is produced, usually 
 somewhat moveable, and 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 membrane through an opening 
 in the tendon sheath. Others seem to originate in a colloid de- 
 generation 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 deeply and lying over a bone, 
 they have been mistaken for exostoses. 
 
 Treatment. — 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 cavity, and the subsequent 
 application of firm pressure. In some cases it may be advisable 
 to lay the part open and remove the cyst wall ; such treatment 
 requires absolute asepsis, since, if infection occurs, most serious 
 consequences may 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 with synovia, usually 
 containing many melon-seed bodies. It forms a large swelling 
 extending above and below the wrist, fluctuation being readily 
 transmitted from one part to the other beneath the annular 
 
 24 
 
370 
 
 A MANUAL OF SURGERY 
 
 ligament; it also extends amongst the muscles of the thenar 
 eminence along the tendon of the flexor longus pollicis. In the 
 treatment rest and pressure, as by Scott's dressing, together with 
 suitable constitutional remedies, may first be tried ; and failing 
 this, an incision should be made both above and below the 
 annular ligament, the cavity being well washed out, and all 
 melon-seed bodies and fibrinous debris removed with a sharp 
 spoon ; a drainage-tube is subsequently inserted. In a few cases 
 it may be necessary to divide the annular ligament in order to 
 efficiently deal with the trouble. The results, however, 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 the 
 surgeon to reduce some displacement, as in setting a fracture ; 
 thus, the tendo Achillis may require division in fractures of the 
 leg in order to overcome muscular contraction. 
 
 Division of tendons is accomplished in two ways, viz., by sub- 
 cutaneous or open incision. The subcutaneous method is made 
 use of where there is little likelihood of injuring important 
 structures. The strictest attention to asepsis is desirable, since 
 the character of the wound, viz., a puncture, and the entire 
 absence of drainage, are most favourable to the development of 
 organisms, if entrance is once given to them. Moreover, the 
 synovial tendon sheath is often, though undesignedly, wounded, 
 and septic inflammation would rapidly spread along this structure, 
 and give rise to the most 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 track thus made, either superficial to or 
 beneath the tendon. The cutting edge is turned towards it, and 
 the tendon divided by a sawing or rocking movement, whilst the 
 structure is put on the stretch by an assistant. Every effort must 
 be made to avoid opening the sheath, since even if the wound 
 remains aseptic, the tendon often retracts more than is desirable, 
 and in healing gains adhesions to the sheath which considerably 
 limit the subsequent freedom of movement of the part. Various 
 opinions are entertained as to whether it is better to pass the 
 knife above or below the tendon ; the advantages of the former 
 method are that there is no likelihood of making an unduly large 
 wound in the skin, and that 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 be 1 ow the tendon, and 
 any such subjacent structures are by mistake included, their 
 
AFFECTIONS OF MUSCLES, TENDONS, AND BURS.E 371 
 
 division is a matter of certainty. Where, however, there is any 
 risk of dividing important structures, such as the external popliteal 
 nerve in tenotomy of the biceps cruris, it is wiser to adopt the 
 open method. In this an incision about 1 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 
 haemorrhage worth mentioning, and the wound is closed by a 
 point or two of suture, dressed antiseptically, and firmly bandaged 
 to prevent extravasation. The malposition is at once corrected, 
 and the part immobilized at the time, or in the course of forty- 
 eight hours, in plaster of Paris. 
 
 Tenotomy of the Tendo A chillis. — The foot is placed on its outer 
 side, and the tendon relaxed by pointing the toes downwards. 
 The tenotome is introduced about 1 inch above its insertion 
 (Fig. 76, F) at the inner margin of the tendon, either superficial 
 to or beneath it, and it is readily divided when the foot is dorsi- 
 flexed. If the surgeon cuts towards the skin, he must be careful 
 not to divide the last few fibres too rapidly, otherwise a con- 
 siderable external wound may be inflicted by the suddenly 
 liberated knife. 
 
 The Tibialis Anticus is usually divided about 1 inch above its 
 insertion, as it crosses the scaphoid (Fig. 78, 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 then replaced by 
 a blunt-ended instrument, and the section is readily accomplished 
 when the foot is abducted. The open method may be adopted in 
 some cases. 
 
 The Tibialis Posticus is usually divided together with the flexor 
 longus digitorum just above the base of the inner malleolus, at a 
 spot about a finger's breadth from the tip of that process in an 
 infant, and about 1^ inches from it in an adult (Fig. 76, E). A 
 small tubercle can usually be felt at this spot, and the section 
 must be made just above. The knife is inserted between the 
 tibia and the tendon, and is kept as near the bone as possible. If 
 correctly placed, it remains fixed without the support of the hand, 
 being grasped between the tendon and the bone. The blunt- 
 ended tenotome is then introduced, 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 if 
 the tendons are too suddenly severed, but even should this occur, 
 a little 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. 77, D). The tenotome is inserted close to the fibula, 
 between the tendons and the bone. 
 
 24 — 2 
 
372 
 
 A MANUAL OF SURGERY 
 
 The Biceps Cruris tendon is best divided by an open operation, 
 on account of the close propinquity 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 insertion into the fibula. It is then lifted upon an 
 aneurism needle and divided ; muscular fibres will probably be 
 found quite close to its lower end. 
 
 The Semimembranosus and the Semitendinosus 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 Stemo -mastoid, see p. 380). 
 
 2. Lengthening a Tendon is sometimes, though rarely, required, 
 
 ft 
 
 n 
 
 Fig. 93. Fig. 94. Fig. 95. 
 
 Figs. 93, 94 and 95. — Z-Operation for Lengthening or Shortening 
 of Tendons. 
 
 In Fig. 93 the method of dividing the tendon is shown. In Fig. 94 the flaps 
 are slipped downwards, one on the other, so as to lengthen the tendon. 
 In Fig. 95 equal portions have been cut away from each half, and the 
 remainders sutured, so as to shorten it. 
 
 in order to overcome the deformity which results from a con- 
 tracted tendon. It may be possible to utilize the method sug- 
 gested on p. 365 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 end. Perhaps a more efficient method is the 
 so-called Z-operation (Fig. 93). The tendon is split longi- 
 tudinally into two halves (be), which are separated one from the 
 other by cross cuts made on opposite sides, one at each end (ab 
 and cd). The two flaps are then drawn apart for a distance 
 corresponding to the increase in length required, and sutured 
 
AFFECTIONS OF MUSCLES, TENDONS, AND BURSM 373 
 
 together ; the resulting bond of union will be as represented in 
 Fig. 94. 
 
 3. Shortening a Tendon is undertaken in some forms of paralytic 
 talipes. 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. 95). This 
 operation will probably give a more solid bond of union than the 
 simpler proceedings in which either a transverse or an oblique 
 section is removed, and the ends sutured together ; in such the 
 sutures are much more likely to cut out. 
 
 4. Tenoplasty, or the incorporation of a strong tendon into a 
 weaker one in order to strengthen it, is rarely undertaken except 
 in talipes, and more particularly in order to reinforce a weak 
 tendo Achillis in paralytic talipes calcaneus, by joining to it a 
 strong and healthy peroneus longus. In order to make an 
 effective bond of union, the healthy tendon must be threaded 
 through the weak and atrophic one, and fixed by sutures in 
 several places. 
 
 Diseases of Bursae. 
 
 Bursae exist as normal structures in many parts of the body 
 exposed 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 consist 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. Examples 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 ; over the internal condyles of 
 the femora, in bad cases of genu valgum ; whilst the false joint 
 or pseudarthrosis which occurs in unreduced dislocations or 
 ununited fractures is practically of this nature. 
 
 Wounds of bursae may be caused by penetrating injuries, or 
 sometimes 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 prevents healing, and then it will be necessary either 
 to excise the bursa, or to open it freely so that it can be stuffed 
 and made to granulate from the bottom. 
 
 The following are the morbid conditions which arise in ad- 
 ventitious as well as normal bursae : 
 
374 A MANUAL OF SURGERY 
 
 i. Acute Simple Bursitis may result from a non-penetrating 
 injury, or from prolonged irritation, especially in gouty or rheu- 
 matic individuals. The part becomes swollen, painful, and tender, 
 and if superficial the skin over it may be hypersemic. Effusion 
 into the cavity quickly occurs, the fluid being spontaneously 
 coagulable in the early stages, and, if resulting from traumatism, 
 mixed with blood. Lymph is deposited on the serous surface, 
 and in many cases results in the formation of adhesions, and 
 possibly obliteration of the cavity. Treatment consists in keeping 
 the part at rest, and applying fomentations, whilst suitable con- 
 stitutional remedies are administered. 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 
 subcutaneous injury of a chronically inflamed bursa, leading to 
 its distension with blood. All the phenomena, local and constitu- 
 tional, usually associated with the formation of a superficial or 
 deep abscess are present. 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 limb, allowing 
 the patella to be distinctly felt through the skin ; the case is then 
 liable to be mistaken for suppuration within the knee-joint, from 
 which, however, it is easily distinguished by the absence of the 
 more acute arthritic symptoms. Implication of subjacent bones 
 and joints sometimes occurs ; thus, the patella or olecranon may 
 become carious, or necrose. The Treatment of suppurative 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 bursas. 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, or if frequent recurrences have been present, the 
 bursal wall is usually reticulated and dense, and adhesions or 
 fibrous cords are often produced. Subacute exacerbations are fre- 
 quently grafted on the more chronic variety. Treatment con- 
 sists in rest and counter-irritation, as by blistering or iodine paint, 
 and if this fails, the bursa should be dissected out. Special care has 
 to be taken in dealing with bursas communicating with joints, such 
 as that under the semimembranosus tendon ; the tumour should 
 not be opened into, if possible, but its neck must be isolated, and its 
 communication with the joint shut off by a catgut or silk ligature. 
 
 4. Chronic Fibroid Bursitis. — -In this variety the walls of the 
 bursa become chronically thickened, as a result of prolonged irrita- 
 
AFFECTIONS OF MUSCLES, TENDONS, AND BURS.E 375 
 
 tion, and also probably from the effect of syphilis. There is but 
 little effusion ; consequently a hard fibroid tumour is met with in 
 the region of the bursa, and in the centre of this is a small cavity. 
 The only Treatment is complete removal. 
 
 5~ Chronic Tuberculous Bursitis occurs either in the form of 
 a fibrinous deposit on the inner wall, together with effusion and 
 the presence of melon-seed bodies ; or the lining membrane 
 undergoes a change analogous to that described as pulpy de- 
 generation of a joint, and perhaps leading to the formation of a 
 chronic abscess. Either condition may be secondary to a tuber- 
 culous arthritis, or may give rise to it, when the bursa com- 
 municates with a joint. If total removal is impracticable, the 
 Treatment consists in laying the part freely open, scraping away 
 all tuberculous tissue, and stuffing the cavity with gauze impreg- 
 nated with iodoform. 
 
 6. Syphilitic Changes may also occur in bursae, in the shape 
 
 Fig. 96 — Enlarged Bursa Patella. (From a Photograph.) 
 
 either of a symmetrical bursitis in the early stages, or later on as 
 a gummatous peri-synovial development. 
 
 Occasionally Gouty Deposits are observed in the walls of bursa, 
 constituting tophi, the irritation of which may predispose to 
 abscess formation, pus mixed with urate of soda crystals being 
 discharged. The bursa over the olecranon is said to be most 
 frequently affected in this way. 
 
 Special Bursse. 
 
 The bursa patella* (Fig. 96), which lies over the lower half of the 
 bone and not over its centre, is very liable to injury and inflam- 
 mation from its exposed situation, and especially in those who 
 
376 A MANUAL OF SURGERY 
 
 kneel much, giving rise to the condition known as ' housemaid's 
 knee.' Any of the above-mentioned varieties of bursitis may be 
 met with, and their signs are so evident that it is unnecessary 
 to again mention them in detail. The relation of the bursa 
 to the patella explains the fact that acute suppuration sometimes 
 gives rise to caries or superficial necrosis of that bone, whilst 
 chronic and subacute inflammations may lead to thickening of 
 the bone from osteoplastic periostitis. 
 
 The bursa beneath the ligamentum patella, between it and the head 
 of the tibia, when distended with fluid, gives rise to a fluctuating 
 swelling felt on either side of the tendon, more especially when 
 the limb is extended ; when the leg is flexed, the swelling 
 diminishes. Chronic enlargement of this bursa may cause the 
 ligamenta alaria to be pushed backwards 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 some- 
 what similar to that caused by a displaced semilunar cartilage, or 
 by a loose foreign body in the joint. The inability to stand with 
 a straight leg, and the presence of the enlarged bursa, are suffi- 
 cient, however, to guide the surgeon to a correct diagnosis. 
 
 The bursa in the popliteal space are often enlarged, especially that 
 between the inner head of the gastrocnemius and the semi- 
 membranosus, leading to a rounded fluctuating 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 bursas. Owing to the proximity of the popliteal vessels, 
 pulsation is occasionally detected ; but it is only heaving, not 
 expansile, in character. The fact that the bursa usually com- 
 municates with the joint necessitates considerable caution in its 
 treatment ; it should be removed by a careful dissection, the 
 communication with the joint being closed by ligature or 
 suture. 
 
 The bursa beneath the insertion of the semitendinosus and gracilis is 
 sometimes inflamed, and is very liable to cause osteoplastic 
 periostitis of the subjacent inner surface of the tibia. 
 
 The bursa beneath the tendo Achillis, if enlarged, presents a 
 fluctuating swelling on either side of that structure, somewhat 
 simulating disease of the ankle-joint, but necessarily limited to 
 the posterior aspect of the joint. The enlargement is usually due 
 to the pressure of badly-fitting boots. 
 
 Distension of the bursa beneath the psoas tendon gives rise to a 
 fluid swelling which usually projects anteriorly, presenting on the 
 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. 
 
AFFECTIONS OF MUSCLES, TENDONS, AND BURSAz 377 
 
 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, obliterat- 
 ing the hollow behind the trochanter, and in its more acute 
 manifestations may be accompanied by abduction and eversion of 
 the limb, in order to relax as far as possible the gluteus. It may 
 thereby somewhat resemble the earlier stages of hip disease, but 
 is known from it by the absence of flexion, and the fact that 
 passive movements, including even the so-called test-movement 
 for hip disease, can be undertaken with but little or no pain. 
 Should suppuration occur, the pus may burrow widely beneath 
 the gluteus. Treatment consists of incision, scraping and disin- 
 fecting the interior, and allowing it to heal from the bottom. 
 
 The bursa over the tuber ischii, if inflamed, gives rise to the con- 
 dition known as ' weavers' 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 ' miners' or students' elbow ' ; suppuration within 
 it is not uncommon, 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 p. 574.) Where treatment by counter-irritation and rest 
 fails, the cavity should be incised and drained. 
 
CHAPTER XVI. 
 
 DEFORMITIES. 
 
 Torticollis. 
 
 Torticollis, or wry-neck, is a deformity produced by a contrac- 
 tion of the sterno-mastoid muscle, the trapezius and deep fascia 
 being also frequently affected, and occasi< ndly the short muscles 
 
 at the back of the 
 neck. It is charac- 
 terized by the affected 
 side of the head being 
 drawn down towards 
 the shoulder, whilst 
 the face is turned 
 towards the sound 
 side, as shown in 
 Fig. 94. When this 
 has lasted for some 
 time, especially in 
 congenital cases and 
 those commencing in 
 childhood, the af- 
 fected side of the 
 head and face be- 
 comes atrophic. The 
 measurement from 
 the external canthus 
 to the angle of the 
 mouth is smaller, the 
 eyebrow is less 
 arched, the nose de- 
 flected, and the cheek 
 less full than on the 
 sound side. No very 
 
 Fig. 97. — Torticollis. 
 The right sterno-mastoid is contracted, and the corre- 
 sponding half of the face atrophic. 
 
 satisfactory explanation of these phenomsna is forthcoming, but 
 they are probably due to imperfect vascular supply. The 
 
DEFORMITIES 
 
 379 
 
 cervical spine becomes laterally curved, with its concavity to the 
 affected side, and a secondary compensatory curve is also present 
 in the dorsal region, so as to maintain the eyes as far as possible 
 on a level. 
 
 The Causes and Varieties of torticollis may be classified as 
 follows : 
 
 i. Congenital torticollis, the result of malformation or malposi- 
 tion in utero, or of some intra-uterine muscular contraction or 
 nervous lesion. 
 
 2. Muscular torticollis, due to intrinsic contraction of the sterno- 
 mastoid, apart from nervous influences, as in cicatricial shortening 
 after intramuscular abscess or gumma. In children it is said to 
 follow the congenital induration of the muscle so often seen, and 
 due to laceration during birth, whilst it is not unfrequently met 
 with as a temporary deformity resulting from cold (rheumatic 
 myositis, or stiff-neck). 
 
 3. Torticollis arising from nervous causes, including spasm and 
 paralysis. Spasmodic torticollis (tonic or clonic) may result (a) 
 from the direct irritation of the nerve trunk or its roots, as by 
 inflamed cervical glands or cervical caries ; (b) possibly from 
 reflex irritation, as by carious teeth, and worms or ovarian 
 mischief; and (c) from irritation of the deep or cortical centres. 
 This latter variety is usually of the clonic type, and often involves 
 the posterior muscles as well as the sterno-mastoid. The 
 character of the movements varies with the actual muscles in- 
 volved. It occurs most frequently, though not exclusively, in 
 women of about thirty years of age, and there is often a family 
 history of nervous diseases, such as epilepsy, etc. The prognosis 
 in these cases is almost always unfavourable, since, even if the 
 localized spasm is cured by appropriate operative treatment, other 
 parts are likely to become affected. Paralytic torticollis arises 
 either from infantile paralysis of one muscle, leading to unbalanced 
 action of that on the other side, or from some peripheral nerve 
 lesion. 
 
 4. Hysteria is also responsible for a certain number of cases. 
 Most commonly the sternal portion is mainly affected, whilst 
 
 the clavicular half may be quite relaxed. In congenital and 
 cicatricial cases the muscle stands out as a hard tense band, an 
 excess of fibrous tissue being present, or the muscular substance 
 almost entirely absent ; but in spasmodic cases the muscle 
 may be well developed and not specially prominent. 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 vertebrae 
 may also be induced, the bodies becoming wedge-shaped and 
 thickest towards the convexity of the curve. 
 
 The Diagnosis of torticollis is readily made. It must not be 
 confounded with cicatricial contraction of the skin of the neck 
 
380 A MANUAL OF SURGERY 
 
 following burns, or the attitude temporarily assumed by a patient 
 with an acute deep-seated abscess of the neck, or with tuberculous 
 caries of the spine associated with lateral deviation. The rigidity 
 of the neck in the latter case, together with the pain caused by 
 movement of or pressure over the vertebrae, should suffice to make 
 the diagnosis clear. Rheumatic inflammation of the deeper liga- 
 ments and muscles of the cervical spine (rheumatic spondylitis) 
 may also be mistaken for torticollis, but it comes on rapidly, and 
 is associated with tenderness on deep pressure. The fact that in 
 tonic cases the muscle is evidently contracted, and stands out as 
 a tense band in the neck, is sufficiently characteristic. Spasmodic 
 torticollis, again, cannot well be mistaken for any other condition, 
 but it may be difficult to distinguish its cause or to localize the 
 affected muscles. 
 
 The Treatment of torticollis necessarily varies with the cause, 
 and thus either anti-phlogistic, anti-neurotic, anti-rheumatic, or 
 anti-syphilitic remedies may be required. When, however, it is 
 due to congenital or tonic contraction of the muscle or its tendon, 
 massage and manipulation may be first tried, or even some form 
 of mechanical apparatus ; but in the majority of cases tenotomy 
 or myotomy will give a more satisfactory result, and is much less 
 tedious and troublesome. 
 
 Two methods of dividing the sterno-mastoid have been em- 
 ployed : (i) The subcutaneous operation is a somewhat undesirable 
 proceeding, on account of the important structures placed 
 immediately beneath it. There is but little danger or difficulty 
 in dealing with the sternal 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. In dealing with the clavicular 
 portion, it has been recommended to introduce a sharp-pointed, 
 and then a blunt-ended, tenotome beneath the muscle, divid- 
 ing it from within outwards, whilst others suggest that a director 
 should first be passed beneath it, and then the muscle divided. 
 (2) The open method is far preferable to any of these plans, as 
 thereby all danger is obviated. The skin is freely incised across 
 the muscle, its anterior and posterior borders defined, and 
 its fibres carefully and fully divided. No attempt should be 
 made to deal with the portion of deep cervical fascia which 
 passes beneath it and securely covers in the important under- 
 lying structures. Any part of the lower half of the muscle 
 may be selected, but the best spot is about ^ inch above the 
 clavicle. The 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, 
 
DEFORMITIES 381 
 
 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 over the 
 right mastoid process above, and below over the front of the left 
 axilla, traction being thus made in the direction of the right or 
 weakened sterno-mastoid muscle. In some cases more efficient 
 support is necessary, and may be obtained by the use of Chance's 
 back splint (p. 387), to which arms are attached at the upper end, 
 bringing pressure to bear upon each side of the head in suitable 
 directions. Where, however, osseous changes are present, the 
 deformity may persist to a great extent, in spite of combined 
 operative and mechanical treatment. 
 
 In cases of clonic torticollis it may be necessary to cut down on, 
 and stretch or excise, the spinal accessory nerve (p. 343). This 
 is not attempted until hygienic and tonic treatment has failed. 
 Where the cause is peripheral, good results may follow ; but 
 when due to central lesions, as is usually the case, we have 
 already stated that failure is not uncommon. In such, division 
 of the posterior cervical nerves, as they lie on the semispinalis 
 colli, will occasionally bring about a cure ; should this fail, it may 
 be justifiable to deal with the cortical centres. 
 
 A Cervical Rib is a deformity of somewhat unusual occurrence. 
 It arises most frequently from the anterior transverse process of 
 the seventh cervical vertebra, but a similar outgrowth sometimes 
 occurs from the sixth. It is mainly composed of cartilage at 
 first, but as age advances it becomes osseous. It passes down 
 behind the nerves to unite with the central portion of the first rib, 
 and occasionally consists of two portions, an upper and a lower, 
 united together by a synchondrosis. No symptoms are produced 
 until the mass by its growth compresses the brachial plexus, or 
 pushes the subclavian vessels forwards, thus leading to trophic 
 and vascular disturbances, as well as to neuralgia and some weak- 
 ness or loss of power in the arm. Nothing should be done to this 
 condition unless pressure symptoms are present, when removal 
 may be required. An incision is made parallel to the anterior 
 border of the lower portion of the trapezius ; the nerves and 
 vessels are separated from the mass of cartilage and drawn aside, 
 and the growth carefully excised with gouge, chisel, or cutting 
 pliers. 
 
 Deformities of the Spine. 
 
 Scoliosis. — By scoliosis is meant a lateral curvature of the 
 spine accompanied by rotation of the vertebrae. Conditions are 
 met with in which the spine becomes deflected laterally as an 
 occasional result of Pott's disease, or in fractures ; such, however, 
 are not generally considered to be genuine scoliosis. 
 
 etiology. — The following are the chief causes of scoliosis : 
 
382 A MANUAL OF SURGERY 
 
 i. It is said to occur very rarely as a congenital deformity, owing 
 to malformation of the vertebrae. 2. It may commence in children 
 at an early period of life as a result of rickets, owing partly to the 
 softened and rarefied condition of the bones, partly to their irregular 
 and uneven growth. It is probably often induced by the method 
 of always carrying children on the same arm in vogue with nurse- 
 maids. A similar change, due to the so-called ' delayed rickets,' 
 may also occur later on in children who are able to run about The 
 primary curve in this type is usually one directed towards the left 
 in the dorsi-lumbar region. 3. Any condition of asymmetry of 
 the body may lead to what is known as statical scoliosis, e.g., con- 
 genital shortness of one leg, unilateral dislocation of the hip, 
 contractions of the knee or hip joints, genu valgum, falling in of 
 the chest wall as a result of empyema, and even old-standing 
 torticollis. If the cause exists in one of the lower extremities, 
 the pelvis is tilted down on the shorter side, producing a lumbar 
 curve with the convexity towards the side of the shortened leg, 
 whilst a compensatory dorsal curve in the opposite direction is 
 subsequently added in order to maintain the general axis of the 
 body. When due to empyema, a primary dorsal curvature is 
 produced, with its convexity towards the sound side. In torti- 
 collis the cervical curve is primary, and a compensatory curve in 
 the opposite direction in the dorsal region usually follows. 4. The 
 most common form of scoliosis, however, is that known as 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 con- 
 dition, often as a result of rapid growth, ccmbined possibly with 
 improper food, defective hygienic surroundings, or exposure to 
 hard work, whereby muscular fatigue is induced. Young women 
 of an anaemic type who suffer from amenorrhcea, and who as 
 housemaids or factory hands have to undertake a good deal of 
 lifting, are especially liable 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 associated with flat foot and genu 
 valgum. Prolonged standing in a position of ease or rest, in 
 which the weight is mainly carried on one 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 lumbar 
 curve usually forms first, its convexity being to the left side, a 
 compensatory dorsal curve, with its convexity to the right, being 
 subsequently developed. 
 
 The Phenomena vary considerably according to the character 
 and extent of the lesion. Sometimes the whole spine is involved 
 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 its absence, in what is sometimes termed the ' flat-backed ' 
 
DEFORMITIES 
 
 383 
 
 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. It will 
 be desirable to describe this carefully, whilst for the opposite condi- 
 tion 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. 
 
 In addition to the lateral displacement, rotation of the bodies of the 
 
 Fig. 98. — Scoliosis seen from 
 Behind. (Tillmanns.) 
 
 Fig. 99. — Spine in Scoliosis seen 
 from in Front. (Tillmanns.) 
 
 vertebra (Fig. 99) towards the convexity of the curves is always 
 present. 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 will 
 always indicate a smaller amount of distortion than really exists. 
 Occasionally there may be some backward projection of the 
 spines at the junction of the two curves. 
 
 The thoracic walls necessarily participate in the process. The 
 
384 
 
 A MANUAL OF SURGERY 
 
 ribs on the right side become to some extent separated from one 
 another, and project posteriorly on account of the rotation of the 
 vertebrae ; the amount of curvature at the angle is consequently 
 increased, 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 thereby 
 opened out; consequently the thorax is flattened posteriorly on 
 that side, but projects in front ; the left breast may thus be 
 rendered prominent (Fig. ioo). In fact, the thorax becomes 
 more or less rhomboidal in shape. The sternum also is somewhat 
 displaced towards the concavity, and twisted so that the anterior 
 surface looks towards the right. The capacity of the thorax is 
 not as a rule affected at first, but in the later stages it is consider- 
 ably diminished, and the 
 
 may 
 The 
 
 Fig. 
 
 ioo. —Section of Thorax in Scoliosis. 
 (After Holmes and Hulke.) 
 
 abdominal viscera 
 even be displaced. 
 scapula follow the thor- 
 acic wall, and hence the 
 right shoulder is pushed 
 upwards and outwards, 
 and this, it is said, in the 
 worst cases may pro- 
 gress to such an extent 
 as to cause the sternal 
 end of the clavicle to be 
 spontaneously dislocated 
 backwards. It is for this 
 ' growing out of the 
 shoulder' in young 
 women that the majority 
 of cases come under 
 observation. The left 
 scapula is generally 
 The effect on the waist varies 
 if the dorsal and 
 
 somewhat lower than the right 
 with the situation and extent of the curves ; 
 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 towards the right side, whilst the 
 dorsal concavity higher up may simulate a false waist. In 
 addition to the above phenomena, the buttocks may be noticed to 
 be asymmetrical, if the scoliosis is of statical origin. The erector 
 spinas muscle stands out unduly on the left, owing to the rotation 
 of the vertebrae, whilst the transverse processes on this side may 
 be unusually evident. 
 
 In the early stages the characteristic deformity disappears on 
 
DEFORMITIES 3S5 
 
 extension of the trunk, as by hanging from a trapeze, or on bend- 
 ing forwards ; 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 the deformity becomes so marked 
 as to simulate the ' hump ' formed in Pott's disease, especially 
 when associated with kyphosis, 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 vertebrae become mis-shapen. The bodies 
 are somewhat 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 concave 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 
 ligaments, which in the early stages are relaxed, become secondarily 
 shortened on the concave side, and may, indeed, disappear, the 
 .bodies of the vertebrae being ankylosed. The muscles are also 
 relaxed in the early stages, but accommodate themselves after- 
 wards to the altered curves of the spine, and hence are contracted 
 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 ascertained. 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 characteristic ; 
 in those cases of scoliosis, however, where there is a projection 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 affec- 
 tion 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. 
 
 25 
 
3 86 
 
 A MANUAL OF SURGERY 
 
 In the Treatment of scoliosis, the cause of the trouble must not 
 be overlooked, 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 wear- 
 ing of a high-heeled boot, whilst contractions of the knee or hip 
 joints should, if possible, be remedied. 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 
 administration of tonics, such as iron and arsenic. Carefully 
 regulated 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 ex- 
 tended. Calisthenic movements and gymnastic 
 exercises, especially on the horizontal bar and 
 trapeze, are also valuable. Of course, these must 
 be arranged so as to exercise the weak muscles and 
 counteract the deformity. Space forbids us describ- 
 ing them here, and we must refer readers to special 
 textbooks. 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, carefully-fitted corset; but should 
 the deformity increase, stronger steel instruments 
 may be employed in which springs are incorporated, 
 T _ whereby it is hoped that correction of the curvature 
 
 I O I. — J r 
 
 may be brought about. In the more severe cases, 
 which are often associated with considerable pain, 
 such a contrivance with axillary crutches is abso- 
 lutely, essential. Plaster of Paris, applied accotding 
 to Sayre's method, is certainly objectionable, since it is irremov- 
 able, and all other local treatment to the back is thus prevented. 
 
 Kyphosis. — By this term is meant a condition of increased 
 dorsal convexity of the back (Fig. 101), which is 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 compensatory condition. 
 
 The 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 con- 
 tinuous habit of stooping, as in reading or writing, and is not 
 
 Fi G. 
 Kyphosis. 
 (After 
 Erichsen.) 
 
DEFORMITIES 387 
 
 uncommon in those suffering from myopia ; (c) various forms of 
 occupation, involving the carrying of heavy weights, or stooping 
 over work, will lead to its appearance in adults, as in porters and 
 cobblers, whilst the use of bicycles which necessitate the riders 
 stooping forwards in order to grasp the handles is becoming a 
 frequent source of this deformity ; (d) in old men it results from 
 senile atrophy. 
 
 2. Kyphosis from general diseases of the spine is a marked 
 feature in osteo-arthritis, osteitis deformans, osteo-malacia, hyper- 
 trophic pulmonary osteo-arthropathy, and acromegaly. In the 
 latter disease the condition is limited to the dorsal region. 
 
 3. Kyphosis from localized disease of the spine is sometimes 
 described, although it is more commonly known by the contradic- 
 tory 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 the observa- 
 tion of the surgeon that a little more notice of the condition is 
 needed. 
 
 Round Shoulders occur most frequently in girls who have grown 
 rapidly, and perhaps developed precociously. The condition 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 myopia 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. — A thorough investigation must be made into the 
 question of causation, and all removable conditions dealt with. 
 Special attention must be directed to the chairs and desks so as 
 to ensure that the child sits in a good position. The essential 
 point in the treatment is to increase the power of the muscles of 
 the back, especially the trapezii, the erectores spina?, the rhom- 
 boidei, and the serrati. This may be accomplished 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* will do as well as 
 any, but of course the exercises must be persisted in. 
 
 * 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 
 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 bar or 
 bars, and straps to fix it in position are also provided. 
 
 25—2 
 
388 
 
 A MANUAL OF SURGERY 
 
 Lordosis (Fig. 102) consists in an increased anterior curvature 
 of the spine in the lumbar region. It is usually produced by 
 continued flexion of the hip, whether due to congenital displace- 
 ment, to unreduced dislocation, 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 
 constant phenomenon in bad cases of uterine fibroids, owing to the 
 increased weight of the uterus or its contents, necessitating back- 
 ward 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. In both cases the centre of gravity of the 
 body is displaced forwards, necessitating the throw- 
 ing backwards of the head and shoulders in order 
 to maintain the equilibrium. 
 
 Spondylolisthesis is the term applied to a curious 
 and somewhat uncommon deformity, in which the 
 lumbar vertebrae slip forwards and downwards from 
 the top of the sacrum. It arises from fracture of the 
 articular processes of the lumbo-sacral synchon- 
 
 FiG.102. Lor- drosis, or from imperfect development of the 
 
 dosis. (After laminae or pedicles of the lowest lumbar vertebra, 
 Erichsen.) as a resu it of which the pressure of loads carried 
 on the shoulders or the weight of a pregnant 
 uterus brings about the displacement. 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 
 well-fitting leather jacket, closely moulded to the pelvis, and 
 supplied with crutches, so as to carry part of the weight down- 
 wards from the axillae to the pelvic support without utilizing the 
 spine. 
 
 Deformities of the Upper Extremity. 
 
 Congenital Elevation of the Scapula (Sprengel's Shoulder) is a 
 condition to which some attention has been recently attracted. 
 The scapula may be normal in size or a little smaller than 
 usual, but is situated above its proper position, thereby causing 
 
DEFORMITIES 389 
 
 some deformity. The muscles attached to its upper border are 
 shortened, but otherwise normal, though in a few instances an 
 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 amount of 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 develop? 
 as a compensatory phenomenon. The condition is supposed to 
 result from abnormal intra-uterine pressure in the same way as 
 congenital torticollis and talipes. The only treatment consists in 
 dealing with the affected muscles by operation, if necessary. 
 This deformity is distinguished from the ' growing-out shoulder ' 
 of ordinary scoliosis by the muscular defects, by the slight- 
 ness of the scoliotic curve, and by the congenital origin of the 
 lesion. 
 
 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 
 much altered in shape and 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 skiagraphy should be employed, so as to ascertain the 
 exact relation of the bones to each other. 
 
 Congenital Deformities of the Finger are much more common, 
 and the account here given'of such defects of the upper extremity 
 applies with equal force to those which occur in the lower. The 
 following varieties may be alluded to : 
 
 Polydactylism consists in the presence of supernumerary fingers 
 and toes, and is often seen. There may be from one to seven 
 additional digits, and the condition is usually symmetrical. One 
 case is on record with twelve and thirteen fingers 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 and metatarsal bones may be present, or 
 they also may be multiplied. T n one of our cases there were six 
 digits and six metatarsal bones ; but the last two digits were sup- 
 ported by an accessory metatarsal apparently springing from the 
 outer side of the fourth. The condition is frequently inherited. 
 The treatment consists in removing the supernumerary digits, if 
 useless, obtrusive, or troublesome. Sometimes the patients are 
 proud of their abnormality, and refuse to part with it. A patient 
 with two weak thumbs may sometimes be benefited by uniting 
 them laterally into a single broad one. 
 
39o 
 
 A MANUAL OF SURGERY 
 
 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 amputations at a higher level. 
 
 Macrodactyly (Fig. 103) consists in a congenital overgrowth of 
 one or more fingers or toes. The structures are perfectly normal 
 in character, and merely gigantic in size for the age of the 
 individual. Amputation may be needed in these cases, as the 
 deformed parts grow out of all proportion to the neighbouring 
 
 Fig. 103. — Macrodactyly and Syndactyly. 
 
 In this case a child, aged two and a half years, had the ring and middle fingers 
 united laterally into a large mass which projected far beyond the others. 
 The middle finger was normal in size, the ring finger was hyper- 
 trophic. A fruitless attempt was made to save the middle finger, but 
 both had finally to be amputated. 
 
 tissues. Thus, 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 reduced to normal shape and size. 
 
 Syndactylism, or webbed fingers, is a condition in which two or 
 more fingers are joined together laterally, either by a thin web 
 
DEFORMITIES 
 
 39' 
 
 consisting 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 below upwards, 
 as healing proceeds, a flap of skin must be transplanted into 
 the angle between the fingers, or an opening in the base of the 
 web may be made and maintained, and the edges allowed to 
 cicatrize before the web itself is divided. Where the union, how- 
 ever, is thick and fleshy, a more extensive operation is needed. 
 Two flaps of skin as long as the web, and half the width of a 
 finger, are respectively raised from the dorsal aspect of one finger 
 and from the palmar aspect of the other, in such a manner that, 
 after the web has been divided, the denuded surfaces can be 
 covered by wrapping the flaps round the lateral aspects of the 
 fingers and suturing them in position. An additional flap of skin 
 must also be fixed in the angle between the separated digits, unless 
 the preliminary measure just described has been undertaken. 
 
 Congenital Contraction of the Fingers is not a very rare de- 
 formity ; it is frequently inherited, and usually limited to the little 
 finger ; it may be associated with congenital hammer-toe. It is 
 due to contraction of the central prolongation of the palmar fascia 
 in the finger, whereas in Dupuytren's contraction it is the palmar 
 fascia itself and its lateral prolongations into the fingers that are 
 involved. Moreover, the character of the deformity differs in that 
 in the congenital form 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 hand 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 curious condition in which, 
 when the patient attempts to open his hand, one finger remains 
 flexed, and on extending it with the other hand it flies open with 
 a jerk or snap. Some slight tenderness and pain is usually felt 
 near the metacarpo-phalangeal articulation, and the cause of the 
 trouble is some obstruction to the free working of the long tendons 
 under the transverse ligament at the root of the fingers. In a few 
 cases a ganglion has been present here, but in most instances it 
 is due to an increase in size of the sesamoid bone which the 
 X-rays have taught us constantly occurs in this situation. Treat- 
 ment consists in an aseptic incision to remove the cause of the 
 obstruction. 
 
 A Mallet Finger is one in which the terminal phalanx is main- 
 tained in a state a flexion owing to some damage to the extensor 
 aponeurosis. It usually follows injuries, which lead either to a 
 separation of the tendon from the bone, or to a thinning of its 
 
392 A MANUAL OF SURGERY 
 
 texture, whereby the flexor tendon is able to act with undue 
 power. The treatment consists in the application of an anterior 
 linger-splint in the early stages, but later on, should the deformity 
 be persistent, an incision is made on the posterior aspect of the 
 joint, and the weak tendon isolated and stitched down in such a 
 way as to give it a better attachment to the bone. 
 
 Contraction of the Palmar Fascia (Dupuytren's Contraction). — 
 This condition is usually met with in middle-aged individuals of a 
 gouty temperament, more often in men than women, and not un- 
 frequently 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 instru- 
 ment, such as an awl, whilst heredity is an important causative 
 factor. Pathologically, it is due to a chronic overgrowth and 
 contraction of the fascia, inflammatory in nature, and cirrhotic or 
 
 Fig. 104. — Dupuytren's Contraction. (From a Photograph.) 
 
 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 in- 
 volved. The induration spreads slowly both up and down the 
 fascial bands into the fingers, which, as it increases, are gradually 
 drawn into the palm and fixed, so that extension becomes impos- 
 sible (Fig. 104). The flexion is limited to the first and second 
 phalanges, the third remaining extended, and, indeed, sometimes 
 assuming a position of hyper-extension, owing to the injudicious 
 application of a splint. The skin over the indurated masses is 
 sooner or later incorporated with them. 
 
 The Diagnosis of Dupuytren's contraction is exceedingly easy, 
 the only condition for which it is likely to be mistaken being the 
 congenital contraction already noted and flexion of the finger due 
 
DEFORMITIES 
 
 393 
 
 to contraction of the long tendons. In the latter case there is, as 
 a rule, no palmar induration, and on attempting to straighten the 
 finger the tendons may be felt to become tense above the wrist ; 
 the terminal phalanx is also flexed in many instances. 
 
 The only satisfactory Treatment is by operation, and the follow- 
 ing methods are those which are most successful : (a) Adams' sub- 
 cutaneous section of the fascia and its prolongations consists in 
 dividing the indurated bands by a tenotome in several places, 
 where they can be felt tense. One 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 satis- 
 factory, (b) Kocher's method 
 consists in the total extirpa- 
 tion of the thickened bands and 
 their prolongations through 
 longitudinal incisions. The 
 fingers are at once straightened, 
 and subsequent contraction is 
 prevented by mechanical appli- 
 ances. We have had many 
 excellent and lasting cures by 
 the latter operation. 
 
 Deformities of the Lower 
 Extremity. 
 
 Coxa Vara, or incurvation cf 
 the neck of the femur (Fig. 105), 
 is a condition to which attention 
 has been called only of recent 
 years. The neck of the bone, 
 instead of passing obliquely 
 
 upwards, is horizontal, or in bad cases directed downwards and 
 usually backwards, whilst shortening from interstitial absorption 
 also occurs, and the head becomes mushroom-shaped (Plate IX.). 
 At first the osseous tissue is softened, but after a while sclerosis 
 supervenes. It is met v.'ith in young children as a result of rickets, 
 or perhaps more frequently in adolescents, when it is sometimes 
 supposed to be a late manifestation 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 
 
 Fig. 105. — Coxa Vara. 
 
 The dotted line represents the 
 normal neck of the femur. 
 
394 A MANUAL OF SURGERY 
 
 gradual slipping down of the epiphysis, which constitutes the 
 head of the bone, or to 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 real shortening of the limb occurs, even up to ih inches. 
 The limb is also everted and the trochanter increasingly pro- 
 minent, especially on flexing the thighs. The movements of the 
 joint are limited, particularly in the direction of internal rotation 
 and abduction, 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 that a scissor-legged 
 condition occurs if both sides are affected. As distinguishing 
 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 suppura- 
 tion never follows, and thickening of the trochanter is not observed. 
 
 Treatment. — In the early stages rest is the essential, and thereby 
 any increase in the deformity already existing is prevented ; local 
 massage and manipulation are also advisable, whilst in children 
 prolonged extension may do good. In the later stages, subtro- 
 chanteric osteotomy, in order to alter the axis of the bone, is per- 
 haps the best measure to undertake, although a cuneiform osteo- 
 tomy of the neck is recommended by some. The subsequent 
 shortening may be dealt with by means of a thick sole to the 
 under surface of the boot. 
 
 Genu Valgum, or knock-knee, is a deformity in which, if the 
 knees are allowed to touch with the patellae looking forwards, 
 the malleoli are separated one from the other — i.e., it is a fixed 
 condition of abduction of the legs from the middle line, with 
 some external rotation (Fig. 106). One or both limbs may be 
 affected, but if due to general causes the double form is more 
 common. Occasionally genu valgum occurs in one leg, whilst 
 the other is in a condition of genu varum. 
 
 There are two main varieties of the disease, viz.: (i) The 
 rachitic genu valgum of young children, and (2) the static form 
 occurring in adolescents. 
 
 The genu valgum of young children is practically always due to 
 rickets, in which the softened condition of the bony tissue on either 
 side of the epiphyses results in an interference with the normal 
 development. It is still an open question as to whether this 
 deformity is primarily due to increased growth on the inner side, 
 or to arrest of development on the outer ; the truth probably lies 
 between the two. It is also a question as to whether the femur 
 or tibia is primarily at fault ; probably the location of the mischief 
 
PLATE IX. 
 
DEFORMITIES 
 
 395 
 
 varies in different cases. Some are certainly due not to epiphyseal 
 mischief at all, but to a rachitic curvature of the diaphysis of the 
 femur, especially when the child has been allowed to walk or run 
 about too early. 
 
 The genu valgum of adolescents, or static genu valgum, occurs 
 most commonly in young people under twenty, of relaxed consti- 
 tution, and particularly in those who, in addition, have to carry 
 heavy weights. Thus, anaemic young women who act as nurse- 
 maids, and young bricklayers, smiths, and porters, are very liable 
 to it. There are many different opinions as to the way in which 
 it is produced, but the most likely explanation is purely mechanical. 
 When a person stands in the erect posture, the perpendicular line 
 which represents the direction 
 in which the weight is trans- 
 mitted downwards from the 
 head of the femur passes 
 through the outer rather than 
 the inner condyle, whilst the 
 latter structure is lengthened 
 in order to maintain the hori- 
 zontal position of the articular 
 surfaces of the knee-joint. A 
 certain amount of strain is 
 thus normally cast upon the 
 internal lateral ligament even 
 in a healthy person, and this 
 is increased as the natural 
 position of rest — i.e., with the 
 f^et separated and slightly 
 abducted — is adopted. A 
 long continuance of this pos- 
 ture tires those muscles on 
 the inner side of the limb 
 which tend to counterbalance 
 this strain, especially if a 
 certain amount of additional 
 
 weight has to be carried, and particularly in those whose bones 
 have rapidly increased in length and weight without any coin- 
 cident 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 mobility of the 
 knee is noticed in the early stages. Subsequently the outer con- 
 dyle becomes atrophied from more weight being transmitted 
 through it, and the inner condyle becomes lengthened from over- 
 growth. It is also important to note that flat-foot and lateral 
 curvature of the spine often accompany this form of genu valgum, 
 the former being also usually due to ligamentous relaxation, whilst 
 the latter may be merely associated with it, or be compensatory 
 if the deformity in the knee is unilateral. 
 
 Fig. io6.- 
 
 -Genu Valgum. 
 
 MANNS.) 
 
 (Till- 
 
396 A MANUAL OF SURGERY 
 
 Occasionally genu valgum is due to traumatic causes, such as 
 fracture of the tibia or femur close to the joint, or lateral dis- 
 location 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 riding, in those with long legs, as in cavalry soldiers ; 
 short-legged individuals, such as jockeys, are more liable to 
 develop a condition of genu varum. 
 
 The Physical Condition of the parts about the knee may be 
 summarized as follows : 
 
 (a) The inner condyle of the femur forms a marked and obvious 
 subcutaneous projection ; the increase in size is mainly in the 
 vertical and transverse directions, and but very little antero- 
 posteriorly, so that, on flexion of the joint, the deformity to a 
 large extent disappears. 
 
 (b) 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. 
 
 (r) Impaired growth and atrophy is observed in the outer 
 femoral condyle and tibial tuberosity, conditions supposed to be 
 due to the weight of the body being transmitted more directly 
 through these structures. 
 
 (d) Relaxation of the ligamentous and muscular tissues takes 
 place on the inner side of the joint. This, however, is not con- 
 stant, especially in the later stages or in cases which are stationary. 
 
 (e) The tendons and ligaments on the outer aspect of the joint 
 are contracted and shortened, especially the external lateral liga- 
 ment, the ilio-tibial band, and the tendon of the biceps. 
 
 (/) The patella tends to be thrown outwards from the angular 
 deformity existing at the knee-joint. Occasionally the bone is 
 actually dislocated, and when this has once happened the dis- 
 placement is very likely to recur from time to time. 
 
 The following secondary conditions may be met with resulting 
 from genu valgum, viz. : The feet are displaced outwards, or 
 occasionally inwards, as best suits the convenience of the patient 
 in obtaining as good a footing as possible ; the bones of the legs 
 and of the thighs are often bent ; whilst, if unilateral, the pelvis 
 is tilted downwards on the affected side, and the spine laterally 
 curved on account of the unnatural shortness of the limb. 
 
 In well-marked cases the gait of the patient is very charac- 
 teristic, since the knees tend to get in the way of each other ; 
 hence the term ' knock-knee.' The legs are kept partially flexed, 
 and as the condyles touch or overlap, they have to be separated 
 at each step to allow of progression, and ihus a curious rolling 
 sort of walk results. Occasionally bursae form over the points 
 where the friction is most marked. 
 
 Treatment. — In rachitic infants, the general condition must be 
 
DEFORMITIES 397 
 
 dealt with in accordance with the rules given elsewhere (p. 527). A 
 suitable diet should be ordered, cleanliness attended to, and plenty 
 of fresh air allowed. Parrish's food is perhaps the best drug to 
 administer, whilst cod-liver oil is rarely needed, since it tends to 
 increase the body-weight, and so may do harm rather than good. 
 Absolute rest in bed is enforced ; the limbs are well rubbed daily, 
 and such manipulation and pressure employed as will tend to 
 remedy the deformity and straighten, if possible, the limb. No 
 pain should be caused, and by perseverance slow but appreciable 
 progress may be made until the limbs are straight. In older 
 children, especially when there is some difficulty in keeping them 
 off their feet, it is better to apply splints on the outer side of the 
 limbs, reaching from the pelvis down to the outer malleoli, or, if 
 need be, beyond them. These are retained in position by water- 
 glass bandages, put on firmly enough to draw the knees out- 
 wards. Such an arrangement is often sufficient in early cases 
 to bring about a cure in the course of a few months. Some 
 authorities have recommended forcible correction of the deformity, 
 and subsequent fixation in plaster of Paris, but the condition of 
 the epiphyses, and the ease with which they are detached, are 
 good reasons against adopting any such method. 
 
 In the static cases the administration of tonics, such as iron and 
 arsenic, combined with rest, massage, and possibly a change of 
 air, will frequently suffice to determine a cure in the early stages. 
 
 When the deformity is somewhat more advanced, more efficient 
 apparatus is needed ; that usually employed consists of an outside 
 iron stem, jointed at the knee, 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. The apparatus is somewhat heavy, but if carefully 
 applied for some months may effect a cure. It is possible that 
 division of the tense structures on the outer side of the joint may 
 considerably assist the process. 
 
 When, however, the osseous deformity is marked, and the patient 
 of such an age as to preclude the hope of a cure by mechanical 
 means, osteotomy must be resorted to. Amongst the many plans 
 which have been suggested, only two need be mentioned here, 
 viz., those devised by Ogston and Macewen. Ogston's operation 
 consists in sawing off the enlarged inner condyle through an 
 incision made by inserting a narrow finger-knife obliquely above 
 the condyle, and pushing it downwards in front of the bone to the 
 level of the articulation. The objections to the plan are the 
 necessary implication of the joint and of the epiphyseal cartilage, 
 so that ankylosis may occur on the one hand, or such interference 
 with the growth of the inner condyle, on the other, as leads later 
 on to genu varum. The immediate result is very satisfactory, 
 
39 8 A MANUAL OF SURGERY 
 
 and it may be used with success in adults where no more growth 
 is expected. Macewcns operation is, however, that most generally 
 applicable, and has practically superseded all others. 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 £ 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 remainder. A similar method may be employed from the 
 outer side, the force used in breaking the inner layer of compact 
 bone comminuting and compressing that portion, and so diminish- 
 ing the deformity. Many 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 straight- 
 ened, 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 immovable 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 if necessary the 
 fibula may also be divided. When these wounds have con- 
 solidated, the femur is dealt with, if necessary. 
 
 Genu Varum (one form of bow-leg) is a less common condition, 
 the exact opposite of genu valgum, and what has been said above 
 of the one is true of the other, if the word ' internal ' be substituted 
 for ' external ' and vice versa. Treatment is only required in bad 
 cases. 
 
 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 
 not being flexed in ntero, but extended with the feet under the 
 chin. It is sometimes the result of paralysis of the flexor muscles 
 of the knee and of the popliteus, or may arise from irregular 
 growth along the epiphyseal line, possibly as a sequela of tuber- 
 culous or other disease of limited extent in that region. It has also 
 been known to occur as an acquired accomplishment m fakirs and 
 
 * An osteotome differs from a chisel in the fact that the former is bevelled on 
 both sides, whilst the latter is merely bevelled on one side. 
 
DEFORMITIES 399 
 
 contortionists. If treatment is necessary, it must be suited to the 
 special requirements of the individual case. 
 
 Contractions of the Knee may arise from many different causes, 
 which may be either intra- or extra-articular in character. The 
 extra-articular causes of this affection may be situated (1) in the 
 skin and subcutaneous tissue, as a result of the contraction of 
 cicatrices of burns or ulcers ; or (2) in the flexor muscles, which 
 may become contracted in consequencce of diffuse suppuration 
 within their sheaths, or of infantile paralysis of the extensors, or 
 as a secondary result of inflammatory troubles in the knee-joint. 
 (3) The contraction is in some cases hysterical in origin, the joint 
 being fixed by muscular action, but remaining healthy, although 
 much local pain and superficial tenderness are complained of. 
 The diagnosis of such a condition is readily made by inducing 
 anaesthesia, or taking the patient unawares, when the limb is 
 found freely moveable and can easily be straightened. The 
 treatment of the preceding conditions is conducted on general 
 principles. 
 
 The articular causes of contracted knee are as follows: (1) Where 
 the capsule and ligaments are affected as well as the muscles, the 
 causative inflammation having been usually of a rheumatic or 
 gonorrhceal nature. The limb is fixed, but there is no actual 
 displacement of the head of the tibia. (2) Fibrous adhesions of 
 greater or less density may pass between the articular surfaces, 
 as a result either of acute synovitis, or of tuberculous or acute 
 arthritis. In the former case some mobility may be present, but 
 in the latter the movements may be very defective. (3) Osseous 
 ankylosis may exist as an outcome of tuberculous or acute 
 arthritis, the position of the limb depending on the previous 
 treatment of the case. Thus the limb may be straight and in 
 good position, but occasionally the tibia is flexed on the femur, 
 whilst its upper articular surface is displaced horizontally back- 
 wards, and the lower limb rotated outwards, constituting what is 
 known as the triple displacement. If the limb has been allowed to 
 lie on its outer side whilst disorganization was proceeding, there 
 may be an additional lateral displacement of the head of the 
 tibia outwards. (4) After partial excision in early life, the knee 
 may become flexed or hyper-extended years later, as a result of 
 irregular growth at the epiphyseal line. Flexion is much more 
 common than extension. 
 
 The Treatment of these conditions necessarily depends on their 
 nature. Where adhesions exist within the joint, or the ligaments 
 alone are contracted, it may be possible to straighten the limb 
 under an anaesthetic by forcible manipulation. Where the con- 
 traction is associated with osseous ankylosis, a suitable wedge- 
 shaped piece of bone {cuneiform osteotomy) should be removed. In 
 the triple displacement ordinary excision may be undertaken, but 
 
400 A MANUAL OF SURGERY 
 
 it is often a difficult matter to remedy the backward displacement 
 of the tibia. The bones should subsequently be kept in position 
 by silver-wire sutures, or other means. 
 
 Rachitic Tibia and Fibula. — It will be hereafter pointed out that 
 the tibia and fibula are liable to a considerable amount of dis- 
 tortion in the course of an attack of rickets if the child is allowed 
 to run about. As a rule, the antero-posterior curve is increased, 
 and some amount of ab- or ad-duction may also be present 
 (Fig. 182). The bones, too, are usually flattened from side to 
 side, presenting a sharp edge, and with a buttress-like support 
 reaching along the concavity ; they become exceedingly dense 
 and sclerosed. Operations for remedying the defect should 
 never be undertaken, however, until all active signs of rickets 
 have disappeared. Osteotomy may then be performed, and 
 the character of the operation will necessarily vary with the 
 amount of deformity. The general rule for the guidance of the 
 surgeon is either to divide the bones at their most prominent 
 part, or, if it is considered necessary, to remove a wedge-shaped 
 portion from the tibia (cuneiform osteotomy) ; the sections should 
 always be made at right angles to the upper and lower segments 
 of the bone respectively. The fibula never needs more than 
 simple division, and this is accomplished through a separate 
 incision. 
 
 The tibia and fibula also become distorted and curved antero- 
 posteriorly as the result of inherited syphilis. The deformity in 
 this case 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 is mainly placed in the 
 centre of the shaft, whilst in rickets the chief deformity occurs 
 either near the knee or a little above the ankle. There ought, 
 therefore, to be but little difficulty in distinguishing these two 
 conditions, and a careful inquiry as to the previous history of 
 the case should materially assist the surgeon in forming a correct 
 diagnosis. 
 
 Talipes. 
 
 By talipes, or club-foot, is meant a deformity of the foot due 
 to muscular, ligamentous, or osseous causes, the displacement 
 occurring mainly at the ankle and mid-tarsal joints. 
 
 Causes. — Talipes may generally be said to result from some 
 derangement in the equilibrium normally maintained between 
 opposing groups of muscles, in consequence of which the more 
 powerful group draws the foot into an abnormal position. Con- 
 sidered more in detail, it is well to study the aetiology of the 
 acquired and congenital forms separately. 
 
 Congenital malformation or malposition is responsible for a 
 certain percentage of the cases. Such may result from imperfect 
 
DEFORMITIES 401 
 
 development of the bones of the foot or leg, or from intra-uterine 
 paralysis of central origin. Other cases seem to be due to a 
 deficient amount of liquor amnii, as a result of which the feet 
 are abnormally compressed, and held in one position. It must 
 be remembered in this connection that in the foetus the legs are 
 naturally in a state of flexion, and the feet usually in the 
 position corresponding to that of talipes varus ; it is easy then to 
 understand that in an unusually small uterus this tendency may 
 be exaggerated. Spina bifida in the lumbar region is occasionally 
 associated with congenital talipes, which is then probably due to 
 impairment of nervous control. The congenital variety is often 
 hereditary, and may occur in several members of the same family, 
 or be transmitted through many generations. 
 
 The acquired varieties are somewhat easier to understand than 
 the congenital, since they arise from definite pathological lesions, 
 such as : (a) Paralysis of central origin, one of the commonest 
 causes of talipes ; in young children it is usually due to infantile 
 palsy (anterior polio-myelitis), whilst a similar affection is 
 occasionally seen in adults, (b) Contraction of muscles, the 
 result of diffuse suppuration, 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 tibialis 
 anticus or posticus, and contraction of one or both of these 
 muscles may cause talipes varus, (c) Essential shrinking, re- 
 sulting from a transformation of the muscle substance into fibro- 
 cicatricial tissue, is occasionally met with in elderly people ; it is 
 due to a chronic inflammation (myositis fibrosa), the nature of 
 which is but little understood, (d) Affections of the main 
 peripheral nerve trunks of the leg also result in talipes. If the 
 internal popliteal nerve is involved, talipes calcaneo-valgus will 
 ensue, whilst a lesion of the external popliteal nerve produces talipes 
 equino-varus, but never to any marked degree, (e) Deep spinal 
 mischief of a sclerosing type occasionally leads to spasm of some 
 group of muscles and talipes of a spastic type. (/) Shortening of 
 the leg from hip or knee mischief often causes a compensatory 
 talipes equinus, whilst injuries or diseases of one of the epiphyses 
 of the leg-bones may stop its growth, 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 
 talipes ; 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, as in the variety 
 known as talipes decubitus. The barbarous custom still practised 
 by the Chinese of forcibly compressing the feet of female children 
 brings about a similar result. 
 
 Varieties. — In considering the different forms of club-foot, it 
 must be remembered that the ankle is a hinge joint only allowing 
 
 26 
 
402 
 
 A MANUAL OF SURGERY 
 
 of flexion and extension, although when fully plantar-flexed a little 
 lateral mobility is also possible. The movements of abduction 
 and adduction of the loot take place chiefly below the astragalus 
 and at the mid-tarsal articulation. Four primary varieties of 
 talipes are hence described, viz. : T. Equinus, in which the heel 
 is drawn up, the patient walking on the toes (plantar-flexion) ; 
 
 A B C 
 
 Fig. 107. — Various Forms of Talipes Equinus. 
 
 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 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 
 longitudinal arch on the inner side. Not unfrequently mixed 
 forms occur, 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 slightest question that T. equino-varus is by far the commonest. 
 If, however, we exclude congenital cases and flat-foot, T. equinus 
 is in all probability the variety most frequently observed. 
 
 Talipes Equinus (Fig. 107, A, B, and C) is almost always acquired ; 
 it has been known to occur congenitally, but this is exceedingly 
 rare. 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 specially tense and rigid. It also occurs as a com- 
 pensatory manifestation where the limb has been shortened, as 
 after hip disease, and a variety known as T. decubitus results 
 from the bed-clothes pressing" for some length of time on the 
 dorsum of the foot of a bed-ridden patient. 
 
DEFORMITIES 
 
 403 
 
 In the slightest cases all that is noticed is that the foot cannot 
 be dorsi-flexed beyond a right angle (right-angled contraction of 
 the ankle). When the condition is more marked, the heel is 
 actually drawn up, and the patient walks on the heads of the 
 metatarsal bones and on the toes, which are usually hyper- 
 extended. Occasionally, however, in neglected cases due to 
 paralysis, the toes, instead of being extended, become flexed, the 
 
 Fig. 108. 
 
 -Congenital Talipes 
 Varus. 
 
 Fig. 
 
 mm 
 
 109. — Paralytic Form of 
 Talipes Equino-varus. 
 
 patient walking on their upper surface (Fig. 107, C) ; if such a 
 condition is allowed to persist, the whole dorsum of the foot may 
 in time be turned downwards. The astragalus is somewhat dis- 
 placed from under the malleolar arch, only the posterior part of 
 the articular surface being in contact with the tibia. In cases 
 due to paralysis the deformity is always associated with 
 dropping of the anterior segment of the foot 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, a condition we shall shortly refer to 
 under the name of pes cavus. In old-standing cases a certain 
 amount of varus is almost always present. In this, as in all forms 
 of talipes, callosities, and perhaps bursae 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, but is not a 
 very unusual result of infantile palsy of the extensor and peroneal 
 muscles, with secondary shortening of the tibialis anticus and 
 posticus, the flexor longus digitorum, and of the tendo Achillis. 
 Other cases are due to a primary spastic contraction of these 
 muscles. 
 
4°4 
 
 A MANUAL OF SURGERY 
 
 The heel is drawn up, and the anterior half of the foot adducted 
 and drawn inwards (Fig. 108). The inner border of the foot is 
 concave, and a well-marked transverse 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. no, A). The 
 
 A B 
 
 Fig. iio. — Neglected Case of Talipes Varus. 
 
 sole of the foot is arched from secondary contraction of the 
 plantar fascia and short muscles of the sole, especially the abductor 
 hallucis, and a longitudinal crease may run down the centre of 
 the sole, owing to doubling over of the outer metatarsal bones 
 (Fig. no, B). 
 
 The most marked Anatomical Changes are found in the astra- 
 galus. In infants the head and neck are normally set at an angle 
 to the body of the bone, being directed slightly inwards ; as 
 growth proceeds, this diminishes from about 35 to 10°, so that 
 in the adult there is but little obliquity of the neck. In Talipes 
 varus this angle is increased, often amounting to 50 or more, the 
 neck at the same time being longer than usual, a condition simu- 
 lating that found in some of the higher apes. The bone also 
 projects forwards from under the tibio-fibular arch, the posterior 
 portion of the upper articular facet alone remaining in contact 
 with it. The scaphoid is displaced to the inner side of the head 
 of the astragalus, so that only the inner portion of the latter 
 structure articulates with it ; the tuberosity is usually in close 
 proximity to, or may even touch, the inner malleolus. The os 
 calcis and other tarsal bones are also modified to some extent in 
 position and shape to correspond with these changes. The dorsal 
 tendons are displaced slightly inwards, usually occupying the 
 centre of the concavity between the foot and the leg. The liga- 
 ments 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. 
 
DEFORMITIES 
 
 405 
 
 The following table (slightly modified from Mr. Tubby's ex- 
 cellent work on Deformities") will suffice to indicate the chief 
 diagnostic points between congenital and paralytic T. equino- 
 varus : 
 
 Congenital. Paralytic. 
 
 History Affection has existed Affection not developed till 
 
 from birth. the second or third year, 
 
 and ushered in by convul- 
 sions, fever, etc. 
 
 Feet affected Usually bilateral. More often unilateral. 
 
 Circulation Good. Feeble; limb is 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. 
 
 Furrows in Sole .... Present. Absent. 
 
 Talipes Calcaneus (Fig. 11 1) is an unusual variety of the 
 deformity, and may be either congenital or acquired. In the 
 congenital form the toes are drawn up- 
 wards so that the heel alone comes into 
 contact with the ground, the sole point- 
 ing forwards. The extensor tendons are 
 contracted, but the toes may be flexed 
 owing to the tension of the flexor longus 
 digitorum. It is sometimes associated 
 with deviation of the foot inwards or 
 outwards, constituting a condition of 
 T. calcaneo - varus or - valgus. The ^ 
 inquired variety is generally due to vi % aBS! 
 infantile palsy of the call musi les, but ^fj^lr ■• 
 
 occasionally results from over-stretching 
 of the tendo Achillis after tenotomy. 
 The longitudinal arch of the foot is 
 increased, partly from the development Talipes Calcaneus. 
 of a large pad of fat over the calcaneal 
 
 tuberosities, but mainly from the toes not being drawn up towards 
 the leg as in the preceding variety. The anterior half of the 
 foot appears to drop forwards from the mid-tarsal joint owing to 
 secondary contraction of the plantar fascia and short muscles of 
 the sole. 
 
 Talipes Valgus is a condition seldom met with as a congenital 
 deformity, except in association with T. equinus. In it the outer 
 side of 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. 112). 
 Considerable pain is usually experienced after walking a short 
 distance. The scaphoid is displaced outwards, so that the inner 
 
 * Macmillan, 1896, p. 398. 
 
406 
 
 A MANUAL OF SURGERY 
 
 portion of the head of the astragalus projects into the sole of the 
 foot, the cartilage being uncovered. This deformity is occasionally 
 due to absence of the fibula. The acquired variety, which is not 
 uncommon (Fig. 113), is produced as a result of paralysis of the 
 tibial muscles, or from spastic contraction of the peronei, the 
 condition in these cases closely simulating the deformity known 
 as fiat-foot. 
 
 The Diagnosis of the different varieties of talipes is, as a rule, 
 
 a t 
 
 Fig. 112. — Talipes Valgus (Congenital), 
 with a Little Tendency to Calcaneus. 
 
 Fig. 113. — Acquired Talipes 
 Valgus. 
 
 easily made, although the cause of the deformity is not always 
 so readily ascertained. In paralytic cases the limb is always 
 atrophied, bluish in colour, and feels cold and clammy. Trophic 
 lesions are not uncommon in the shape 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 congenital 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 
 limbs are well nourished, at any rate at first. In spastic cases 
 (most frequently T. equinus) spasm or contraction of other parts 
 is usually present, which renders the diagnosis obvious ; one or 
 both limbs may be affected ; the muscles, at first firmly con- 
 tracted, may finally atrophy. 
 
 The Treatment of talipes is always somewhat tedious, demand- 
 ing care and patience on the part of all concerned. In the con- 
 genital variety no time should be lost in correcting the deformity, 
 and, in fact, treatment 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. At 
 the same time the muscles on the offending side of the limb 
 should be rubbed and stimulated. In the early stages of the 
 paralytic variety friction and faradization of the paralyzed muscles 
 must be regularly undertaken. At a somewhat later date treat- 
 
DEFORMITIES 
 
 407 
 
 ment by the application of suitable mechanical apparatus may 
 suffice to restore the foot to its normal position. If this is un- 
 successful, division of the contracted tendons, ligaments, and 
 fasciae will be necessary, whilst in severe and neglected cases 
 more extensive operations in the shape of tarsectomy or tarsotomy 
 may have to be performed. 
 
 Talipes equinus, if secondary to hip disease, should not, as a rule, 
 be interfered with. In other early cases, it may be remedied by 
 
 Fig. 114. — Sayre's Apparatus for Talipes Equinus. 
 The upper figure shews how the strapping is fixed to the plantar splint. 
 
 what is known as Sayre's apparatus (Fig. 114). 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 of the strapping 
 is thereby increased, the foot is gradually extended. In the more 
 serious varieties tenotomy of the tendo Achillis may be required, 
 accompanied, if necessary, by division of the plantar fascia, whilst 
 in neglected cases, or where tenotomy has failed, excision of the 
 astragalus gives most excellent results, the patient being able to 
 walk subsequently with a plantigrade foot. 
 
 Talipes equino-vavus may be treated in the early stages by apply- 
 ing to the foot a carefully-fitted malleable splint (Fig. 115), 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 
 tendo Achillis may be divided and the equinus element cured, 
 thereby rendering the varus condition more amenable to pressure. 
 Should this fail, tenotomy of the tibial tendons may be under- 
 taken, and the limb is at once restored to a good position, and put 
 up in plaster of Paris. In the more marked cases division of the 
 tense ligaments on the inner side of the foot (syndesmotomy) may 
 
4 o8 A MANUAL OF SURGERY 
 
 be necessary, particularly the anterior portion of the internal 
 lateral ligament of the ankle-joint. The abductor hallucis muscle 
 may also require section. 
 
 In neglected cases where the patient walks on the outer aspect 
 of the foot, two chief forms of operative treatment have been 
 advocated, viz., tarsectomy, and Phelps' operation, i. In tarsectomy, 
 a wedge shaped portion of bone is removed from the outer 
 
 Fig 115. — 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 as good a position as possible, and the leg-piece bandaged on. Each 
 week the foot-piece is bent a little more towards the normal position. 
 
 aspect of the foot. This is accomplished through an incision 
 round the outer border on a level with the cuboid. The thick 
 subcutaneous structures, including the bursa, are removed, and 
 the tendons stripped up from the bones both on the dorsal and 
 plantar aspects by the aid of a raspatory, and held aside by 
 retractors. The extensor tendons are already displaced some- 
 what inwards, and hence are not injured by this proceeding. The 
 tarsus is now 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 into consideration, and as far as possible 
 the sections are made at right angles to the anterior and posterior 
 segments of the foot respectively. The wound is closed, and the 
 foot placed in a good position, in which it is maintained by plaster 
 of Paris. The after-treatment is likely to be prolonged, but 
 otherwise the results are excellent, the foot, although a little 
 shortened, being firm and plantigrade. 2. Phelps' opevation con- 
 sists in dividing all the structures on the inner aspect of the foot 
 through a vertical incision, starting above just in front of the 
 internal malleolus. Joints are, if need be, opened, tendons and 
 ligaments divided, and the foot put up in a good position with 
 the wound gaping. Healing may be accelerated by skin grafting. 
 
DEFORMITIES 
 
 409 
 
 The results are at first quite as good as those attained by tarsec- 
 tomy, and the operation has the advantage of not shortening the 
 foot ; but there is a decided tendency for the deformity to recur 
 as cicatrization advances. 
 
 In talipes calcaneus all that may be needed is division of the 
 extensor tendons ; but in the paralytic variety some form of 
 apparatus must always be worn. Where the tendo Achillis is 
 thin and attenuated, a portion of it may be excised, and the ends 
 united by suture ; or the healthy peroneus longus tendon may be 
 grafted into the tendo Achillis ; or the tubercle of the os calcis 
 into which the latter is inserted may be sawn off and reattached 
 by a nail or peg to the bone at a lower level (Walsham) ; but the 
 prognosis in all forms due to paralysis is somewhat unsatisfactory. 
 
 Talipes valgus, if unrelieved by the application of suitable boots, 
 may need division of the peroneal tendons, or in severer cases 
 wrenching the foot into position, and fixation in plaster of Paris. 
 Removal of a wedge-shaped portion of bone from the inner aspect 
 of the foot may be undertaken, but is not very successful. 
 
 Flat-foot (syn. : Splay-foot or Spurious Valgus) is a condition 
 frequently seen in young adults whose occupation exposes them 
 to long standing, over-fatigue, or the carrying of heavy weights; 
 hence it is commonly met with in nurse-girls and shop-boys who 
 have only recently left school, any general deterioration of the 
 health also assisting in the production of the deformity. It occurs 
 as a natural condition in many of the negro races, and is more 
 often seen in long than in short feet. 
 
 Mechanism. — As already stated, there is some difference of 
 opinion amongst surgeons as to the primary causative factor in 
 the production of this deformity. The most generally accepted 
 idea is that it is in the majority of cases due to a relaxation of the 
 inferior calcaneo-scaphoid ligament, which extends between the 
 adjacent surfaces of the os calcis and scaphoid, supporting the 
 under surface of the head of the astragalus, and thus keeping up the 
 inner portion of the longitudinal arch of the foot. This in its turn 
 is braced up by the tendon of the tibialis posticus and an expan- 
 sion backwards therefrom to the os calcis, as also by the plantar 
 fascia and ligaments, and by the short muscles of the sole. When 
 the weight of the body increases rapidly, and out of all proportion 
 to the muscular development, chis important ligament is likely to 
 yield, and then the head of the astragalus is displaced downwards 
 into the foot, causing obliteration of the instep. Possibly paresis, 
 if not paralysis, of the tibialis anticus assists in this process, allow- 
 ing the peronei tendons to abduct the front of the foot from the 
 mid-tarsal joint, and in the later stages these tendons are often 
 found tense and rigid. By the majority of authorities, this con- 
 traction of the peronei is considered to be secondary to the liga- 
 mentous lesion, and quite independent of any weakening of the 
 
4io 
 
 A MANUAL OF SURGERY 
 
 tibial muscles. Occasionally the deformity is due to a gonor- 
 rhoeal inflammation of the inferior calcaneo-scaphoid ligament, 
 which becomes relaxed and yields under the weight of the body. 
 However produced, the deformity is tolerably characteristic 
 (Fig. 116). 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 there is a tendency to eversion of its anterior portion : 
 the outer border may be slightly raised from the ground. The 
 head of the astragalus is distinctly felt a little in front of and 
 
 Fig. 116. — Flax-foot. 
 
 below the internal malleolus, whilst the sustentaculum tali, which is 
 normally to be distinguished about three-quarters of an inch below 
 the malleolus, is buried by this displacement. The tubercle of 
 the scaphoid is less evident than usual, being situated below and 
 in front of the head of the astragalus. The gait becomes some- 
 what shuffling, and severe pain is experienced, not only in the sole, 
 but also about the heads of the metatarsal bones and in the toes. 
 Sometimes it is extremely marked in the metatarso-phalangeal 
 joint of the great toe, which may be enlarged and rigid, owing to 
 an associated osteo-arthritis. 
 
 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 
 ligaments to recover themselves ; at the same time the parts 
 should be well rubbed with stimulating embrocations, and tonics 
 administered to improve the general tone of the systen. In the 
 next stage, where the deformity, though present on standing, can 
 be made to disappear by manipulation, or on making the patient 
 stand on tiptoe, some slight support is advisable, and probably 
 an indiarubber or cork instep pad worn inside the sock or stock- 
 ing will be all that is necessary. In addition to this, square-toed 
 
DEFORMITIES 
 
 411 
 
 boots must be used, so as to prevent any tendency to an increase 
 in the valgoid position of the anterior segment of the foot. It is 
 also wise to make the patient walk with the toes turned inwards, 
 and in some cases assistance may be obtained by ordering him 
 to sit cross-kneed, in the tailor position, so as to exercise a certain 
 amount of constant pressure inwards upon the front of the feet. 
 Regular exercises ought to be instituted, such as raising the body 
 on tiptoe 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. Elastic tension applied to the sunken 
 arch is also useful in many of these cases ; Golding-Bird's sling 
 can be employed for this purpose. It consists of a loop of soft 
 webbing passed round the ankle and then under the instep, its 
 
 Fig. 117. — Mr. Golding-Bird's Sling 
 of Soft Webbing for supporting 
 the Arch of the Foot. 
 
 Fig. 118. — The Sling applied. 
 
 free end being drawn up on the inner side and attached to an 
 elastic accumulator which is connected with a steel garter-piece 
 (Figs. 1 17 and 118). In still worse cases a metal spring or instep 
 pad may be required ; but frequently the tenderness of the sole is 
 so great that it cannot be borne. 
 
 When the affection has reached a later stage, and the deformity 
 cannot be remedied by ordinary manipulation, forcible rectification 
 under an anaesthetic may be employed. The foot is firmly grasped 
 in the two hands or in a Thomas's wrench (Fig. 119), and the 
 anterior portion is forced inwards and backwards in such a way 
 as to draw the scaphoid round the head of the astragalus as a 
 fulcrum, and thus restore the arch. Probably a number of 
 adhesions in the astragalo- scaphoid and other joints will be felt to 
 give way during this manipulation. Tenotomy of the peronei is 
 sometimes required before rectification of the position is possible. 
 
412 A MANUAL OF SURGERY 
 
 The foot is then put up in plaster of Paris and kept at rest for 
 some weeks. Satisfactory results have followed. 
 
 In advanced cases that have been entirely neglected, operative 
 proceedings are necessary, and probably the best of the many 
 that have been suggested consists in removal of a wedge-shaped 
 portion of bone from the inner side. Ogston advises that this 
 should be taken from the neck of the astragalus, but others have 
 advised either removal of the scaphoid or of a wedge-shaped 
 section of the foot without respect to joints (Stokes). 
 
 Pes Cavus (Hollow or Claw Foot) is a condition characterized by 
 increased concavity of the plantar arch, so that when the indi- 
 vidual stands there is a greater interspace than usual, if not an 
 absolute break, between the impressions produced by the anterior 
 and posterior segments of the foot (Fig. 107, B). It is almost 
 always an acquired deformity, although a few cases of congenital 
 cavus have been reported. Corresponding to the increased con- 
 
 Fig. 119. — Thomas's Wrench. (Down Bros.) 
 
 The two cross-bars are protected by thick indiarubber, and can be approxi- 
 mated or separated by rotation of the handle. The anterior portion 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. 
 
 cavity in the sole, there is a marked convexity on the dorsal 
 aspect of the foot, whilst the toes are generally in the condition 
 to be immediately described as hammer-toe ; the heads of the 
 metatarsal bones are unduly prominent below, and callosities 
 often form beneath them. Considerable pain and inconvenience 
 are occasioned by these associated deformities. 
 
 Causation. — Duchenne originally maintained that it arose from 
 paralysis of the interossei and lumbricales in a manner similar to 
 that which leads to the main-en-griffe after paralysis of the ulnar 
 nerve, and it is quite possible that this accounts for a certain small 
 proportion of the cases. Others rightly associate it with a slight 
 degree of talipes equinus (right-angled contraction), and Parkin 
 of Hull has worked out its method of production from this cause. 
 The weight is normally carried to the ground mainly through the 
 heel, but also partly through the toes ; in these cases it is, how- 
 ever, only transmitted through the toes and front of the foot, and 
 since the anterior extensor muscles are supposed to be weak and 
 paretic, the short flexors are able to act at an advantage, and by 
 
DEFORMITIES 
 
 413 
 
 contracting draw the heel downwards so as to reach the ground, 
 and thus the arch is increased. 
 
 The Treatment in the early stages consists in friction applied 
 to the weakened muscles of the leg, together, possibly, with the 
 application of a splint to the sole. In more marked cases division 
 of the tendo Achilles is needed, together with subcutaneous section 
 of the tense plantar fascia. The deformity of the toes usually 
 disappears when the equinus is corrected, but may require further 
 attention. 
 
 Hallux Rigidus (syn : H. nexus) is a painful condition of the 
 great toe, due to an affection of its metatarso-phalangeal articula- 
 tion. It usually occurs in young males with flat-feet. The foot 
 is abnormally long ; its circulation is defective : the toe itself 
 may be in good position, but not unfrequently the first phalanx is 
 flexed, and the distal one hyper-extended. The joint is practically 
 in a condition of chronic traumatic arthritis, with fibrillation of the 
 cartilage and lipping of its margins. It is probably due to abnormal 
 
 
 Fig. 120. — Hallux Valgus. 
 
 pressure being brought to bear upon it 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 give 
 attention to the boots. 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. — This condition consists in a displacement out- 
 wards 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 (Fig. 120). 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 elderly people, and is often associated with 
 osteo-arthritis of the metatarso-phalangeal joint of the hallux, 
 the greater power of the adductor group of muscles explaining 
 the deformity. The cartilaginous surface of the head of the first 
 metatarsal bone becomes exposed beneath the skin, and by the 
 constant irritation of the boot it becomes inflamed, its structure 
 
4i 4 A MANUAL OF SURGERY 
 
 and shape altered, and the joint more or less disorganized. Two 
 other conditions are also met with arising from 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 usually communi- 
 cating with the joint, and leading to its disorganization. A 
 marked bony outgrowth is usually found under the bursa, 
 springing from the inner side of the head of the bone, and due 
 to a localized chronic periostitis. 
 
 The Treatment of hallux valgus in its earliest stages consists 
 in the use of correctly-shaped boots, with the inner border straight 
 from toe to heel. In worse cases an apparatus may be worn, 
 consisting of a band around the dorsum of the foot, to which is 
 attached a support running along its inner border, towards which 
 the great toe can be drawn by elastic tension. In the most 
 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 convexity backwards. 
 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 is thus weakened, and the deformity is probably aggra- 
 vated. An inflamed bunion is treated by removing all local pres- 
 sure, and applying fomentations. If the joint is involved in 
 suppurative disease, excision of the head of the bone, or amputa- 
 tion of the toe, may be required. In less serious cases it may 
 suffice merely to remove the thickened bursa. 
 
 Hammer-toe. — This deformity is constituted by hyper-extension 
 of the first phalanx, marked flexion to an acute angle of the 
 second, and either flexion or extension of the terminal phalanx, 
 so that the first interphalangeal 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. 121). Corns form 
 upon the points ot pressure (1, 2, and 3), especially on the dorsal 
 aspect, and a subcutaneous bursa over the head of the first 
 phalanx (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 Causes are numerous. 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 
 
DEFORMITIES 415 
 
 and drawn up out of the way of pressure : (c) it follows contrac- 
 tion of the plantar fascia, and is then associated with pes 
 cavus and talipes equinus : (d) paralysis of the interossei and lum- 
 bricales may also lead to this condition in the same way that the 
 viain-en-griffe follows ulnar paralysis. 
 
 However caused, the hyper-extension of the first phalanx is 
 
 2 I 
 
 Fig. 121.- — Hammer-toe. (After Keen and White.) 
 
 1, Callosity over head of metatarsal bone in sole ; 2, callosity over end of toe ; 
 3, callosity or corn over head of first phalanx ; 4, adventitious bursa over 
 the same bony point. 
 
 associated with a contracted state of the extensor tendons, which 
 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. 
 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 this may in the first place 
 be directed to the contracted tendo Achilis and plantar fascia, if 
 such conditions are present, or to division of the lateral ligaments 
 of the first inter-phalangeal articulation. Division of the extensor 
 tendons may also be tried, but probably the displacement of the 
 base of the second phalanx is such that nothing short of removal 
 of the head of the first phalanx holds out any prospect of perma- 
 nent relief. An incision 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. The foot is put up on a splint, and care taken to maintain 
 the toes in a good position by the use of some suitable appliance 
 (Fig. 122). 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 ; ampu- 
 tation should then be performed. 
 
4 i6 
 
 A MANUAL OF SURGERY 
 
 Fig. 122. — T-shaped Splint for 
 Hammer-toe, which can be used 
 in Slight Cases, or after 
 Operation in Bad Cases. 
 
 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, 
 but also radiating thence up and 
 down the limb. It often occurs 
 in gouty or rheumatic subjects, 
 and may be attributed to some 
 injury; a slight degree of flat- 
 foot and the wearing of tight 
 boots certainly predispose to it. 
 Morton's explanation is that, as 
 a result of the pressure of badly- 
 fitting boots, the metatarsal bones 
 and phalanges are laterally dis- 
 placed, and the digital nerves 
 compressed either between the 
 third and fourth or between the 
 fourth and fifth. That this displacement does occur in some cases 
 has been demonstrated by skiagraphy, but it is doubtful whether 
 the nerves are in reality compressed between the bones. R. Jones, 
 of Liverpool, has recently adduced weighty reasons for believing 
 that the pain is rather to be explained by compression of the nerves 
 between the bones and the ground. The foot is usually found to 
 be broader than usual, and 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. In a few cases 
 small bony enlargements have projected from the heads of the 
 metatarsal bones, and in others definite fibrous growths have been 
 found in the subcutaneous tissues ; in other cases a simple peri- 
 pheral neuritis may explain the manifestations. The pain is 
 generally induced by walking, and comes on in characteristic 
 paroxysms. Lateral pressure over the metatarsal bones some- 
 times relieves the pain, Occasionally evidences of osteo-arthritis 
 are manifested in one of the neighbouring joints. 
 
 Treatment consists in resting the foot, whilst 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 broad anteriorly, and fitted with an 
 instep pad if necessary. Morton's recommendation — viz., excision 
 of the head of the metatarsal bone — may be reserved for the more 
 aggravated and serious forms. 
 
CHAPTER XVII. 
 
 INJURIES OF BONES— FRACTURES. 
 
 Contusion of a Bone and of its periosteum is usually a mattei 
 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 osteomyelitis, 
 resulting in necrosis, mav be lighted up. The Treatment of an 
 uncomplicated case consists merely in the application of cooling 
 lotions or a bandage, whilst if periosteal 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 without 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. 388). The deformity can 
 generally be remedied by the application of a little force. 
 
 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 has a considerable 
 influence in the determination of fractures, and for two reasons : 
 firstly, because the strength and elasticity of bones vary consider- 
 ably at different periods of life ; and, secondly, because the liability 
 to injury is likewise variable. From two to four fractures are 
 not uncommon, owing to the unsteady gait and frequent falls to 
 which little children are exposed ; from four to six they are less 
 common, the bones often bending so as to cause green-stick frac- 
 tures, whilst injuries near joints induce separation of epiphyses ; 
 from six years onwards fractures are frequent enough, and 
 increase steadily with the age, old people being peculiarly liable 
 to this form of accident, owing to the brittleness of their bones. 
 
 Sex. — As might be expected, fractures are more common in the 
 male sex during boyhood and adult life ; but up to the age of 
 
 27 
 
4 i8 A MANUAL OF SURGERY 
 
 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. 
 
 Morbid Conditions of the Bones predispose to fracture in a marked 
 manner, very slight force occasionally sufficing to bring it about. 
 Under this heading may be included: (i) Atrophy of bone, from 
 whatever cause it arises. Thus, it may be of the senile type, as 
 manifested especially in the cervix femoris ; or it may be due 
 to want of use, as in a paralyzed limb or from an ankylosed 
 joint. Certain nervous affections, such as general paralysis and 
 other forms of insanity, and even tabes dorsalis, are often asso- 
 ciated with atrophic conditions of the bones, which lead to 
 fracture without any apparent cause. (2) Fragilitas ossium or 
 osteo-psathyrosis consists in an inherited tendency to spontaneous 
 fracture. It results in a multiplicity 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. 
 (3) General bone diseases, such as rickets and osteo-malacia, also 
 predispose to fracture ; in those due to the latter affection there is 
 usually no attempt at repair. (4) Local bone disease may also 
 constitute an important predisposing factor by so weakening the 
 bone as to lead to its fracture from a very slight injury. Thus, 
 sarcoma and secondary cancer of bone are often first recognised 
 by causing a spontaneous fracture, whilst manipulation of a limb 
 which is the seat of caries or necrosis may lead to a similar 
 result. 
 
 The Exciting Causes of Fracture are threefold : (1) Direct violence, 
 the fracture occurring at the spot struck. The direction of such 
 lesions is often transverse, and they are not unfrequently com- 
 minuted, or complicated with injuries to the adjacent soft parts. 
 
 (2) When due to indirect violence, the bone gives way at a distance 
 from the point to which the force is applied. 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 dis- 
 advantage ; if a person jumps from a carriage or train in motion, 
 the same conditions obtain. Fractures produced in this way are 
 often oblique or spiral in direction, and as the displacement may 
 be considerable, there is great risk of them becoming compound. 
 
 (3) Muscular action is most commonly the cause of fracture of 
 small bones, or of osseous prominences into which powerful 
 muscles are inserted. The patella and olecranon are not unfre- 
 
INJURIES OF BONES—FRACTURES 419 
 
 quently broken in this way, the former often occurring from 
 sudden and vigorous efforts to avert a fall. Occasionally 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 may be caused by blows upon the 
 mother's abdomen, or by abnormal or violent uterine contractions, 
 especially if the liquor amnii is deficient in amount ; when 
 multiple, they are usually due to fcetal syphilis. They may 
 present any type of deformity at birth, and may be partially or 
 completely united. They must be clearly distinguished from 
 malformations resulting from imperfect development. 
 
 Congenital Fractures are produced during birth by violence 
 used by the accoucheur, or from excessive uterine contractions. 
 They are most common in the thighs if due to traction, or in the 
 skull if due to the pressure of forceps. 
 
 Varieties of Fractures. — Many terms are used to describe the 
 multiplicity of conditions which may be met with in connection 
 with a broken bone. The following are the more important : A 
 Simple Fracture is one in which the skin is unbroken, or, at any 
 rate, where the external air has no admission to the site of injury. 
 A Compound Fracture is present when the skin or mucous mem- 
 brane over the injured spot is lacerated, so that there is direct 
 communication between the fracture and the external air. In the 
 base of the skull, however, a fracture may open up one of the 
 deeper air-sinuses, and thus cause it to become compound without 
 any apparent external lesion. These terms, though sanctioned 
 by the approval of centuries, are neither of them good, sub- 
 cutaneous and open being preferable. A subcutaneous fracture is 
 often anything but a simple injury, and may result in the most 
 disastrous consequences, whilst an open fracture may be a matter 
 of 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 entirely interrupted. Various 
 forms of Incomplete Fracture are described, and since the introduc- 
 tion of skiagraphy their presence has frequently been determined 
 in cases which would otherwise have been overlooked. Thus, 
 the green-stick fracture is one which only occurs in young children, 
 and most often in those thai are rickety ; curved bones, such as 
 the clavicle, are usually affected, and the fracture merely involves 
 the convexity 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 without fracture and the inner table alone splintered. 
 Fissured fractures also are often only partial. 
 
 Complete Fractures may be transverse, though this is not very 
 
4 20 A MANUAL OF SURGERY 
 
 common ; oblique, arising usually from indirect violence ; spiral, 
 when the fracture is due to a force acting longitudinally, but at 
 the same time with a rotary movement superadded ; 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 ; see Plate X.). A longitudinal fracture is one due to Assuring 
 or splitting of the bone in its long axis ; it is most common in 
 military surgery, as the result of gunshot injuries; the neighbour- 
 ing joints may or may not be involved. If it is combined with a 
 transverse fissure, it is often termed T-shaped. Comminuted is a 
 term used to describe the condition when the bone is broken into 
 more than two pieces ; impacted, when one fragment is driven into 
 the other ; multiple, when more than one fracture exists ; com- 
 plicated, when important structures, such as an artery or joint, are 
 damaged as well as the bone. 
 
 The Separation of an Epiphysis is not an uncommon occurrence 
 in people under twenty-two years of age. It results from injury 
 or violence directed to the ends of the bones, but occasionally is 
 more or less spontaneous, or predisposed to by disease of the 
 epiphysis or of the adjacent portion of the diaphysis {e.g., from 
 inherited syphilis, or acute infective or tuberculous epiphysitis). 
 The ends of the femur, humerus, or radius are those most often 
 affected. The line of cleavage usually runs through the soft 
 spongy bone on the diaphyseal side of the cartilage, so that there 
 is cartilage with spicules of bone on one side, and spongy bone on 
 the other. The direction taken is in the main transverse, but most 
 epiphyses are more or less concave or cup-shaped, the ends of the 
 diaphyses being convex. In very young children, where the 
 epiphysis is entirely or mainly cartilaginous, the lesion is almost 
 always a pure separation of the epiphysis from the shaft ; but at a 
 later date it is not unusual for the fracture also to implicate the 
 adjacent end of the diaphysis (Fig. 143). A very marked feature 
 in all these lesions is the stripping up of the periosteum, which, 
 though loosely attached to the shaft and easily detached from it in 
 children, is firmly adherent to the cartilage, and hence retains its 
 connection with it, thus frequently limiting displacement. If, 
 however, the force is sufficient, the periosteum is torn through on 
 one side by the edge of the bone, and the periosteal ' sleeve ' 
 which thus invests it may to some extent hinder reduction. The 
 displacement is mainly lateral, and may somewhat resemble that of 
 a dislocation. Union usually occurs by means of bone, and arrest 
 of the longitudinal growth may follow, though not so frequently 
 as was at one time supposed, and probably only when the parts 
 are not in exact apposition. This is a matter of special import- 
 ance where one of the bones of the leg or forearm is affected, since 
 deformities of the hand or foot often result from the continued 
 growth of the uninjured bone. Suppuration sometimes occurs as 
 a sequela in unhealthy children, or when the accident is due to 
 
PLATE X. 
 
 Oblique Fracture of Tibia, showing the Ends of the Fragments' shaped 
 
 en bee de flute. 
 
 The skiagram was taken from the front through a casing of plaster of Paris, the 
 
 irregular outline of which can be seen on the inner side of the limb. 
 
 To face p. 420.] 
 
INJURIES OF BONES— FRACTURES 421 
 
 preceding disease of the epiphysis, and may result in an acute 
 arthritis, possibly necessitating amputation. 
 
 Partial detachment of an epiphysis (the juxta-epiphyscal strain of 
 Oilier) often occurs, giving rise to phenomena similar to those of 
 a sprain ; if overlooked and neglected, it is likely to prove a fertile 
 source of tuberculous disease, or may interfere with the growth of 
 the limb. The essential feature is a more or less tender but 
 very distinct swelling of the bone close to the epiphysis, but the 
 neighbouring joint remains unaffected. Treatment consists in 
 immobilization in plaster of Paris. 
 
 Signs of Fracture. — The history usually given by the patient is 
 that, as the result of some accident, he felt, or perhaps heard, 
 something 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, bruising, and swelling, 
 as a result of the effusion of blood from the torn and lacerated 
 structures. 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 
 discoloration 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 thicken- 
 ing, and possibly to serious adhesions and limitation of move- 
 ment ; this fact is correctly utilized as an argument in favour of 
 the treatment of fractures by an open operation. It is unusual for 
 suppuration to occur after a simple fracture, but if the patient is 
 very debilitated, and his germicidal powers diminished, auto- 
 infection and abscess may result. 
 
 2. Preternatural mobility in the continuity of the bone may be 
 demonstrated by manipulation, but never unnecessarily. Im- 
 paction of the fragments prevents its occurrence. 
 
 3. Partial or complete loss of function also follows. 
 
 4. Crepitus is obtained by moving the limb and rubbing the 
 rough ends against one another. It can only be felt when the 
 fragments are moveable and can be brought into contact, but not 
 when there is wide separation or impaction. When an epiphysis 
 has been detached, it is softer in character. 
 
 5. Change in shape of the limb or deformity from displacement is 
 almost always present. There are three chief factors at work in 
 producing deformity, 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, usually due to an 
 
4 22 A MANUAL OF SURGERY 
 
 increased curvature of the bone from the unbalanced action of 
 powerful muscles, especially when the line of fracture is not far 
 from the end of the shaft, as in fracture of the upper third of the 
 thigh ; 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 fragments, 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. 
 
 Such are the typical signs of a fracture, but it goes without 
 saying that all of them are not present in every case, and that it 
 is not always easy to ascertain the existence or not of such a 
 lesion. Comparison with the opposite limb, and gentle manipula- 
 tion to demonstrate abnormal mobility or crepitus, must be under- 
 taken to settle this point, but no undue violence should be used. 
 
 The X rays have proved of the greatest value in these cases, 
 and where there is any doubt as to the existence or not of a 
 fracture, the limb should be at once skiagraphed. 
 
 General or Constitutional Effects. — These may be divided into 
 two groups : 
 
 i. Immediate Effects, consisting of shock and haemorrhage. 
 Shock is greater or less according 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 concussion of the brain or 
 injury to the spinal cord may also be produced. Hemorrhage 
 always occurs either in simple or compound fractures, and it may 
 progress to a considerable degree from laceration of important 
 vessels or even of the main artery of a limb. 
 
 2. Secondary or Remote Effects. — Fracture fever 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 ioo° F. in uncom- 
 plicated cases. It is a form of aseptic traumatic fever, probably 
 due to the absorption of fibrin ferment. In compound fractures 
 where asepsis is not attained, any form of wound infection may 
 result, and even general septicaemia or pyaemia. 
 
 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. 221). 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. 
 
INJURIES OF BONES— FRACTURES 423 
 
 Fat embolism is a condition resulting from the absorption of 
 broken-up fat globules after any injury which results in the con- 
 tusion or laceration of fatty tissue. If at the same time much 
 tension from effusion of blood is present, as in fractures where the 
 medullary fat is involved, this process is more likely to occur. 
 As a general rule, no harm results, since the great mass of the 
 fat is filtered off by the lungs or eliminated by the kidneys (as 
 can be demonstrated after death by staining with osmic acid). 
 The pulmonary obstruction may, however, become so great as to 
 lead to a fatal issue from dyspnoea ; whilst if the cerebral vessels 
 are also blocked, syncope, or even coma, may be induced. The 
 symptoms, which are gradual in their onset, usually commence 
 about the third day, but may not be evident for a week or more. 
 
 Complicated Fractures. 
 
 1. Comminution of one or both fragments is due to excessive 
 violence, or perhaps to exceptional brittleness of the bones. As 
 long as the skin remains unbroken, sound union is usually ob- 
 tained, though with an increased amount of callus. Occasionally 
 comminution may be a cause of non-union, a small detached 
 portion of dense compact tissue being wedged cross-wise between 
 the fragments, especially in the case of the tibia or femur. In a 
 compound fracture serious mischief may result from sepsis. 
 
 2. Fracture implicating a Joint. — In healthy individuals no 
 untoward result is met with ; the joint is for the time filled 
 with blood, which, however, is soon absorbed, and the fissure in 
 the cartilage closed by plastic lymph. Adhesions are, however, 
 very liable to form, as also new bony deposits, leading to defective 
 mobility or even locking of the joint. Early passive movement 
 and the breaking down of adhesions under chloroform may 
 improve matters. If the patient has a tuberculous tendency, 
 arthritis will possibly be lighted up, whilst osteo-arthritis is often 
 induced by an accident of this nature. 
 
 3. The same violence that causes the fracture may at the same 
 time produce a Dislocation in a neighbouring joint. Treatment 
 should be undertaken immediately ; the limb is firmly fixed 
 in splints commanding both fragments, and reduction attempted 
 under chloroform. Failing this, consolidation must be allowed 
 to proceed, and then the case dealt with as one of old-standing 
 dislocation (p. 547). If the fracture involves, or is close to, the 
 articular end of the bone, as is not unfrequent at the elbow and 
 shoulder, it may be advisable to operate at once, opening the 
 joint, reducing the dislocation, and wiring the fragments ; or it 
 may be better to remove the small detached articular portion. 
 
 4. The Main Artery of a limb may be compressed, contused, 
 punctured, or ruptured. Thrombosis results, with or without such 
 an extravasation of blood as may impede the venous return. If 
 
4 2 4 A MANUAL OF SURGERY 
 
 the peripheral vessels are healthy, no permanent harm need follow, 
 unless the vein is also implicated, and then moist gangrene is 
 likely to supervene. If the terminal vessels are calcareous and 
 rigid, so that there has been a preceding condition of chronic 
 anaemia, dry gangrene will probably ensue. In the slighter cases 
 an aneurism may subsequently develop. For further details, 
 see Chapters V. and X. The Treatment must necessarily vary 
 in different cases. The ideal practice would be to cut down in 
 every case where a large artery is punctured or ruptured, remove 
 clots, and tie above and below the injury in the vessel ; but, 
 owing to the extensive laceration and displacement of the parts, 
 it is not always advisable to do so, and, indeed, it should never 
 be undertaken without the most rigid asepsis. If it is considered 
 unwise to lay the parts open, the main artery may be compressed 
 or tied above the fracture, but only where the distal circulation 
 has been re-established ; in the absence of this condition, gangrene 
 would be certain to ensue. If neither of the above-mentioned 
 expedients can be adopted, an expectant plan of treatment must 
 be followed. The limb is thoroughly purified, wrapped in aseptic 
 wool, placed on appropriate splints, and slightly elevated. Should 
 gangrene supervene, amputation is the only resource ; it need not 
 be undertaken for a few days if the limb is aseptic, so as to allow 
 a distinct line of separation to form ; but if septic, early removal 
 through or above the line of fracture is essential. 
 
 5. Laceration of the Veins of a limb results in extravasation of 
 blood, which is not so extensive as when an artery is wounded, 
 from the fact that thrombosis is more easily determined owing to 
 the lesser blood-pressure, but the congestion and oedema of the 
 distal part of the limb which follow constitute serious additional 
 elements predisposing to gangrene. Simple compression of the 
 veins produces oedema, which, even in favourable cases, may 
 persist for some time, needing for its removal firm bandaging, 
 massage, and cold douching. 
 
 6. The Nerves of a limb may be injured at two different periods. 
 (a) Immediate injury is due to laceration or rupture, either of the 
 whole trunk, or, as is more common, of the nerve fibrillae, without 
 loss of continuity of the sheath. Paralytic and anaesthetic pheno- 
 mena follow, but are usually recovered from. (b) Secondary 
 symptoms result from inclusion and compression of the nerve 
 in the callus, or from injudicious splint pressure. Irritative 
 symptoms in the shape of neuralgia and muscular spasms are 
 first manifested, followed by paralysis and anaesthesia. This 
 usually occurs about three or four weeks after the accident, 
 and may disappear in a month or two, or persist. Treatment is 
 always for a time of the expectant type, even when the paralysis 
 is immediate, since total rupture of a nerve is rare, and restoration 
 of function the rule rather than the exception. When, however, 
 the symptoms persist, the parts must be laid open, the nerve freed 
 
INJURIES OF BONES— FRACTURES 425 
 
 from adhesions, or exuberant callus removed, and such measures 
 taken as will best secure the nerve from further compression. 
 
 Union of Fractures. 
 
 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 farther 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, according to Oilier, the 
 rupture is not always complete all round, a ' periosteal bridge ' 
 perhaps persisting, and playing an important part in the repara- 
 tive process, especially if the fracture is not accurately set. The 
 muscles and neighbouring tissues are also 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 inaugurated by the blood-clot 
 becoming invaded by leucocytes, and after a time it is absorbed, 
 the haemoglobin passing through various stages of degeneration, 
 and thereby staining the surrounding tissues. At the same time, 
 a rarefying inflammation occurs in all the injured and lacerated 
 structures, as a result of which there is an exudation of plasma 
 into their substance, whilst the connective-tissue cells proliferate 
 actively, and thus a cellulo-plastic exudation forms around and 
 between the lacerated tissues and broken ends of the bone, which 
 is transformed into granulation tissue by vascularization from 
 circumjacent vessels. Calcification of this material follows, pre- 
 ceded or not by a cartilaginous or fibrous change, and this calcified 
 material is in its turn replaced by bone, which, at first soft and 
 spongy, becomes after a time firm and sclerosed. Of course, 
 these changes do not occur simultaneously in all the tissues 
 involved, and we must refer to them as they affect the periosteum, 
 the medulla, and the bony substance itself. 
 
 The periosteum becomes thickened and more vascular, and its 
 connection with the bone is loosened for a short distance by an 
 exudation of plasma, which is soon followed by a new deposit of 
 spongy bone on the surface, as a result of the irritation. The 
 space beneath the periosteum is quickly occupied by granulation 
 tissue, which unites with that developed from surrounding torn 
 structures and with that coming from the bone itself, and this ovoid 
 mass binding the fractured ends together is known as the pro- 
 visional or enskeathing callus. The transformation of this callus into 
 bone starts from the periosteum ; if it has been totally lacerated, 
 ossification commences at the furthest point from the fracture 
 where the irritation caused thereby is felt, and gradually spreads 
 
426 A MANUAL OF SURGERY 
 
 in. If a periosteal bridge is left, ossification commences on its 
 under surface, and not unfrequently in skiagrams a line of newly- 
 formed bone can be seen passing from one fragment to the other, 
 and evidently due to this cause. Some authorities maintain that 
 new bone derived from periosteum in this manner is always pre- 
 ceded by cartilage, but this is probably not the case, although the 
 presence of cartilage in the repair of fractures is more common 
 than was formerly supposed. It is most likely to occur in cases 
 where absolute immobilization has not been obtained — e.g., after 
 fractures of the ribs and in children. 
 
 The changes obtaining in the medulla consist in its becoming 
 hyperaemic for some distance from the seat of fracture and its 
 transformation into granulation tissue, which unites with that 
 springing up from the opposite fractured surface. Ossification 
 commences in this, probably from the inner aspect of the compact 
 shell, from which fine spicules of bone gradually permeate the 
 granulation mass until the whole is ossified, constituting the 
 internal callus, or, better, the medullary plug. There is here no 
 formation of cartilage. 
 
 Naturally, the bony tissue involved in the fracture is the last 
 to engage in these changes, and the denser the bone, the longer 
 they are in being completed. The fractured end becomes hyper- 
 aemic, and practically passes into a condition of rarefying osteitis, 
 the bone cells proliferating, 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 ; but the union with the periosteal callus is 
 slower, since all the blood-clot and the damaged surface of the 
 bone must be entirely removed before this is possible ; indeed, 
 the annular bond of union between the two layers of compact 
 bone, to which was originally applied the name ' definitive callus,' 
 is probably of periosteal origin, and not derived at all from the 
 fractured surface. 
 
 It will thus be obvious that the continuity of a bone is restored 
 long before the act of repair is completed, and that such union 
 depends on the ossification of the ensheathing callus. The 
 rapidity of this process varies with the amount of periosteal 
 laceration, but in many cases the callus is sufficiently firm to 
 allow of gentle passive movement in ten to twelve days, and in 
 three or four weeks it may be so firm that it is difficult to bend 
 the bone with the fingers. The newly-formed osseous tissue is 
 at first soft and spongy, but gradually becomes denser. As the 
 so-called definitive callus becomes stronger, the ensheathing 
 callus disappears, 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 
 
INJURIES OF BONES— FRACTURES 
 
 42/ 
 
 circumstances, to be so absolutely restored as to show no signs 
 of its having been fractured. 
 
 Thus far we have been supposing that the broken ends are 
 accurately apposed and the limb immobilized ; but little callus is 
 formed (Fig. 123, A), and that equally and evenly all round the 
 site of the fracture. Where, however, movement is possible, the 
 amount of callus is much increased. 
 
 Where the ends of the bones partially overlap (Fig. 123, B), 
 the amount of ensheathing callus (c) is correspondingly increased, 
 and fills up all the spaces left by the overlapping of the frag- 
 ments. The projecting margins of bone are rounded off, and the 
 
 Fig. 123. — Diagram to represent Union of Fractures: A, when the 
 Ends are in Close Apposition ; B, when the Ends are only Par- 
 tially Apposed; and C, when the Fractured Surfaces are not in 
 Contact at all. 
 
 a, True or definitive callus ; b, internal or medullary callus ; c, external or 
 provisional callus. 
 
 medullary cavities closed by plates or plugs (b) ; the amount of 
 definitive callus (a) is usually small, but varies with the actual 
 conditions present. The main bond of union is the ensheathing 
 mass, a considerable portion of which persists. Some deformity 
 is sure to remain after such an accident, and it is unusual for the 
 medullary canal to be restored ; frequently one or more plates of 
 bone are found crossing it- 
 
 If the fractured ends are not placed in contact at all (Fig. 123, C), 
 the medullary cavity of each fragment is closed by a plate of 
 internal callus (b), and union is secured by a large mass of en- 
 sheathing callus (c). 
 
 Where comminution has occurred, the splintered fragments are 
 matted together by an abundant formation of granulation tissue, 
 which is subsequently transformed into callus. 
 
42 8 A MANUAL OF SURGERY 
 
 The soft tissues around— muscles, tendons, etc. — are repaired in 
 the usual way, but one cannot overlook the fact that such repair 
 is often very imperfect, owing to the infiltration of the parts with 
 blood and the subsequent adhesions that form. In fact, although 
 the bones may unite perfectly, the functional result may be most 
 disappointing. 
 
 The removal of the clot and the formation of granulation tissue 
 usually take about a week or ten days, and new bone formation 
 commences about the end of the first week. By the fourth or 
 sixth week, according to the size and vascularity of the bone and 
 the recuperative power of the individual, the fracture will be con- 
 solidated, but in the lower limb it is often eight weeks before the 
 patient can bear any weight upon it. Months may, however, pass 
 before the final stage of complete repair is attained. 
 
 In conclusion, one must allude to the fact that a sarcoma some- 
 times develops at the site of fracture within a comparatively 
 short time of the accident, and is presumably derived from an 
 overgrowth of the callus. 
 
 The Treatment of simple fractures is sometimes a matter of but 
 little difficulty, although when the bones are much displaced or 
 comminuted, it may not be easy to correct the deformity or to 
 maintain the fragments in position. Constitutionally , all that is 
 needed is to restrict the diet, eliminating all stimulating and 
 unnecessary articles, at the same time attending to the state of 
 the bowels. This is especially needed in fractures of the lower 
 extremity, where the patient must be confined to bed for some 
 time. In elderly people the general health is very likely to suffer, 
 partly from the shock of the accident, partly from the enforced 
 and sudden change of habit, necessitating a somewhat generous 
 diet and the administration of a certain amount of stimulant. 
 
 The Local Treatment of a simple fracture consists, first, in setting 
 the limb— that is, in reducing the deformity and restoring the 
 fractured ends to a normal position — and then in fixing it. 
 
 First Aid. — In moving the patient from the spot where the 
 accident happened, it is necessary to temporarily secure the limb 
 in as good a position as possible ; splints have often to be im- 
 provised from sticks, umbrellas, newspapers, and so forth. In a 
 railway accident the splintered debris of the carriages may be 
 employed for this purpose, and the upholstery of the seats as 
 padding. A broken leg may also be firmly tied to the other limb, 
 which is thus converted into a temporary splint. 
 
 Reduction of a fracture is usually accomplished by a combination 
 of traction or extension applied to the lower segment of the limb, 
 with manipulation of the fractured ends, counter-extension being 
 at the same time maintained by an assistant. In some cases it is 
 necessary to relax certain muscles in order to facilitate reduction ; 
 thus, in fractures of the leg, the lower fragment is liable to be 
 
INJURIES OF BONES— FRACTURES 429 
 
 drawn up by the muscles attached to the tendo Achillis, and to 
 obviate this the knee should always be flexed by an assistant, 
 who holds up the leg and makes counter-extension, whilst the 
 surgeon reduces the deformity by traction on the lower part of 
 the limb ; section of this tendon is sometimes required in these 
 cases. The manipulation is painful, but, if possible, an anaesthetic 
 should be dispensed with, as one can never be certain whether 
 or not the patient will struggle during its administration. It is 
 unwise to use too much force in order to correct decided shorten- 
 ing from muscular contraction ; it is better to relax the muscles 
 by the adoption of a suitable position, or to apply continuous 
 extension. There can be no question that in bygone days patients 
 were subjected to a great deal of unnecessary pain from misguided 
 efforts to ' set ' the fracture. 
 
 The maintenance of the limb in a good position is provided for 
 by the application of suitable splints. These consist of materials, 
 such as wood, leather, zinc, poroplastic, etc., according to the 
 requisites of the case. If of wood, zinc, or tin, they are usually 
 made according to some general pattern, and fitted to the patient 
 by means of pads ; if formed of leather or poroplastic, they should 
 be shaped so as to meet any peculiarities of the part. A paper 
 pattern is first fitted to the opposite limb, and the splint is then 
 cut to the desired shape ; it is softened by immersion in hot or 
 cold water, moulded to the part, and allowed to dry. Where 
 leather is employed, the addition of a little vinegar to the water 
 assists in rendering it soft and supple. The edges and corners 
 are finally rounded, and the interior padded with wool or lint. 
 The general rules relating to the application of splints are as 
 follows : (i.) The joints both above and below the site of fracture 
 should always be immobilized ; (ii.) the splints must be sufficiently 
 large to firmly encase the part, or if flat, to project a little beyond 
 it, so that the limb may be fixed by the splint, and not the splint 
 by the limb ; (iii.) careful attention must be given to the padding 
 so as to prevent irritation or sloughing of the skin. In out- 
 Datient practice, where the patients are not too careful as to 
 personal cleanliness, it is advisable to pad the splint with some 
 antiseptic material, such as boracic lint, in order to prevent the 
 development of vermin. It is better not to apply a roller bandage 
 under the splint in the situation of the fracture. The splints may 
 often with advantage be first fixed to the limb by one or two turns 
 of strapping, and then secured by ordinary calico bandages ; 
 these must not be applied too tightly, since the swelling of the 
 limb not unfrequently increases afterwards, and undue constric- 
 tion resulting in gangrene may ensue. Moreover, a limb en- 
 sheathed in bandage must never be flexed, but the flexion should 
 always be made first ; if this is not attended to, the bandage may 
 cut into the soft tissues, and by compression of the vessels cause 
 gangrene. It is sometimes advisable to bandage the whole of the 
 
430 A MANUAL OF SURGERY 
 
 limb from the fingers or toes upwards, so as to prevent oedema 
 from the pressure of the apparatus obstructing the venous return. 
 The patient should always be seen on the day following the 
 application of the splints, and the condition of the fingers or toes 
 carefully examined ; if they look at all blue, or feel numb and 
 cold, the bandages must be slightly relaxed. 
 
 Various forms of Fixed Apparatus are used in the treatment of 
 fractures, especially in the later stages when the swelling has 
 disappeared, and in children. The materials most commonly 
 employed are starch, water-glass, and plaster of Paris. 
 
 The starch bandage is utilized only in cases where great 
 strength and rigidity are not required. The limb is carefully 
 padded with cotton wool, and over this are applied thin strips of 
 cardboard soaked in starch so as to fit the limb. These are secured 
 by a bandage, the meshes of which are well impregnated with a 
 starch solution, and over all may be placed another bandage, the 
 under surface of which is also rubbed with starch. When this 
 dries, it produces a firm mass, sufficient to immobilize the limb. 
 It should be put on fairly tight, the wool padding, if thick enough, 
 sufficing to prevent injurious constriction. If employed in the 
 early stages of fractures, it becomes loose when the swelling of 
 the limb diminishes, and must then be readjusted by slitting up 
 and paring away a portion on one or both sides. 
 
 The water-glass bandage is applied by first swathing the limb 
 with a thick padding of cotton wool, or bandaging it with boracic 
 lint ; around this a coarse canvas bandage soaked in a solution of 
 silicate of soda, strong enough to be of the consistency of treacle, 
 is applied ; several thicknesses of the bandage are required in 
 order to give it the necessary strength. The great advantage of 
 this material is that it is light, easily applied, and makes very 
 little mess ; the chief objection is that it dries but slowly, taking 
 fully twenty-four hours to become hard and firm. 
 
 Plaster of Paris, though rather messy and increasing con- 
 siderably the weight of the limb, is one of the best means of 
 securing prolonged immobilization. It may be applied directly 
 to the outside of a layer of cotton wool or boracic bandage ; but 
 frequently a coarse canvas bandage or a suitable piece of house- 
 flannel is employed as a foundation on which to place it. (a) The 
 dried plaster may be rubbed into a coarse canvas bandage, which 
 prior to use is soaked for a few minutes in cold water, to which 
 a little salt or alum may be added in order to hasten its 
 setting ; it is then wound round the limb, wmich has been 
 previously padded with boric lint or wool, and on the exterior of 
 this fresh plaster of the consistency of cream is applied. To 
 make this cream of the right strength, the dried powder is cast in 
 spoonfuls into a bowl of cold water until it no longer sinks im- 
 mediately, but a portion remains floating on the surface. The 
 mixture is then stirred with an iron spoon, and is ready for use. 
 
INJURIES OF BONES— FRACTURES 431 
 
 (b) It may also be fitted to any part of the body, according to a 
 method introduced by Mr. Croft, of St. Thomas's Hospital. If 
 required for a limb, pieces of flannel are cut into the shape of 
 lateral splints, two for each side, and sufficiently large to encase it 
 comfortably. After protecting the limb with wool or lint, one of 
 the lateral segments, the outer side of which is well soaked with 
 plaster, is placed in position, and the second portion, which has 
 been totally immersed in the plaster, is then placed over it, a little 
 extra plaster being perhaps rubbed in ; the two are now secured 
 by a muslin bandage. After this has set, the opposite side of 
 the limb is dealt with in exactly the same way, and when the 
 whole is solid, the muslin bandage is cut through in front, but is 
 left untouched behind so as to form a hinge. If it is considered 
 necessary, thin strips of wood or tin may be incorporated in any 
 of these arrangements, so as to add to their strength. 
 
 Early immobilization by means of plaster of Paris has been 
 advocated by certain Continental and American authorities, and so 
 much confidence have they in it that even fractures of the femur 
 are dealt with in this way within a few days of the accident, and 
 the patient allowed to walk about. Such ambulatory treatment has 
 not received much support in this country, and does not seem to 
 us in accord with the principles that guide us in restoring a limb 
 to functional as well as mechanical soundness. 
 
 A most valuable adjuvant in the treatment of fractures is 
 Massage, advocated so forcibly by Lucas-Championniere, whilst 
 in some cases Early Mobilisation is also desirable. The part is 
 kept in splints only long enough to ensure the non-recurrence of 
 displacement, and the patient is encouraged to use the limb. It 
 has long been recognised that after an accident of this nature the 
 limb is likely to remain for some considerable period weak and 
 stiff, owing partly to atrophy of muscles, partly to cicatricial 
 adhesions between various divided structures, and in part to con- 
 traction of ligaments in neighbouring joints. It is the object of 
 massage to prevent or obviate these disabilities. In a fracture 
 with displacement through the shaft of a long bone, massage of 
 the soft tissues should commence about three weeks after the 
 injury (for the femur a little later), and be conducted methodically 
 day by day, the splints being removed for the purpose and re- 
 applied subsequently ; neighbouring joints will also be rubbed, 
 and passive movements of the same commenced as soon as advis- 
 able. Possibly some pain may be noticed at first, but it soon 
 disappears, and the patient experiences a sense of comfort. 
 Repair is hastened, but of course the patient must not put any 
 strain on the bone until it is quite consolidated. In fractures near 
 joints or through the articular ends of bones, it is sometimes pos- 
 sible to discard splints entirely, or at any rate to use them only for 
 a short time, steadying the part by some simple contrivance, such 
 as a sling or strapping. Massage is commenced within a few days 
 
43? A MANUAL OF SURGERY 
 
 and regularly persisted in. For such injuries as fracture of the 
 anatomical neck of the humerus, the simpler varieties of Colles's 
 or Pott's fracture, and for some fracture-dislocations in the neigh- 
 bourhood of the elbow, this plan of treatment has been already 
 proved to be of the greatest service. In one case of the first men- 
 tioned of these lesions, which we treated by this means at hospital, 
 the result was most gratifying ; the limb was merely kept in a 
 sling, and massage was commenced within three days of the 
 accident ; within a fortnight the patient was able to raise his arm 
 without help to a right angle, and he went out subsequently with 
 a limb the movements of which were almost perfect. 
 
 During the last few years considerable impetus has been given 
 to the Early Operative Treatment of fractures in order to secure 
 complete fixation and the restoration to health and usefulness in 
 as short a space of time as possible. At first this plan was only 
 utilized for such bones as the patella or olecranon, but the excellent 
 results which followed, and the increased confidence with which 
 antiseptic methods were employed, soon removed all the fears of 
 opening up a so-called simple fracture in order to deal directly with 
 the ends of the bone. Moreover, it soon became obvious, when 
 once sepsis had been excluded, how much better results often 
 followed compound fractures which had been operated upon than 
 simple fractures which had been treated by the routine immo- 
 bilization, especially after oblique fractures of the larger bones. 
 The reason for this was that accurate apposition of the fragments 
 apart from operation is almost impracticable in such cases, whilst 
 the infiltration of the tissues with blood leads to much fibrosis and 
 the formation of many adhesions ; moreover, the more lengthy 
 immobilization results in greater atrophy of muscles and stiffness 
 of joints, and hence the commercial value of a working man 
 after a fracture of the thigh or leg is very considerably depreci- 
 ated, owing partly to persistent deformity, partly to the joints 
 being stiff, whilst the period of convalescence is reckoned by 
 months rather than weeks. Should, such a case be operated on, 
 the blood being removed, and the end of the bones freed from 
 intervening tissues and securely united by wires, screws, or pegs, 
 convalescence may be anticipated in a comparatively short time ; 
 the bone retains its normal length ; early massage of the muscles 
 and joints above and below becomes practicable, owing to the 
 fixity of the limb, and thus atrophy on the one hand, and stiffness 
 on the other, are avoided. 
 
 At the same time one must emphasize the gravity of these 
 operations, which are only justifiable when complete asepsis can be 
 maintained, whilst the manipulative dexterity required in order to 
 bring them to a successful issue is such that, in our opinion, the 
 general practitioner, who undertakes but little operative work in 
 the year, is not justified in performing them. 
 
 As to the actual operation, the incision to expose the bone 
 
INJURIES OF BONES— FRACTURES 433 
 
 should be extensive, so as to give plenty of room and allow exit 
 to as much of the extravasated blood as possible. The ends of 
 the fragments are then cleared, and brought into position, attention 
 being directed to make certain that there is no abnormal rotation, 
 and fixed by suitable forceps with a large grasp, e.g., Peters'. 
 The fragments are drilled in one or two places, and silver wire or 
 plated screws introduced ; the ends of the wires are twisted up, 
 cut short, and the knot hammered down into the periosteum. 
 Various encircling contrivances of the collar type have been sug- 
 gested in order to assist in the fixation of the bone, and may prove 
 useful under certain circumstances. 
 
 Complications arising during Treatment. — (i) If an elderly 
 patient is kept in bed for any length of time in the recumbent 
 posture, hypostatic pneumonia is likely to ensue. It occurs most 
 commonly after intracapsular fractures of the cervix femoris, and 
 non-union often results, since the patients must be allowed to get 
 about on crutches at an early date, the limb being merely fixed 
 by a Thomas's splint. (2) Bedsores are very liable to supervene in 
 old people with fractures which need treatment in the recumbent 
 posture. (3) Crutch palsy is the result of compression of the 
 brachial nerves between the head of the humerus and the pad of 
 a crutch. It may affect all the nerves of the upper extremity, or 
 may pick out any one of them, and then most commonly the 
 musculo-spiral. It can usually be prevented by the use of spring- 
 padded crutches with cross-pieces for the hands, so as to allow 
 the patient to partially relieve the axillary pressure by supporting 
 the weight of the body by means of the arms. When it has 
 occurred, the use of crutches must be discontinued, and faradism 
 and massage employed to the affected muscles. (4) When the 
 muscles of a part have been firmly compressed by splints, they 
 may undergo a rapid intrinsic atrophy with contraction, con- 
 stituting what is known as Ischemic contraction. This is observed 
 most frequently in the hand, and is then due to the direct pressure 
 of the splints on the muscles of the forearm. The fingers become 
 clawed and flexed, and the wrist is sometimes hyper-extended. 
 It is recognised from the results of a nerve lesion by the absence 
 of sensory or trophic phenomena. Treatment consists in exposing 
 and lengthening the contracted tendons, if massage fails. The 
 outlook is, however, not very promising. (5) Gangrene may arise 
 from fractures in a variety of ways : (i.) From the immediate 
 effects of the injury, either by its direct action on the tissues, or by 
 causing arterial thrombosis in a limb with atheromatous vessels, 
 or from rupture of the artery with consequent venous thrombosis, 
 owing to the pressure of the extravasation ; (ii.) by the super- 
 vention of spreading gangrene in a compound fracture ; (iii.) from 
 errors in the course of treatment, as by bandaging the limb too 
 tightly, so as to constrict the vessels ; or by the bandage becoming 
 unduly tight, owing to the subsequent swelling of the limb ; or by 
 
 28 
 
434 A MANUAL OF SURGERY 
 
 flexing a joint after bandaging it, the bandage cutting into the 
 soft tissues ; or by the localized pressure of a splint which has 
 been insufficiently padded. Moist gangrene is the type met with 
 in all cases, except when the limb has been previously drained of 
 its fluids by an atheromatous condition of its vessels. (For rules 
 of treatment, see Chapter V.) 
 
 Compound Fractures. 
 
 A compound fracture is one in which there is a communication 
 between the external air and the site of injury. It is produced by 
 direct or indirect violence, and any of the complications or modifi- 
 cations met with in simple fractures can be present. The bones 
 may be but little displaced, or protrude through the opening in 
 the skin, and under such circumstances may be much bruised or 
 comminuted, and even contaminated with dirt or mud. 
 
 The chief dangers of compound fractures are, firstly, hemorrhage, 
 the blood, instead of collecting within the tissues of the limb, 
 escaping externally, although subcutaneous extravasation is not 
 uncommon ; and secondly, the advent of sepsis. The latter is the 
 more important, and may lead to the most serious consequences. 
 Portions of muscle and periosteum, which in a simple fracture 
 would be removed or incorporated in the new formation of 
 callus, become inflamed in septic cases, and even slough. Small 
 isolated fragments of bone are almost certain to necrose if sup- 
 puration ensues, whilst the severest forms of septic osteomyelitis 
 may occur, endangering the patient's life by pyaemia. Such 
 results are more likely to follow when the external wound is 
 small and insufficient provision has been made for drainage. 
 Immense advances in the treatment of these conditions have 
 been made since the introduction of antiseptic surgery, and 
 where such is regularly and efficiently practised, these dangerous 
 complications are rarely seen. 
 
 The Method of Union of a compound fracture is practically the 
 same as that occurring in simple fractures. If the wound can be 
 rendered aseptic, and there is not much bruising, it may be 
 closed by suture except at the spot where a drainage-tube is in- 
 serted. Primary union may thus be obtained, and then repair 
 according to the details already described will follow. If, however, 
 suppuration occurs, it is probably attended with a greater or less 
 amount of necrosis, and possibly diffuse suppuration in the soft 
 parts ; the wound will therefore remain open for a tine, varying 
 with the acuteness of the local phenomena. It is gradually closed 
 by granulations, which extend upwards from below, and the 
 deepest part of this granulation tissue, which is derived from the 
 bone and periosteum, and contains osteoblastic elements, will be 
 transformed into callus, and finally into true osseous tissue. 
 
INJURIES OF BONES—FRACTURES 435 
 
 Repair is much slower under these circumstances than in a 
 simple fracture, since the suppuration may have interfered with 
 the osteogenetic powers of the periosteum, and thus the new bone 
 formation is dependent solely on the osseous tissue itself, which is 
 always slow to react. 
 
 The Constitutional Symptoms following compound fractures are 
 much more marked than in simple cases. Even where sepsis 
 is prevented by efficient treatment, some amount of aseptic 
 traumatic fever is certain to supervene for a few days, whilst, 
 if infection occurs, there is a period of marked febrile disturbance 
 for a week or ten days, similar to that which is seen in all septic 
 lacerated wounds (p. 197). 
 
 In the Treatment of compound fractures, the main object is to 
 render the wound aseptic and to give efficient exit to the dis- 
 charges. For this purpose the patient should in most cases be 
 anaesthetized, the wound enlarged and thoroughly washed out 
 and even scrubbed with some potent antiseptic, such as carbolic 
 lotion (1 in 20). Loose fragments of bone are removed, and 
 portions denuded of their periosteum may be taken away lest 
 necrosis should ensue ; where fragments retain any considerable 
 connection with the soft parts, they may be left without fear, and 
 of course as little periosteum should be removed as possible. 
 When a sharp end of one of the fragments is protruding through 
 a small opening in the skin, it is first thoroughly purified before 
 attempting its reduction, and then replaced, after enlarging the 
 wound in the skin, or a portion is sawn off. Haemorrhage is 
 dealt with in the usual way, and the fragments are placed as nearly 
 as possible in their normal position. If there is no comminution 
 and the fragments can be brought accurately into position, it is 
 well to fix them by the insertion of silver wire, or of ivory pegs, 
 or plated screws ; but where the ends of the bones are com- 
 minuted, the small portions must be arranged in position as well 
 as possible, and no attempt made to wire them. A good-sized 
 drainage-tube is inserted, and, if need be, counter-openings are 
 made ; the limb is then placed on appropriate splints, and the 
 external wound closed or not according to circumstances. Under 
 such a regime the majority of uncomplicated cases will do well. 
 Immoveable apparatus may be applied after a time, windows being 
 left in the plaster casing to allow wounds to be dressed. 
 
 In compound fractures which have been attended with com- 
 plications directed to vessels, nerves, and neighbouring soft parts 
 or joints, the prognosis and course of the case may be consider- 
 ably modified ; treatment suitable to each of these conditions must 
 be adopted. 
 
 The question of Amputation will necessarily be raised in the 
 more serious cases ; but it is unnecessary to add anything here to 
 what has already been stated in Chapter VIII. (p. 199). 
 
 28—2 
 
436 
 
 A MANUAL OF SURGERY 
 
 Ununited Fractures. 
 
 Three varieties of ununited fracture have been described : 
 (i) Absolute non-union is said to be present when no attempt at 
 repair is made. This rarely occurs except when some definite 
 bone disease exists, such as sarcoma or osteo-malacia, or when in 
 
 v" 
 
 Fig. 124. — Ununited Fracture with False Joint. 
 Surgeons' Museum.) 
 
 (From College of 
 
 a very debilitated patient there has been no attempt to fix the 
 limb. (2) Fibrous union consists in the development of a more or 
 less firm mass of connective tissue as the bond of union between 
 the ends of the bones, which are either rounded off and closed by 
 a thin plate of bone or cartilage, or are sometimes atrophic and 
 pointed. (3) A false joint, or pseudarthrosis, is a condition in 
 which the ends of the fragments are covered either by bone or 
 cartilage, and more or less altered in shape, so as to form a 
 shallow ball-and-socket joint, the capsule being represented by 
 the surrounding fibrous tissue, and the synovial cavity by an 
 adventitious bursa, which results from the friction of the two ends 
 (Fig. 124). 
 
 The most common situations for ununited fractures are project- 
 ing processes of bone to which powerful muscles are attached, 
 
INJURIES OF BONES— FRACTURES 437 
 
 such as the patella, olecranon, coracoid process, posterior half of 
 the os calcis, etc. ; whilst in long bones the middle of the shaft of 
 the humerus and the upper and lower thirds of the femur are the 
 favourite sites. 
 
 Many different Causes may be associated in determining the 
 defective union of fractures, but the following are the more 
 important : (1) Want of apposition of the bony ends, owing to 
 muscular action — e.g., in the patella, when the two fragments 
 are widely separated, or in the femur, where they may over- 
 lap ; (2) the interposition of fluid or such substances as muscular 
 or aponeurotic tissue, or detached fragments of compact bone ; 
 (3) want of rest, one of the most common causes, as in the 
 middle of the shaft of the humerus, where, unless the elbow is 
 well supported, complete immobility cannot be obtained, and 
 non-union is likely to result ; (4) defective blood-supply to one or 
 both fragments, as by injury to the nutrient artery, or as in intra- 
 capsular fracture of the cervix femoris, where the only source of 
 supply to the upper fragment is a small twig derived from the 
 obturator artery running along the ligamentum teres ; (5) local 
 affections of the bone, such as malignant tumours, destruction of 
 the periosteum by inflammation, or the undue pressure of pads 
 upon the newly-formed callus ; (6) general bone disease, as osteo- 
 malacia ; and (7) general constitutional weakness or debility, 
 sometimes due to definite diseases, such as scurvy or severe 
 syphilis, sometimes to general asthenia or alcoholism. It has 
 been proved that senility, pregnancy, and the cancerous cachexia 
 do not, as used formerly to be stated, predispose to this condition. 
 
 The Signs of an ununited fracture are usually obvious, mobility 
 between the fragments being easily obtained, although without 
 crepitus. 
 
 The Prognosis is good if suitable treatment is adopted. In 
 children, however, the condition is often maintained even after 
 operation, and, in fact, may be aggravated by it, the ends of the 
 bone becoming atrophic, rounded, and covered by cartilage ; in 
 such the final resource is not unfrequently amputation. 
 
 The Treatment of ununited fractures is now conducted on per- 
 fectly definite lines. (1) The parts are refixed in an immoveable 
 apparatus, preferably plaster of Paris, for six weeks, whilst means 
 are adopted to improve the general health, as by a stay at the 
 seaside and the administration of tonics. (2) Failing this, the 
 ends of the bones may be well rubbed together, so as to excite 
 local action, and the parts again fixed. Regular massage is useful, 
 and enforced congestion of the limb by an elastic tourniquet 
 applied for an hour or two daily has also been recommended. 
 (3) Should this be unsuccessful, operative measures must be 
 undertaken. If the bone is tolerably superficial, and the ends 
 not very far apart, they should be exposed, sawn into shape, 
 fitted together (preferably by a dove-tailing process), and secured 
 
438 
 
 A MANUAL OF SURGERY 
 
 by stout silver wire, which may be left in situ permanently, and 
 if aseptic, becomes encapsuled. If, however, the bones are deeply 
 placed, so that the operation to expose the ends and fit them 
 together becomes a very severe one, it is often better practice to 
 leave them in their bad position, and merely 
 fix them by the insertion of ivory pegs or 
 nickel-plated screws. Thus, in the upper end 
 of the femur non-union is usually associated 
 with overlapping of the ends of the bone to 
 a considerable extent. To expose and fit 
 these together would necessitate a very ex- 
 tensive dissection ; it is wiser in such cases 
 merely to cut down in front upon the upper 
 anterior fragment, drill two holes in different 
 directions through both fragments, and into 
 these insert suitable ivory pegs. Two holes 
 should always be employed, to prevent slip- 
 ping of the fragments during the many neces- 
 sary manipulations ; whilst one drill is 
 removed for the insertion of the peg, the 
 other holds the bone steady. As a rule, the 
 pegs may be allowed to remain permanently, 
 but occasionally they become loose in three 
 or four weeks, and" need removal. Their 
 presence causes the formation of a large 
 amount of callus, and by this means the frac- 
 ture is consolidated. It is well to examine the 
 fracture by the X rays from time to time to 
 see that the bones are still in position, and 
 for this purpose the dressings need not be 
 removed, if metal splints are not used. 
 
 Disunited Fracture is the term applied to 
 a rare condition, in which a fracture which 
 had been firmly united becomes separated 
 again. It is only met with when the indi- 
 vidual develops some extremely debilitating disease, such as 
 scurvy, and may be recovered from under suitable treatment 
 directed to the cause, and by fixation of the parts. 
 
 Vicious Union (Fig. 125) of fractures results either from imper- 
 fect readjustment of the ends of the bone prior to placing the limb 
 on an immoveable apparatus, or from the parts not being kept at 
 rest, and hence becoming subsequently displaced. Various kinds 
 of deformity and disfigurement, accompanied or not by loss of 
 function, may result from this accident. In some cases it may 
 be advisable to leave things alone, but where the deformity or 
 functional disability is serious, means must be taken to remedy 
 matters. If observed early, it is not difficult to readjust the parts 
 by simple pressure under an anaesthetic, if necessary re-fracturing 
 
 Fig. 125. — Old Frac- 
 ture of Femur 
 with Vicious 
 Union. 
 
INJURIES OF BONES— FRACTURES 439 
 
 the bone ; but this should only be undertaken whilst the callus 
 is soft, ue., within three or four weeks of the accident. Some 
 surgeons apply this method of osteoclasia even when consolidation 
 has been accomplished, using for the purpose levers and powerful 
 clamps ; but in our opinion such treatment is most undesirable 
 and highly unscientific, since it is difficult to accurately gauge the 
 amount of damage concurrently inflicted on the soft parts. We 
 much prefer the open method, cutting down on the bone, re-divid- 
 ing it, removing redundant callus, and fixing the fragments by 
 silver wires, pegs, or screws. 
 
 Special Fractures. 
 
 Bones of the Face.— The Nasal bones are broken as a result of 
 direct violence, by the fist, a cricket-ball, stick, etc. The fracture 
 is generally transverse, and situated just above their free margins; 
 occasionally, when greater force is used, it occurs close to the root 
 of the nose, and may then be associated with fracture of the frontal 
 bone or base of the skull. In young people the cartilages alone 
 may be separated. There is usually considerable deformity from 
 depression or lateral displacement of the fragment, although it 
 may at first be masked by the amount of bruising. Severe 
 epistaxis, surgical emphysema, and cerebral symptoms, are some- 
 times met with as complications. The fracture very readily 
 becomes consolidated, and the deformity is thus often irremediably 
 fixed. It is most important, therefore, to determine the presence 
 or not of a fracture at once, and this can only be made out, when 
 much swelling is present, by grasping the organ and moving it 
 from side to side to elicit crepitus. The Septum is sometimes 
 broken and depressed in association with the above injury, but it 
 may occur alone in other instances, giving rise to lateral displace- 
 ment. This need not result in obvious deformity, but may lead 
 to considerable nasal obstruction and discomfort. The Treatment 
 of these cases consists in immediate replacement of the bones, 
 advisably under an anaesthetic ; this may be accomplished by the 
 pressure of some blunt instrument, such as a pair of padded 
 dressing forceps, the blades of which are introduced within the 
 nostril, or by distension of a suitable indiarubber bag with air or 
 water. A pad of lint or gauze soaked in carbolized oil is then 
 inserted to maintain the position, and a guttapercha or zinc splint 
 moulded to fit the bridge. In old-standing cases, where there is 
 much depression, but little can be done, although the deformity 
 has been remedied by bone-grafting. Lateral displacement can 
 usually be remedied by mechanical appliances or operation. 
 
 The Lachrymal bone has been broken by direct violence, the 
 fracture usually extending from the nasal bone to the lateral mass 
 of the ethmoid. Interference with the flow of tears and surgical 
 emphysema are the two most marked symptoms. 
 
440 
 
 A MANUAL OF SURGERY 
 
 The Malar bone is but rarely fractured without the other bones 
 of the face being involved. When it does occur, it is almost always 
 associated with damage to the anterior wall of the antrum and con- 
 siderable depression of the fragments. An attempt should be 
 made to replace the parts by pressure from within the mouth. 
 
 The Zygoma is fractured by direct violence applied from with- 
 out ; the broken portion may be depressed below the surface, 
 but vertical displacement is limited by the attachment of the mas- 
 seter below and of the temporal fascia above. Reposition, either 
 by manipulation from within the mouth, or even by operation, is 
 .essential in order to prevent interference with the subsequent 
 mobility of the jaw. Perhaps the simplest plan to adopt is to 
 encircle the zygoma subcutaneously with a loop of silver wire 
 and drag it up to its natural level. 
 
 The Superior Maxilla is invariably broken as a result of direct 
 injury, such as a gunshot wound or a blow; it is almost always com- 
 pound, and often bilateral. The alveolar portion is either partially 
 or entirely detached, or a transverse fissure, extending as far as 
 the pterygoid processes on each side, may render the whole palate 
 and lower part of the facial skeleton moveable. Not unfrequently 
 all the bones of the face are smashed and comminuted, severe 
 haemorrhage sometimes 
 resulting from wounds of the 
 internal maxillary artery or 
 its terminal branches. As 
 a rule, Treatment consists in 
 merely keeping the patient 
 quiet and applying cooling 
 lotions ; union occurs with 
 great readiness, but is some- 
 times associated with sup- 
 puration and necrosis. The 
 patient must be fed by a 
 tube, and a carefully fitted 
 dental plate should be ap- 
 plied to a broken alveolus. 
 
 The Inferior Maxilla is usually fractured by direct violence, but 
 occasionally by force applied indirectly, as when a carriage passes 
 over the bone, laterally compressing the two sides, and leading to 
 a fracture in the middle line. Most frequently the lesion is a 
 little in front of the mental foramen (Fig. 126), this being a weak 
 spot at the junction of two strong parts, viz., the symphysis menti 
 and the alveolar process carrying the molar teeth ; the bone is 
 further weakened by the long narrow alveolus which lodges the 
 canine tooth. This fracture may sometimes be double when great 
 violence has been applied to the symphysis." A solution of con- 
 tinuity also occurs close to the angle behind the molar teeth, 
 whilst the coronoid process and condyle have occasionally been 
 
 Fig. 126. — Lower Jaw, indicating the 
 Most Common Sites of Fracture. 
 
INJURIES OF BONES— FRACTURES 
 
 441 
 
 broken, the former only as a result of great force, e.g., a gunshot 
 wound, the latter from either direct or indirect violence. 
 
 The Signs of fracture are very evident if the lesion is situated 
 anteriorly ; but when behind the teeth, diagnosis may be much 
 more difficult. The usual variety is almost always compound, 
 owing to the firm attachment of the muco-periosteum to the 
 alveolar border. Laceration of the gums, the blood-stained 
 saliva soon becoming foetid, the irregularity in the line of the 
 teeth, and the easily elicited crepitus, all constitute a typical 
 picture. There is often considerable pain, owing mainly to the 
 tearing of the mucous membrane, but possibly due to implication 
 
 of the inferior dental nerve. The 
 main trunk, however, generally 
 escapes, owing to the position of the 
 fracture in front of the mental fora- 
 men, whilst in those behind there 
 is but little displacement. Smart 
 haemorrhage sometimes occurs from 
 laceration of the accompanying 
 artery. The posterior fragment is 
 often somewhat raised, whilst the 
 anterior portion is depressed by the 
 action of the hyoid muscles, and may 
 override the other, owing to the 
 direction of the fracture, the anterior 
 fragment including more of the outer 
 surface of the bone than the pos- 
 terior. The direction of the displace- 
 ment is reversed in some cases. 
 When situated at the angle or in the vertical ramus, there is such 
 equal muscular support on the two sides that but little displacement 
 results. When the fracture passes through the neck of the condyle, 
 that process is drawn forwards and inwards by the external 
 pterygoid, whilst the body of the bone is freely moveable antero- 
 posteriorly, and displaced towards the fractured side. When the 
 coronoid process is detached, it is dragged upwards by the temporal 
 tendon, but no great displacement can occur, owing to the exten- 
 sive attachment of the tendinous fibres. 
 
 In those cases of fracture which are compound (and this includes 
 the great majority), septic inflammation of the ends of the bone 
 often ensues, leading to localized necrosis, and sometimes to 
 septic pneumonia, or even to general pyaemia. 
 
 The Treatment of a fractured mandible is frequently a matter 
 of difficulty, owing partly to the septic element, and partly to 
 the difficulty of fixing the jaw without interfering with the 
 patient's nutrition ; hence the co-operation of a skilled dentist 
 should always be secured. 
 
 1. As a temporary measure, and indeed as a permanent appli- 
 
 Fig. 127. — Application of 
 Four-Tailed Bandage for 
 Fracture of Lower Jaw. 
 
442 
 
 A MANUAL OF SURGERY 
 
 ance in simple cases, without much displacement of the fragments, 
 and where dental assistance is not to hand, all that is needed is 
 an efficient four-tailed bandage. This is made by taking a piece 
 of calico 4 inches wide and i yard in length, and splitting each 
 
 Fig. 
 
 128. — Leather Splint 
 for Lower Jaw. 
 
 Fig 129. — Leather Splint 
 applied 
 
 end into two, leaving about 8 inches undivided, and in the centre 
 of this a small longitudinal cut is made, into which the point of 
 the chin is inserted. The two lower tails are then drawn up and 
 tied over the vertex, whilst the two upper ends are secured 
 behind the occiput, and then, to prevent slipping, are knotted to 
 the ends of the former (Fig. 127). This apparatus is maintained 
 firmly in position for three weeks, the patient being fed on fluids 
 passed between the teeth or through the gap behind the last 
 molar, and all movement of the jaw prohibited. The mouth 
 should be frequently washed out with some antiseptic lotion. 
 Union is usually secured in five weeks. 
 
 2. If patients are unruly, or if the above apparatus fails to 
 maintain the fragments in position, a moulded guttapercha or 
 leather splint may be applied, made in the shape indicated in 
 Fig. 128, the upper portion being folded back, and the lower 
 portion drawn up around the bone. It is lined with lint, and 
 secured by bandages or tapes passed through holes, and tied as 
 shown in Fig. 129. 
 
 3. Where there is much displacement, the fragments must be 
 fixed. Wire sutures passed around or between the teeth and tied 
 are distinctly objectionable, causing the teeth to become loose and 
 perhaps diseased. Hammond's ivive splint is the best apparatus to 
 employ. It consists of a firm wire collar or framework (Fig. 130), 
 which encircles the whole series of teeth in the lower jaw. It is 
 accurately fitted by a dentist, firstly, to a cast of the jaw, sub- 
 sequently to the jaw itself, and is fixed by several wires passing 
 from one half to the other between the teeth. 
 
INJURIES OF BONES— FRACTURES 
 
 443 
 
 4. In cases where a Hammond's splint fails in remedying the dis- 
 placement, or where the teeth are defective, a Kingsley's apparatus 
 (Fig. 131) may be used with advantage. It consists of a vulcanite 
 splint fitted over the teeth or alveolar process of the mandible. 
 
 Fig. 130. — Hammond's Splint for Fracture of Lower Jaw. 
 
 and extending for a sufficient distance on each side of the fracture 
 to steady the fragments. To the front of this are attached curved 
 metal bars, which extend sideways from the angles of the mouth 
 over the cheeks. It is kept in position by passing a bandage over the 
 bars and under the chin (Fig. 132), and secures thereby excellent 
 immobilization of the fragments, even when the mouth is opened. 
 
 5. Wiring of the fragments together may be required in a few 
 cases. The wires must be passed either through the bone below 
 the teeth — a task not easy to accomplish without an external 
 wound — or through the empty alveoli of neighbouring teeth, 
 which are extracted for the purpose. 
 
 When septic inflammation occurs of such severity as to lead to 
 necrosis, it is often best to delay all operative treatment until the 
 sequestrum has been detached, and the parts are more healthy, 
 the patient's mouth in the meantime being frequently cleansed 
 with antiseptic lotions. Wiring of the fragments may then, if 
 necessary, be undertaken with good hope of success. 
 
 Fracture of the Hyoid Bone is uncommon, arising usually from 
 direct violence, such as a forcible grasp or the constriction of the 
 neck in hanging. Either the body may be broken, or one of the 
 cornua separated. The symptoms produced are: Pain on attempt- 
 ing to move the tongue, jaw, or neck ; a husky voice ; and de- 
 formity, which can sometimes be detected from without. Occa- 
 sionally the mucous membrane is perforated, and bleeding into 
 
444 
 
 A MANUAL OF SURGERY 
 
 the pharnyx may occur, whilst oedema of the glottis may super- 
 vene. The fragments should be approximated as well as possible 
 by manipulation between one finger in the mouth and the hand 
 outside, and the neck then fixed by a poroplastic collar. 
 
 Fig. 131. 
 Kingsley"s Splint for Fracture 
 of Lower Jaw. 
 
 Fig. 132. 
 Kingsley's Splint applied. 
 
 Fracture of the Ribs may arise in two distinct ways: (1) By 
 direct violence, as by blows or stabs, the fragments being driven 
 inwards, and damage to the underlying pleura, lungs, liver, or 
 diaphragm, being very likely to occur ; or (2) much more fre- 
 quently by indirect violence, as when the chest is compressed 
 between a cart-wheel and the ground, or between a wall and the 
 back of a waggon. The ends of the ribs are then approximated 
 beyond the limits of natural elasticity, and they give way at the 
 most convex part — i.e., near the angle. The viscera may be con- 
 tused, but less often than in the former class, although haemo- 
 thorax from rupture of the parietal pleura is not uncommon. 
 One or several ribs may be broken, but the displacement is rarely 
 marked, except in cases due to direct violence where several ribs 
 have been ' staved in.' The fifth to the eighth ribs are those 
 usually injured, being more prominent and fixed at both ends; 
 the first and second ribs are so well protected by the clavicle as 
 to be seldom broken by direct injury, although great violence 
 from above downwards to the outer end of the clavicle may lead 
 to such an accident ; the lower ribs often escape on account of 
 
INJURIES OF BONES— FRACTURES 
 
 445 
 
 their greater mobility. Elderly women and persons suffering 
 from general paralysis of the insane are specially prone to this 
 fracture. 
 
 The Symptoms are tolerably obvious, viz., a sensation of some- 
 thing snapping or giving way, a sharp localized catching pain at 
 the site of the injury, increased on deep breathing and coughing, 
 and possibly some local extravasation and swelling. Pain is also 
 elicited by conjoined pressure upon the sternum and spinal column, 
 whilst the fracture may be evident on palpation, or crepitus 
 detected when the patient coughs or on auscultation. When 
 
 several ribs are driven in, a marked 
 depression results, but if a single 
 bone is broken in a fat individual, the 
 diagnosis may be extremely obscure. 
 For the clinical history of lesions of the 
 lungs or pleura?, see Chapter XXX. 
 
 Treatment. — The affected side 
 should be firmly strapped with broad 
 strips of adhesive plaster, so as to 
 limit its movements. The strips, 
 i^ to 2 inches wide, should extend 
 beyond the middle line, both front 
 and back, and are applied from below 
 upwards whilst the chest is in a state 
 of forcible expiration, each strip over- 
 lapping the preceding one and cross- 
 ing the direction of the ribs (Fig. 1 33). 
 A firm woollen bandage should then 
 be applied over all. If the ends of 
 the bone are driven inwards, strapping can rarely be borne, as it 
 tends still further to irritate or compress the lung. Under such 
 circumstances all constriction of the chest must be avoided, the 
 patient being confined to bed with a sandbag between the 
 shoulders, and the arm bound to the side. When the lower ribs 
 are broken, tight applications are generally contra-indicated, since 
 the diaphragm is likely to be irritated, and troublesome hiccough 
 may result. Ribs unite readily, but a considerable amount of 
 callus is formed owing to the difficulty of satisfactorily fixing the 
 broken ends. 
 
 Separation of a Costal Cartilage sometimes occurs, giving rise to 
 the same symptoms and requiring the same treatment as a broken 
 rib. Occasionally the cartilage itself may be fractured. In each 
 case the resulting bond of union is osseous. 
 
 Fracture of the Sternum is almost always due to direct violence, 
 although it has been known to yield from excessive flexion of 
 the body after fracture of the spine, or from muscular strain 
 during parturition. The line of fracture is usually transverse, the 
 bone giving way either between the manubrium and gladiolus 
 
 Fig. 
 
 133. — Method of strap- 
 ping Broken Ribs. 
 
446 A MANUAL OF SURGERY 
 
 or a little below this level. The fragments may remain in situ or 
 the upper portion be displaced backwards, the deformity in such 
 cases being very evident, and great dyspnoea resulting. As a late 
 effect, aneurism of the arch of the aorta may occur. 
 
 Treatment. — The patient should be kept in bed with a pillow 
 between the shoulders, and the chest strapped as for fractured 
 ribs. If the patient cannot bear this position, he should be 
 allowed to sit up with the body leaning forwards. Reposition 
 can sometimes be effected by manipulation and extension of the 
 spine. 
 
 Fractures of the Upper Extremity. 
 
 Fracture of the Clavicle. — No bone in the body, with the ex- 
 ception of the radius, is broken more frequently than the clavicle ; 
 this is due to its exposed position and its buttress-like action in 
 keeping out the point of the shoulder, so that every shock to the 
 arm is transmitted through it to the trunk. Hence, although 
 fractures from direct violence do occur, it is more usually broken 
 as the result of force directed to the hand or shoulder, such as a 
 fall from a horse. The injury is very common in children, being 
 then often of a greenstick nature, and more frequent in men 
 than in women. The bone may yield in four different spots, viz. : 
 
 i. At the Sternal End, an unusual occurrence, due to direct 
 or indirect violence. The displacement varies with the line of 
 fracture ; if transverse, it is slight, but if oblique, and this is most 
 usual, the outer fragment is drawn downwards and forwards as 
 in the next variety, though to a less degree. 
 
 2. Through the Greater Convexity, the commonest situation. 
 The bone yields about its centre, or a little external to it, and the 
 line of fracture is slightly oblique, running from before backwards 
 and inwards. The displacement is quite characteristic, and is 
 present in any fracture situated between the rhomboid ligament 
 on the inner side and the coraco-clavicular ligaments on the outer, 
 being less marked, however, when the fracture is nearer the 
 extremities than in the centre of this space. The patient presents 
 himself with a history of injury and severe pain, supporting the 
 elbow with the other hand, the head being bent over to the affected 
 side, so as to relax the muscles of the neck, and the arm being 
 powerless. On closer examination, one finds that the point of the 
 shoulder is less prominent than usual, being approximated to the 
 middle line, and on a lower level than the other, whilst at the seat 
 of fracture is a slight bony projection. This deformity is accounted 
 for by a displacement of the whole outer fragment downwards, 
 forwards, and inwards (Fig. 134) ; the outer end, however, is 
 more displaced than the inner, so that the fractured surface of the 
 outer fragment looks upwards, inwards, and backwards, although 
 it is placed immediately below the inner fragment. The deformity 
 
INJURIES OF BONES— FRACTURES 
 
 447 
 
 is mainly due to the weight of the arm acting upon the outer 
 fragment when the buttress-like action of the bone is gone, 
 allowing the scapula, to which it is firmly united by ligaments, 
 to embrace the curved thor- 
 acic wall, from which it 
 is usually separated. The 
 action of the muscles passing 
 from the trunk to the upper 
 arm may have some effect, 
 but can only be looked on 
 as an accessory, and not the 
 main cause of this displace- 
 ment. The position of the 
 inner fragment is probably 
 but little altered, since it is 
 held in place by the rhom- 
 boid ligament ; the apparent 
 projection of its outer end is 
 due rather to the depression 
 of the outer fragment than 
 to elevation of the inner by 
 the sterno-mastoid. 
 
 3. Between the Coraco- 
 
 Fig. 134. — Fracture of Clavicle 
 through Greater Convexity. (Till- 
 
 MANNS.) 
 
 St, Sterno-mastoid ; S, subclavius ; P mi, 
 pectoralis minor; S m.serratus magnus. 
 
 clavicular Ligaments, usually 
 arising from direct violence, 
 and with but little displace- 
 ment, owing to the tension of the ligaments and to the fact that 
 the periosteum is not torn across. The signs of local trauma and 
 crepitus are, however, present, though not very obvious. 
 
 4. At the Acromial End, external to the trapezoid ligament, and, 
 again, usually produced by direct violence. The inner fragment 
 retains its position unaltered, but the outer fragment is dragged 
 down by the weight of the arm, and forwards by the action of the 
 muscles, so that it lies at right angles to the rest of the bone. 
 
 Complications arise most frequently in cases produced by direct 
 violence. The subclavian vein may be injured, or the brachial 
 plexus ; and even the dome of the pleura and the subjacent lung 
 have been wounded. Gangrene of the arm has resulted from 
 obstruction to the vessels. 
 
 Treatment. — Where there is little or no displacement, all that 
 is needed is to immobilize the arm in a sling and to keep the 
 patient quiet. 
 
 For fractures with displacement many different plans of treat- 
 ment have been adopted. In order to replace the fragments, the 
 surgeon should stand behind the patient, who is seated, with 
 his knee between the scapulae ; traction is then made upon the 
 shoulders, and the point of the acromion is drawn upwards and 
 backwards. To maintain the fractured ends in apposition the 
 
448 
 
 A MANUAL OF SURGERY 
 
 following methods have been recommended: (a) The simplest, 
 which can always be applied on an emergency, and perhaps the 
 best even for a permanent application, is that known as the three- 
 handkerchief plan. Two large handkerchiefs, folded double and 
 rolled into bands, are placed vertically, one over each shoulder 
 and under each axilla ; each is lightly knotted behind, and the 
 ends firmly tied to the opposite handkerchief across the middle 
 
 
 
 
 \ \ 
 
 4 
 
 
 ■ 
 
 dl 1 
 
 
 •Z--*r*mi 
 
 ^- — .- -^y , -*f^^ y *^ 
 
 -^A — . 
 
 M 
 
 
 s. iM^""""""* 
 
 1 
 
 
 
 
 iBi~^ 
 
 Fig. 135. — Sayre's Method of Strapping for Fractured Clavicle. 
 
 line. By this means the point of the shoulder is kept outwards 
 and backwards. The third handkerchief is now folded crosswise 
 and used as a sling to support the elbow, which is drawn well 
 forwards, the hand being placed over the sound clavicle. If this 
 apparatus is employed permanently, the knots must be examined 
 every few days, especially at first, as the handkerchiefs always 
 stretch a little, and require occasional tightening, (b) Sayre's method 
 is very useful, especially in treating children. A long strip of 
 adhesive plaster, 3^ inches wide or less, according to the size of 
 the patient, is passed round the arm a little below the axilla, as 
 a loop, with the sticky side out, and then around the body with 
 the adhesive side inwards, the arm being drawn well back, and 
 the loop and ends secured by stitches (Fig. 135). If this has 
 been firmly applied, it may now be used as a fulcrum, so that as 
 the elbow is drawn forwards, the point of the shoulder is directed 
 backwards and outwards, and thus the main deformity is overcome. 
 Another strip of a similar width is applied over the elbow (a small 
 hole being cut to receive the point of the olecranon), and by this 
 means the arm is raised and drawn forwards and the hand placed 
 on the opposite shoulder, and the desired position is thus main- 
 tained. In children more than one strip of plaster will be 
 needed in order to secure the arm, whilst an additional bandage 
 is also useful. Excellent results follow this plan of treatment. 
 
INJURIES OF BONES— FRACTURES 449 
 
 (c) In ladies, where even the slightest deformity is undesirable, it 
 is better to confine them to bed ; the head is kept low without a 
 pillow, and a sandbag placed between the scapulae, the arm being 
 bandaged to the side. This position must be maintained for 
 three weeks, and even then only very limited movement allowed. 
 
 (d) The old-fashioned plan of treatment by means of an axillary 
 pad, a figure-of-8 bandage crossing behind the shoulders, and an 
 elbow sling, has been to a large extent superseded by Sayre's and 
 other methods. Union is probably attained in four weeks, but 
 the movements of the arm should be restricted for some time 
 longer. A considerable amount of callus is usually formed, and 
 there is very likely to be some slight persistent deformity. 
 
 Fractures of the Scapula. — 1. The Acromion Process may be 
 broken by direct violence applied to the point of the shoulder. 
 The arm hangs powerless at the side, supported by the other 
 hand, and the shoulder is flattened. The irregularity of the bone 
 can be readily detected, and crepitus can be elicited by raising 
 the elbow and rotating the arm. Occasionally merely the tip is 
 detached, and then the above signs will not be present. The 
 Treatment consists in raising the elbow, and bandaging the arm 
 to the side. 
 
 2. The Coracoid Process is rarely fractured, and only from direct 
 violence. There is but little displacement, on account of the many 
 powerful ligaments attached to it, and the only treatment needed 
 is to raise the arm by a sling, and to keep it at rest by the side. 
 
 3. The Body of the scapula is broken as a result of considerable 
 direct violence, which is often primarily received by the spine, 
 and also bruises the thick muscles above and below it. There 
 is but little displacement, if, as is usually the case, the fracture 
 is transverse just below the spine. A longitudinal fracture may, 
 however, result in the inner or vertebral fragment being drawn 
 upwards and outwards in front of the axillary portion by the 
 serratus magnus and levator anguli scapulae. The diagnosis is 
 made by grasping the bone firmly, and moving one fragment on 
 the other ; crepitus may thus be obtained. The Treatment con- 
 sists in bandaging the arm to the side, and possibly applying 
 strapping to support the fragments. 
 
 4. Fracture of the Neck of the bone is usually due to great 
 violence directed to the shoulder, but it is a rare accident. A 
 portion of the articular surface is broken off and displaced down- 
 wards in some few cases of dislocated shoulder (Fig. 136, A); or 
 the fracture has been known to run through the anatomical neck 
 (Fig. 136, B), either condition causing slight lengthening of the 
 arm, and displacement downwards of the head of the humerus. 
 Treatment. — The arm must be kept to the side and raised. 
 
 More commonly, however, the fracture involves the Surgical 
 Neck (Fig 136, C), extending from the suprascapular notch 
 
 29 
 
450 
 
 A MANUAL OF SURGERY 
 
 above to just below the origin of the triceps muscle, so that the 
 detached fragment includes the coracoid process. Flattening of 
 
 the shoulder results, 
 with prominence of the 
 acromion, lengthening 
 of the arm as measured 
 from the acromion to 
 the external condyle, 
 and crepitus on raising 
 and rotating the limb. 
 Treatment. — The bone 
 is replaced by pressure 
 in the axilla, if neces- 
 sary under chloroform, 
 and fixed by an axillary 
 pad or the f\ - shaped 
 leather splint recom- 
 mended by Erichsen, 
 whilst the arm is kept 
 to the side. 
 
 Fractures of the Upper 
 End of the Humerus. — 
 i. Of the Anatomical 
 Neck, the so-called ' In- 
 tracapsular Fracture ' 
 (Plate XL). This is 
 always due to blows or 
 falls on the shoulder, 
 never to indirect vio- 
 lence. It is evidenced 
 by signs of a severe 
 local trauma, with loss of mobility of the arm. The head of the 
 humerus is found to be irregular in shape on examination from 
 the axilla, and the fragment, if detached, may be distinctly felt. 
 Crepitus is obtained on moving the arm, and there is some slight 
 shortening, but not more than half an inch. In most cases the 
 upper fragment is not totally detached, but remains connected 
 with the rest of the bone by a few shreds of capsule, and thus 
 necrosis is prevented. Should impaction occur, the small upper 
 fragment is driven into the lower, and marked deformity of the 
 head of the bone results. The acromion becomes unduly pro- 
 minent, and the rounded projection of the deltoid is diminished, 
 unless, as often happens, the swelling due to extravasation is 
 considerable. Repair takes place mainly from the lower end, 
 and, owing to the difficulty of apposing and immobilizing the 
 fragments, a considerable mass of callus is usually formed. 
 Examination must be conducted with great care lest impaction 
 
 Fig. 136. — Fractures of the Neck of the 
 Scapula. 
 
 A, Through the glenoid fossa ; B, through the 
 anatomical neck ; C, through the surgical 
 neck. 
 
PLATE XI. 
 
 Impacted Fracture of Anatomical Neck of Humerus. 
 
 To face p. 450.] 
 
PLATE XII. 
 
 Fracture of Surgical Neck of Humerus. 
 
 To follow Plate XI. .] 
 
INJURIES OF BONES— FRACTURES 
 
 451 
 
 be disturbed, or any capsular attachments broken through. The 
 Treatment usually recommended is to bind the arm to the side, 
 and apply evaporating lotion for a few days if great ecchymosis 
 exists. A pad or f~|-shaped splint is then placed in the axilla, 
 and retained in position by a soft bandage or handkerchief passing 
 over the top of the shoulder, and tied under the opposite axilla ; this 
 assists in raising the arm, which is also supported by an elbow- 
 sling. Finally, a comfortable poroplastic or leather cap is fitted 
 over the shoulder and buckled on. Union generally occurs in 
 about six weeks, but often results in great stiffness, for the 
 removal of which massage and even manipulation under chloro- 
 form are required. To obviate these sequelae, it is well to treat 
 the case by early massage and manipulation, the limb being 
 merely supported in a sling ; the massage should commence 
 about the third day (see page 431 ). 
 
 2. Of the Surgical Neck, the ' Extracapsular Fracture ' 
 (Plate XII.). The bone yields in this case below the muscles 
 attached to the tuberosities, but above 
 the insertions into the bicipital groove 
 and its margins of the latissimus 
 dorsi, pectoralis major, and teres 
 major. It usually results from 
 violence applied directly below the 
 point of the shoulder, but also from 
 falls on the hand or elbow. The 
 fracture is more or less transverse, 
 and the displacement a double one : 
 the upper fragment is rotated out- 
 wards, and generally adducted by 
 the muscles inserted into the tuber- 
 osities, especially the subscapularis ; 
 whilst the lower fragment is drawn 
 inwards by those attached to the 
 bicipital groove, and upwards by the 
 deltoid, coraco-brachialis, biceps, and 
 triceps (Fig. 137). The appearance 
 of the patient is sufficiently charac- 
 teristic ; the head of the bone is still 
 in the glenoid cavity, so that there 
 is no loss of the fulness of the 
 shoulder (Fig. 138, C), although there is a depression just below, 
 unless it is obliterated by the extensive haemorrhagic effusion. 
 The elbow is directed away from the side, and the axis of the 
 lower fragment is upwards and inwards. Crepitus can be 
 obtained by extending and rotating the arm, which is shortened 
 an inch or more. This fracture is often very painful from pressure 
 of the upper end of the lower fragment against the brachial 
 nerves. If impaction occurs, the signs are much less evident, 
 
 29 — 2 
 
 PM 
 
 Fig. 137. — Fracture of Sur- 
 gical Neck of Humerus. 
 
 S, Subscapularis; L.D, latissi- 
 mus dorsi ; D, deltoid ; P.M, 
 pectoralis major. 
 
452 
 
 A MANUAL OF SURGERY 
 
 and, indeed, may be very equivocal ; the lower fragment is usually 
 driven into the upper, and only slight shortening or displacement 
 may be present. 
 
 Complications. — The axillary vessels may be seriously damaged, 
 or more commonly some of the nerves sustain injury, especially 
 the circumflex, which winds round the neck of the bone close to 
 the site of the fracture. 
 
 Treatment. — Immobilization of the fragments is absolutely 
 necessary in this fracture. It may be secured by the application 
 of an axillary pad and a shoulder-cap, whilst the arm is kept to 
 the side, and the hand supported by a sling. The elbow should 
 be allowed to hang to overcome the shortening. Middeldorpf's 
 
 Fig. 138. — Outlines of Shoulder. 
 
 A, Normal shoulder ; B, dislocation of shoulder ; C, fracture of surgical neck 
 
 of humerus. 
 
 triangle (Fig. 140) may be used with advantage in this fracture. 
 Firm union usually results in four and a half to six weeks, but 
 with the formation of a good deal of callus ; massage and passive 
 manipulations should be daily employed from the third week 
 onwards, the apparatus being taken off for the purpose and 
 reapplied, if necessary. 
 
 3. Separation of the Upper Epiphysis occurs up to the age of 
 eighteen to twenty years and involves the head and both the 
 tuberosities. The upper end of the shaft is somewhat conical 
 in shape, the apex of the cone fitting into a depression in the 
 middle of the epiphysis (Fig. 139). The lesion usually follows the 
 line of the cartilage ; but the displacement is often incomplete, 
 partly from the conical projection hitching against the inner edge 
 of the epiphysis (a doubtful occurrence), but mainly from the 
 persistence of a well-marked periosteal sleeve or bridge on the 
 outer and posterior side. The shaft usually travels forwards, its 
 
INJURIES OF BONES— FRACTURES 
 
 453 
 
 upper end projecting so as to be felt and sometimes seen beneath 
 the skin an inch or more below the acromion ; occasionally a well- 
 marked inward displacement is superadded so that the condition 
 somewhat resembles a subcoracoid dislocation. The presence of 
 the head of the bone in the glenoid cavity should prevent this 
 mistake, whilst the softness of the crepitus distinguishes it from a 
 fracture. 
 
 Treatment. — It is most important to reduce this displacement, 
 since otherwise interference with the growth of the limb is almost 
 certain to ensue. This may be effected by traction upon the arm 
 under an anaesthetic, assisted perhaps by slight rotary movements 
 or abduction ; but should these manoeuvres not be successful, it is 
 quite permissible to open the joint antiseptically, and restore the 
 parts to their correct position. After reduction the limb is treated 
 
 Fig. 139. — Separation of the Upper Epiphysis of the Humerus. 
 
 as for a fracture of the neck. Should union occur in the displaced 
 position, considerable limitation of movement results from the 
 projecting edge of the diaphysis ; this may be improved by cutting 
 down and chiselling it away. 
 
 4. The Great Tuberosity is occasionally torn off as a result 
 of direct or muscular violence, or as a complication of fracture 
 through the neck. If the whole tuberosity is separated, there is 
 marked deformity, resulting in a great increase in the breadth of 
 the shoulder. The fragment is displaced upwards and backwards 
 by the unopposed action of the supra- and infra-spinatus, whilst 
 the shaft of the humerus is drawn forwards and partially dislocated 
 (or subluxated) by the subscapulars and other muscles. A dis- 
 tinct sulcus is felt between the two bony masses, and if they can 
 be brought together, crepitus is obtained. Treatment. — A pad is 
 placed in the axilla, and the elbow kept to the side so as to 
 
454 
 
 A MANUAL OF SURGERY 
 
 throw the upper end of the bone outwards, whilst the tuberosity 
 is drawn down to this as far as is possible by the pressure of 
 a pad strapped on, the elbow being also supported by a sling. 
 Another plan suggested is to elevate and extend the arm above 
 the head, keeping it supported by pillows, till union has occurred 
 — a most uncomfortable and tedious proceeding. A much more 
 efficacious method, and one that need not be feared where asepsis 
 is maintained, is to cut down on the fragment, and wire or peg it 
 in position. 
 
 Fractures of the Shaft of the Humerus may arise from any 
 form of violence, whether direct or indirect, whilst it is the 
 commonest site for fracture of the shaft of a long bone from 
 muscular violence, as, e.g., in throwing a cricket-ball. The signs 
 
 Fig. 140. — Middeldorpf's Triangle for Fractured Humerus. 
 
 For the sake of clearness, the bandages, etc., have been represented as much 
 smaller than would be the case in the living subject ; a Gooch splint may 
 also with advantage be applied to the forearm. 
 
 of the injury are very obvious, and most typical. The displace- 
 ment depends largely on the position of the fracture. If it occurs 
 above the insertion of the deltoid, but below that of the muscles 
 inserted into or around the bicipital groove, the upper fragment is 
 drawn inwards, and the lower upwards and outwards. If, how- 
 ever, it is below the deltoid, the upper fragment is drawn outwards, 
 and the lower upwards and inwards. As the line of fracture ap- 
 proaches the elbow, the displacement tends to become more antero- 
 posterior than lateral, following the change in direction of the bone. 
 The most common complication is injury to the musculo-spiral 
 nerve which winds round the shaft close to its centre. 
 
INJURIES OF BONES—FRACTURES 455 
 
 Treatment. — An internal angular splint reaching from the axilla 
 to the wrist must be applied, together with three small lateral 
 splints to fix the fragments, or a piece of Gooch or kettle-holder 
 splint ; the limb is kept to the side in a sling. Union is usually 
 complete in five weeks. 
 
 It is not at all uncommon to meet with an ununited fracture of 
 the shaft of this bone ; this is probably due, not to any anatomical 
 reasons, but simply to the fact that the necessity for fixing and 
 supporting the elbow-joint has not been appreciated, the forearm 
 being allowed to hang loose on the false plea of tending to 
 diminish the shortening. 
 
 A very useful appliance for all fractures of the humerus is the 
 Middeldorpf triangle (Fig. 140). It is carefully padded all round 
 so that the angles and edges are protected, and applied so that 
 its base is in contact with the body-wall and its obtuse-angled 
 apex in the elbow. It is fixed by a strap or bandage passed from 
 the axillary angle over the same shoulder and under the opposite 
 axilla, as also by a sheet or bandage round the trunk. Pieces of 
 Gooch splinting can be applied to the arm, thus completely im- 
 mobilizing the humerus, and the forearm is also fixed. The 
 fingers are left free, or if there is any tendency to swelling they 
 are bandaged. One great advantage of this apparatus is that it 
 is equally efficacious when the patient is standing as when he is 
 recumbent. 
 
 Fractures of the Lower End of the Humerus. — In dealing with 
 any injury in the vicinity of the elbow, it is absolutely essential 
 that the relative position of the bony points, which can there 
 be felt, should be accurately established, and a comparison made 
 with those of the opposite side. Both arms are stripped and 
 examined in similar positions, a good plan being to place (if 
 possible) the hands on the top of the head, so that the elbows 
 look forwards. Normally four bony prominences can be made 
 out, viz., the two condyles, the olecranon, and the head of the 
 radius. The relation of the olecranon to the condyles varies with 
 the position of the elbow. If the forearm is extended, the tip of 
 the olecranon just touches the intercondyloid line, but is placed 
 nearer the inner than the outer condyle, whilst in flexion of 
 the forearm it lies below that line. The head of the radius in all 
 positions of the arm is immediately below the outer condyle, and 
 can be felt rotating beneath a dimple in the skin which appears 
 at that spot. When the arm is flexed to a right angle, the tip of 
 the olecranon is a little in front of the posterior surface of the 
 upper arm, so that a ruler placed along that surface misses the 
 olecranon ; this is a useful guide in ascertaining if the bones of the 
 forearm have been displaced backwards or forwards. 
 
 Another important feature depends on the fact that the axis of 
 the forearm does not correspond with that of the arm, the former 
 being in a position of slight abduction (about 15 ), constituting 
 
456 
 
 A MANUAL OF SURGERY 
 
 what is known as the 'carrying angle' (Fig. 141, A). Lateral 
 deviation following fractures in the neighbourhood of the elbow 
 results in modifications of this angle, and if these are allowed to 
 persist, conditions of cubitus varus or valgus (Fig. 141, B, C) 
 ensue, which much interfere with the utility of the limb. 
 
 1. Transverse Supracondyloid Fracture, involving the shaft 
 about 1 or 2 inches above the joint, is due either to a fall on the 
 hand with the arm bent, when the lower fragment is usually dis- 
 placed backwards, or much less commonly to a fall on or violence 
 directed to the point of the elbow, when the displacement is either 
 forwards or backwards. When the lower fragment is displaced 
 backwards, it is also drawn up by the action of the triceps upon 
 the olecranon, a certain amount of angular as well as vertical 
 
 Fig. 141. — Outlines of Upper Extremity to show A, Normal carrying 
 Angle (a = 15°); B, Cubitus Varus; C, Cubitus Valgus. 
 
 deformity being thus produced ; when displaced forwards, ap- 
 parent lengthening of the forearm results, with a loss of prominence 
 of the olecranon. The former of these conditions is likely to be 
 mistaken for a dislocation of both bones backwards at the elbow 
 (cf. Fig. 142, A and B), but may be recognised by the following 
 facts : (a) The relative position of the bony points at the elbow 
 is unimpaired ; in a dislocation they are necessarily disturbed. 
 
 (b) The upper arm measured from a tubercle which can be easily 
 felt at the back of the acromion to the outer condyle is shortened 
 in a fracture, but remains the same length in a dislocation. 
 
 (c) The forward projection of the lower end of the upper frag- 
 ment is felt above the crease of the joint, whilst in a dislocation 
 it corresponds with it. (d) The deformity is easily reduced with 
 
INJURIES OF BONES— FRACTURES 
 
 457 
 
 crepitus, but readily reappears ; in a dislocation the bones are 
 replaced with difficulty, but after replacement they usually remain 
 in position. It may be difficult and at times almost impossible to 
 recognise this condition at once, owing to the amount of swelling 
 and ecchymosis present ; the application of a cooling lotion for a 
 few days will so reduce this as to permit a thorough examination, 
 and this is most essential, as a wrong diagnosis probably leads to 
 bad treatment and much subsequent impairment of function of 
 the limb. Skiagraphy will at once determine the nature of the 
 lesion. Lateral deviation sometimes occurs, and the restoration 
 of the normal ' carrying angle ' must always be aimed at. 
 
 Much care is needed in the Treatment of these cases in order to 
 prevent ankylosis or deformity, and the stereotyped application of 
 
 A B 
 
 Fig. 142. — Fracture of Lower End of Humerus (B) compared with Dis- 
 location of Radius and Ulna backwards at Elbow (A). (Tillmanns.) 
 
 an internal angular splint is by no means sufficient. To correct 
 the backward deformity tne elbow must be flexed, and traction 
 made upon the forearm, which is placed in a position of full 
 supination. It may then suffice to apply an anterior angular 
 splint in the bend of the elbow, and a straight posterior splint 
 reaching below the tip of the olecranon, so as to keep it well 
 forwards ; or perhaps it would be better to apply a carefully- 
 moulded gutter-shaped posterior splint reaching well above and 
 below the elbow, and a shorter anterior splint fitting down to the 
 bend of the joint. In these fractures the elbow-joint is not as a 
 rule involved, and therefore passive movement is not commenced 
 too early, for fear of deformity owing to yielding of the callus. 
 In displacements of the bone forwards an anterior angular splint 
 should be employed, and possibly a short posterior one in addition. 
 
458 
 
 A MANUAL OF SURGERY 
 
 2. Separation of the Lower Epiphysis of the Humerus is a very 
 common accident in children. At birth and for some years 
 afterwards the epiphysis consists of a single mass of cartilage, 
 including the two condyles as well as the articular surface, and 
 these are all involved in any separation, together possibly with a 
 fragment of the diaphysis (Fig. 143). As, however, growth and 
 ossification proceed, the shaft encroaches rapidly upon the inner 
 portion of the epiphysis, so that the epiphyseal line becomes almost 
 rectangular (Fig. 144), the internal condyle being isolated from 
 
 Fig. 143. — Separation of the 
 Lower Epiphysis of the Humerus 
 in an Infant under Three Years. 
 (Museum of Royal College of 
 
 Surgeons.) 
 
 A, Epiphysis, including both con- 
 dyles ; B, small portion of the 
 diaphysis detached with epiphysis ; 
 C, diaphysis; D, loose periosteal 
 bridge. 
 
 Fig. 144. — A and B, Lower End 
 of the Humerus at Three 
 Years and Fifteen Years of 
 Age. (Semi -diagrammatic ; 
 after Quain's Anatomy.) 
 
 In A, there is only one centre of 
 ossification; in B, all the centres 
 in the lower epiphysis have 
 united with the exception of that 
 for the internal condyle. 
 
 the rest of the epiphysis. As a result of this, separations of the 
 epiphysis after puberty do not include the internal condyle ; the 
 accident at this period is situated relatively much nearer the joint 
 than in infants, and consequently is more likely to be followed 
 by impairment of movement. The displacement is generally 
 backwards, with some amount of lateral deviation (Plate XIII.). 
 Treatment. — Reduction can usually be accomplished by flexion, 
 
PLATE XIII. 
 
 Separation of the Lower Epiphysis of the Humerus, with Displacement 
 Outwards in a Young Person, a little over the Age, of Puberty. 
 
 The outer condyle has been broken off, as well as the epiphysis, and displaced 
 upwards and outwards ; above this fragment is seen a shadow caused by the 
 stripping up of the periosteum. The ulna and radius accompany the lower 
 epiphysis of the humerus outwards. 
 
 To /ace p. 458.] 
 
INJURIES OF BONES—FRACTURES 
 
 459 
 
 splints may suffice to 
 it is an open question 
 
 Fig. 145. — Fractures 
 of Internal Con- 
 dyle AND EPICONDYLE 
 
 of Humerus. (Till- 
 
 MANNS.) 
 
 and the application of antero-posterior 
 maintain the fragment in position ; but 
 whether it is not wiser, at any rate in 
 small children, to avoid splints and trust 
 to full and complete flexion alone, the 
 hand being bandaged down to the shoulder 
 on the same side. Passive movements 
 should commence from about the eighth 
 day. 
 
 3. The Condyles have been broken off 
 both by direct and indirect violence, 
 though more commonly by the former. 
 This particularly applies to the inner con- 
 dyle, since the outer is sometimes broken 
 by indirect violence, such as a fall on the 
 hand, owing to the laxity of the elbow- 
 joint on this side allowing considerable 
 mobility between the radial head and the 
 capitellum of the humerus. Fracture of 
 the external condyle always involves the 
 elbow-joint, and is more common than 
 
 that of the inner. The line of fracture runs from the condylar 
 ridge downwards and inwards so as to separate the capitellum, 
 or even encroach upon the trochlear surface. The fragment is 
 but little displaced, and can be felt to move on the rest of the 
 bone with crepitus, which may also be produced by rotation of 
 the hand and radius. The accident is associated with much pain 
 and ecchymosis. Fracture of the internal condyle may be intra- 
 or extra-capsular. The extra-articular variety (Fig. 145) consists 
 of a mere displacement of the tip of the condyle (or epicondyle), 
 probably a separation of the epiphysis, since it occurs mainly in 
 children. The small fragment is drawn a little downwards by 
 the muscles attached to it, and the fracture is readily detected by 
 the usual signs ; it may be associated with injury of the ulnar 
 nerve. The intra-artictdar form is the more common, and extends 
 from the condylar ridge to the trochlear surface, implicating the 
 coronoid and olecranon fossae. The fragment is displaced a little 
 upwards and backwards, the ulna usually accompanying it, so 
 that on extending the elbow the olecranon appears unduly 
 prominent, the lower end of the humerus projects anteriorly, and 
 the forearm is slightly adducted (cubitus varus). The ulnar 
 nerve may also be injured in this case. 
 
 Treatment. — Flex the forearm and place it on an angular splint, 
 using a pad and strapping to maintain the fragments in position. 
 If the joint has been involved, there is a great tendency to 
 impairment of its usefulness, and passive movement should be 
 started early. Possibly in these cases it would be wiser to apply 
 no splints, and treat the fracture by early massage, or perhaps 
 even better to operate and fix the fragment by wire or screw. 
 
460 A MANUAL OF SURGERY 
 
 4. T- or Y-shaped Fracture usually occurs as the result of direct 
 injury. A fissure extends into the joint between the condyles, 
 and may either bifurcate to either side in a Y-shaped manner, 
 detaching partially or completely the two condyles, or it may be 
 connected with a transverse supracondyloid fissure, constituting 
 the T-shaped variety. If the fragments are not totally detached, 
 there will be much bruising and pain, but no crepitus ; but if the 
 fragments are separated, the condyles will move on each other 
 with crepitus, and the elbow will be widened with much deformity. 
 In these cases the joint is very likely to become stiff, owing not 
 only to adhesions within it, but also to the filling up of the fossae 
 in the lower end of the humerus with callus. Excess of violence 
 leads to comminution, and luxation of the bones of the forearm 
 may also occur. A marked feature of these cases is the rapidity 
 with which swelling supervenes, owing to haemorrhage into and 
 around the joint, rendering accurate diagnosis difficult. Treat- 
 ment must be directed towards reducing the swelling, and then, 
 after manipulating the fragments into as good a position as 
 possible, antero-posterior angular splints are applied, and passive 
 motion started early. Possibly an antiseptic incision and wiring 
 or pegging of the fragments would give better results, whilst in 
 some cases excision of the ends of the bones may be required. 
 
 Fractures of the Ulna. — 1. The Olecranon is frequently broken 
 by direct violence, the patient falling on the bent elbow, but 
 occasionally by muscular action. The displacement is often 
 very considerable, the fragment being drawn up by the triceps 
 and tilted backwards (Plate XIV.) ; but if the ligamentous fibres 
 passing from the tendon to the fascia of the forearm remain 
 intact, there is but little separation. When complete, the bones 
 of the forearm are displaced forwards, and almost dislocated. The 
 line of fracture usually runs through the base of the process at its 
 attachment to the shaft, and is for the most part transverse. 
 Great swelling in and around the joint comes on early ; on exami- 
 nation, the detached fragment can be readily distinguished, and 
 between it and the shaft a sulcus, which increases on flexion and 
 diminishes on extending the forearm. The nature of the union 
 depends on the amount of separation of the fragments, and the 
 treatment adopted. If the fragments are not brought accurately 
 into apposition, fibrous union is likely to occur, and although the 
 new cicatricial tissue may stretch considerably, a useful elbow 
 sometimes results ; in some cases the fragment is drawn up 
 and fixed to the humerus, and a false joint is developed below 
 it. If, however, the fragments are brought in contact, bony union 
 follows, though even then some impairment of function may ensue 
 owing to the callus encroaching on the articular surface, which 
 is always involved. In all cases the ulnar nerve is exposed to 
 injury. 
 
PLATE XIV. 
 
 Fracture of Olecranon before Operation. 
 
 To face p. 460. 
 
PLATE XV. 
 
 Fracture of Olecranon Two Weeks after Operation. 
 
 From the same patient as Plate XIV. It will be noted that, though the fragments 
 are in apposition, they are not united. 
 To follow Plate XIV.] 
 
PLATE XVI. 
 
 Fracture of Olecranon (Six Weeks after Operation). 
 From the same patient as Plates XIV. and XV. The fragments are now united 
 
 by bone. 
 
 [To follow Piatt XV. 
 
INJURIES OF BONES— FRACTURES 461 
 
 Treatment. — The most satisfactory plan is to lay the parts 
 freely open, to thoroughly clear the joint of all blood and 
 exudation, remove shreds of tendon and ligaments which may 
 be placed between the fragments, and then wire them together, 
 the wire just extending down to the articular cartilage (Plate XV.). 
 The same precautions and after-treatment must be followed as in 
 dealing with the patella. A similar plan should be adopted in all 
 compound cases, and in those where loose fibrous union has 
 occurred with a resulting weak and relaxed elbow ; in the latter 
 instance the new fibrous tissue must be entirely dissected away 
 and the bony surfaces freshened. If an operation is not under- 
 taken, the arm should be put up on a straight anterior splint, the 
 fragment being drawn into position as well as possible by means 
 of a pad and figure-of-8 bandage. Gentle passive movement and 
 massage should commence at the end of a fortnight. 
 
 2. The Coronoid Process is so deeply placed and so well pro- 
 tected that fractures must necessarily be very uncommon, except 
 as an accompaniment of dislocation of the ulna backwards. The 
 signs relied on in making a diagnosis are that reduction of the 
 dislocation is easier than usual and associated with crepitus, and 
 that the deformity is likely to recur. The Treatment consists in 
 apposing the bony surfaces, if possible, by flexing the forearm. 
 Bony union is, however, less important than a freely moveable 
 elbow, and therefore passive movement is commenced early. 
 
 3. The Shaft of the Ulna is often fractured by itself as a result 
 of direct violence, to which its exposed position renders it pecu- 
 liarly liable. Fracture also occurs as a complication of several 
 of the forms of dislocation of the radius alone (Plate XXVII. ). 
 The superficial position of the posterior border renders examina- 
 tion of the bone easy ; if displacement or a breach of substance 
 occurs, it is readily detected, but when merely a fissure exists, it 
 is not so easy to make out. The constant pain referred to one 
 spot, the slight mobility, and possibly crepitus, indicate the char- 
 acter of the lesion. No longitudinal displacement can occur if the 
 radius remains intact, and under such circumstances the only 
 deformity consists in a slight drawing forwards of the upper frag- 
 ment by the brachialis anticus, whilst the lower fragment is 
 approximated to the radius by the pronator quadratus. Treat- 
 ment. — The arm is placed midway between pronation and supina- 
 tion, the deformity corrected, and the limb kept at rest between 
 anterior and posterior splints, or in plaster of Paris. 
 
 4. The Styloid Process may be detached by direct violence, or 
 as a complication of fracture of the lower end of the radius. The 
 displacement may be considerable and very evident, being governed 
 by the direction of the violence. Treatment consists in replacing 
 the fragment by manipulation, and fixing it by adhesive plaster ; 
 an anterior splint is applied with the hand adducted. 
 
462 A MANUAL OF SURGERY 
 
 Fractures of the Radius. — i. The Head of the Radius is rarely 
 broken alone, such an accident being usually associated with 
 other injuries to the elbow, as, for instance, fracture of the outer 
 condyle or some form of dislocation. The upper epiphysis may 
 be separated, or there may be merely a transverse or vertical 
 fissure ; but under any circumstances the displacement is slight if 
 the orbicular ligament remains intact. In complete separation 
 the head is immoveable, and crepitus is produced when the arm 
 is rotated ; bony union usually follows with more or less im- 
 pairment of function, but sometimes the head, or a portion of it, 
 remains detached as a loose body in the joint. All that is needed 
 is the application of a splint, the limb being kept midway between 
 pronation and supination, and early passive movement instituted. 
 Excision of the head may be required for comminution, or for 
 fixation of the joint by excessive formation of callus. 
 
 2. The Neck, i.e., the portion between the orbicular ligament 
 and the biceps tuberosity, is occasionally broken. The lower frag- 
 ment is drawn upwards and forwards by the biceps, causing a 
 bony projection on the front of the elbow, especially evident on 
 attempting to flex the joint, whilst the forearm is pronated with 
 loss of the power of rotation, and the head of the bone does not 
 accompany the shaft on passively rotating it. Treatment. — The 
 arm is flexed to relax the biceps, and the limb placed on a 
 posterior angular splint, with a pad over the front of the lower 
 fragment. Passive movement should not be commenced too early, 
 as the lesion is extra-articular, and the biceps may produce per- 
 manent deformity if allowed to act upon unconsolidated callus. 
 
 3. The Shaft of the radius is broken either by direct violence 
 or by falls on the palm ; the latter accident, however, rarely 
 causes fracture except at the lower end. The signs are sufficiently 
 evident, owing to the superficial position of the bone, consisting 
 of localized pain, 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 insertion 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 practically impossible to command 
 the small upper fragment, the lower must be brought into apposi- 
 tion with it by fully supinating the forearm and hand after flexing 
 the elbow, and applying a posterior splint, the patient being pre- 
 ferably kept in bed for a time and the arm laid on pillows. It 
 may afterwards be supported in a hollow leather splint carried 
 across the body, and with the palm directed upwards. 
 
 When the fracture is placed below the insertion of the pronator teres, 
 
PLATE XVII. 
 
 Fracture of Shaft of Radius (Anteroposterior View; 
 
 To face /. 462. 
 
PLATE XVIII. 
 
 Fracture of Shaft of Radius (Lateral View). 
 
 From the same patient as Plate XVII., and showing excellently the necessity for 
 taking skiagraphs from two points of view. 
 To follow Plate A7V/.] 
 
PLATE XIX. 
 
 Colles"s Fracture: a Simple Case, wtthoct much Lateral Displacement 
 
 oj Hand. 
 
 To follow Plo>. xvm | 
 
PLATE XX. 
 
 Colles's Fracture: a Bad Case, with the Styloid Process of the Ulna 
 torn off and much or i ward displacement ok hand. 
 
 To follow Plato XIX.} 
 
INJURIES OF BONES— FRACTURES 463 
 
 the upper fragment is drawn forwards by the action of the biceps, 
 and inwards by the pronator, assuming a position midway between 
 pronation and supination ; the lower fragment is approximated to 
 the ulna partly by the direct action of the pronator quadratus, partly 
 by the supinator longus tilting the upper end inwards;, the hand is 
 fully pronated looking downwards. Union to the ulna by callus 
 thrown across the interosseous space is not unlikely to occur. Treat- 
 ment by anterior and posterior splints may here be adopted, with a 
 good interosseous pad interposed between the limb and the splints, 
 the arm being placed midway between pronation and supination, 
 and the hand fully adducted. 
 
 4. The Lower End of the Radius is broken with extreme fre- 
 quency, constituting what is known as Colles's Fracture. This 
 injury occurs 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 pronated and extended. The line of fracture is 
 placed about 1 inch from the wrist, though rather under 
 than over this. It is usually transverse, but occasionally 
 oblique in an antero-posterior direction, sloping from above down- 
 wards and forwards, so that the fracture is nearer the wrist-joint 
 in front than it is behind, and also not uncommonly oblique later- 
 ally, slanting from without downwards and inwards (Plate XIX.). 
 
 The displacement is somewhat complicated, (a) The lower 
 fragment is carried backwards and a little upwards, a condition 
 resulting from the direction of the violence, viz., a fall on the 
 palm of the outstretched hand, the radius being thus 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 action of the radial extensor muscles of the wrist, and often 
 by impaction of the fragments, (b) From the fact that the main 
 violence is received by the ball of the thumb, owing to the extreme 
 pronation of the hand, the outer side of the lower fragment is 
 displaced more than the inner, which, moreover, remains fixed to 
 the ulna by the strong inferior radio-ulnar ligaments. This 
 position is in part kept up by the tension of the extensors of the 
 thumb and the supinator longus, but mainly by impaction of the 
 fragments. The hand and carpus always follow the lower frag- 
 ment, and hence the former becomes markedly abducted, causing 
 the styloid process of the ulna to become unduly prominent, and 
 lower than that of the radius, whereas it is normally placed on a 
 slightly higher level. Occasionally the styloid process of the ulna 
 is actually torn off, or the internal lateral ligament ruptured, 
 allowing displacement outwards of the whole hand (Plate XX.). 
 (c) The lower fragment is also rotated around a transverse axis, 
 so that the lower articular surface looks backwards as well as 
 downwards, a displacement due to the fact that in falling the 
 force is directed, through the carpus, more to the posterior than 
 
464 A MANUAL OF SURGERY 
 
 to the anterior aspect of the bone, (d) The upper fragment is 
 pronated and approximated to the ulna by the pronator quadratus 
 muscle. The deformity produced by the fracture is therefore very 
 characteristic. The hand is in a position of radial abduction, and 
 usually pronated, with the fingers 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. 147) ; (ii.) on the back of 
 the wrist is a prominence which terminates abruptly above, 
 caused by the projection of the lower fragment (Fig. 146) ; 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. In doubtful cases 
 
 Fig. 146. — Colles's Fracture : Fig. 147. — Colles's Fracture : 
 
 Lateral View. Palmar View. (Tillmanns.) 
 
 help in diagnosis may be obtained by observing the relative 
 position of the two styloid processes ; normally, that of the radius 
 is well below that of the ulna, but in cases of fracture the ulnar 
 projection is below that of the radius. 
 
 As already stated, the fracture is commonly impacted, the 
 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 considerable 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. — To reduce the deformity, extension and manipula- 
 tion are both needed. The patient 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 
 elbow, and the hand is then forcibly extended and adducted ; 
 
INJURIES OF BONES— FRACTURES 465 
 
 disimpaction is thus brought about, and a little manipulation 
 enables the fragments to be moulded into position. 
 
 Many plans have been adopted in the application of splints for 
 this fracture: (1) A piece of Gooch splint is perhaps the most 
 simple and efficacious. It is shaped so as to cover the radius 
 front and back as far as the middle line of the arm, and extends 
 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) Caw's splint (Fig. 148) consists of 
 two shaped pieces of wood fitting the front and back of the radial 
 side of the forearm, whilst to the palmar one is attached an oblique 
 rod to be grasped by the fingers, and thus the hand and wrist are 
 
 ^y ; /i/iiinii!!iiiiiiii/ii,iiiiiiff/ if/i/iiii/rf///,7////// 
 
 Fig. 148. — Carh's Splint for Colles's Fracture of Left Hand. 
 
 maintained in a position of adduction, whilst the fingers can be 
 freely moved. (3) The Pistol splint consists of a straight portion 
 fitted to the front of the forearm, whilst the handpiece is bent at 
 an angle like the butt-end of a pistol. It may also be applied to 
 the back of the forearm, together with a short straight splint on 
 the palmar aspect reaching to the wrist. It keeps the hand and 
 arm in excellent position, but is objectionable because the fingers 
 are also restrained. If, however, it is shortened at the end of four 
 or five days so as not to extend beyond the knuckles, it may be 
 used without doing harm. (4) Two straight splints may be 
 applied to the front and back of the forearm, which is kept mid- 
 way between pronation and supination ; neither should extend 
 beyond the knuckles, so that the fingers are free. The weight of 
 the hand, when the arm is slung, keeps it in a position of adduc- 
 tion. 
 
 Union is usually firm enough in a fortnight to permit the 
 removal of the splints, the arm being kept in a leather or gutta- 
 percha support for some time longer. Massage and passive 
 movement should be employed after the first week, and the 
 fingers left free and exercised after the first day or two. 
 
 5. Separation of the Lower Epiphysis of the radius occurs in young 
 
 30 
 
4 66 
 
 A MANUAL OF SURGERY 
 
 people under twenty, and, when the lower fragment is displaced 
 backwards, 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, 
 causing the fracture to become compound. The lower end of the 
 ulna may also be involved in the accident, either the epiphysis 
 being separated, or the shaft broken a little above. This condi- 
 tion may also 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 also occurs in some cases (Fig 149). Treatment is 
 practically the same as for Colles's fracture. 
 
 Fig. 149. — Skiagram of Displacement of Lower Epiphysis of Radius, 
 and of the hand outwards. 
 
 Should arrest of growth result from this accident, the hand 
 retains its connection with the stunted radius, but the ulna con- 
 tinues 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. 
 
 Fracture of both Bones of the Forearm may result from direct 
 or indirect violence, but more commonly from the former. Any 
 part of the bones may yield, but the middle and lower thirds 
 are most frequently affected, owing to their greater exposure. 
 The line of fracture may be transverse or oblique, and the dis- 
 placement varies both with this and with the force employed. 
 Occasionally both bones are broken close to the wrist by a fall 
 
PLATE XXL 
 
 Fracture of both Bones of the Forearm, with Displacement outwards. 
 To/ace p. 466.] 
 
INJURIES OF BONES— FRACTURES 467 
 
 on the palm of the hand (Plate XXL). The upper fragments are 
 usually drawn together and pronated, whilst the lower end of the 
 radius is drawn up by the supinator longus. The diagnosis of 
 these fractures is very simple, since there is, as a rule, obvious 
 deformity. Treatment consists in reduction by extension con- 
 joined 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. 462), whilst below that spot the usual position midway 
 between pronation and supination may be allowed. Union is 
 generally complete in five or six weeks. 
 
 Fractures of the Metacarpal Bones and Phalanges are not un- 
 common, being due to direct violence, and hence usually trans- 
 verse in direction. There is generally but little displacement, 
 though occasionally the fragments may overlap. An oblique 
 fracture sometimes occurs through the base of the first meta- 
 carpal, separating the anterior portion, which remains in situ, 
 whilst the rest of the shaft is drawn upwards and backwards. 
 There is always a certain amount of localized swelling and 
 tenderness in these fractures. The only treatment required 
 is immobilization for a short time, and for the phalanges a small 
 zinc splint moulded along the front of the finger acts admirably. 
 
 Fractures of the Pelvis. 
 
 Fractures of the pelvic bones are almost always the result 
 of direct injury, such as blows, gunshot wounds, and railway, 
 carriage, or cart accidents. For convenience they may be de- 
 scribed under the following headings : 
 
 1. Fractures of the False Pelvis. — A portion of the crista ilii 
 may be broken off, or the anterior or posterior spines separated, 
 or merely a fissure in the bone produced. But little importance 
 attaches to such conditions, as the displacement can never be great, 
 although a portion of the crest may be drawn down by the glutei 
 muscles, or the anterior superior spine displaced by the sartorius; 
 in severer cases, when the bones are crushed and comminuted, 
 the true pelvis is likely to be also affected, and more serious con- 
 sequences may then arise. Considerable pain is always produced 
 by these conditions, especially on any vigorous respiratory move- 
 ments. Union occurs readily, all the treatment required being to 
 keep the patient 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 usually runs into the obturator foramen, and 
 may detach both the horizontal ramus of the pubes and the 
 ascending ramus of the ischium from the rest of the innominate 
 
 30—2 
 
4 68 
 
 A MANUAL OF SURGERY 
 
 Fig. 150. — Fracture of the Pelvis. 
 (Bryant.) 
 
 bone (Fig. 150). This is frequently conjoined v/ith a fracture 
 through the sacro- iliac synchondrosis 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 con- 
 tinued strain, whether di- 
 rected 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. The Symptoms 
 are those of shock and pain in and around the pelvis, especially 
 on movements of the legs or on coughing. There may be local 
 ecchymosis, and tenderness over the pubic ramus, and the patient 
 either cannot stand, or feels as if he were falling to pieces on 
 attempting to do so. There is rarely any deformity, although 
 occasionally such an occurrence is noted. 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. Complications frequently arise from injury to the 
 internal viscera, especially the bladder, rectum, urethra, or vagina, 
 as indicated by haemorrhage into or from these organs. An aseptic 
 catheter should be passed as a routine proceeding, and if the 
 urine is blood-stained, it is tied in. 
 
 Treatment. — The patient should be moved with the greatest 
 care, for fear of producing or increasing visceral complications. 
 He is put to bed, and any obviously displaced fragments reduced, 
 if practicable, possibly under an anaesthetic. A broad flannel 
 bandage should be applied, the knees tied together, and a leather 
 or poroplastic splint moulded to the pelvis. Visceral complica- 
 tions must receive attention, as indicated elsewhere. Union 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. 
 
 3. Fracture of the Acetabulum is of two types : either the 
 posterior lip is broken off as a result of violence directed against 
 it by the head of the femur, which is dislocated backwards by the 
 same accident ; or a fall on the trochanter may cause a simple 
 fissure extending into or across the cavity, or may resolve it into 
 
INJURIES OF BONES— FRACTURES 469 
 
 its three constituent elements, or may even drive the head of 
 the bone into the pelvis. In the former case, the limb is in the 
 position of a dorsal dislocation ; this can be reduced without 
 difficulty, and possibly with crepitus, but manifests a great 
 tendency to recur. Prolonged extension with a long splint is 
 needed in such cases. In the latter class of injury a mere fissure 
 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 fracture of the neck of the femur, but there is usually only 
 very slight mobility, and the head of the bone may be felt within 
 the pelvis on rectal examination. An attempt should be made to 
 free the head of the bone, and the case treated as one of fracture 
 of the neck of the femur ; but a fatal issue is very likely to follow. 
 
 4. Fracture of the Tuber Ischii results from falls in the sitting 
 position. The diagnosis is often obscure. 
 
 5. Fracture of the Sacrum is always due to direct violence of 
 considerable 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 ; irregularity in the shape of the bone may be detected 
 from within (per rectum) or from without. Treatment. — The 
 lower fragment should be replaced, if possible ; but considerable 
 difficulty may be experienced in keeping it in position. A well- 
 fitting pelvic band, with rest in bed, is probably all that is necessary. 
 
 6. Fractures of the Coccyx are by no means uncommon as a 
 result of 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, defalcation, etc., since the coccygeus muscle which is 
 attached to this bone forms part of the lower diaphragm of the 
 abdomen. 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 to correct 
 the deformity. Sometimes the bone unites at an angle, causing 
 much pain and discomfort, whilst difficulty in parturition may also 
 arise from this cause. Excision of the bone is 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 
 
47o 
 
 A MANUAL OF SURGERY 
 
 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, but it is not common to 
 obtain healing by first intention. 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 coccydynia, which may quite prevent the patient from 
 following his avocations. 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 are commonly divided into 
 intra- and extra-capsular varieties, and, although this is by no means 
 free from objections, yet it constitutes a useful working basis. 
 
 The Intracapsular Fracture, or fracture near the head (Fig. 151), 
 though it has occurred in children and adolescents, is almost in- 
 variably met with in persons in advanced life, 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 en- 
 larged, 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 atrophied. The neck 
 of the bone is sometimes more horizontal 
 than usual, and the head sinks below its 
 usual position. Under such circumstances, 
 it requires but little violence to produce a 
 fracture, the direction of which varies ac- 
 cording to the force applied. As a rule, 
 the accident is due to some slight stumble 
 or fall, such as slipping off the kerb or 
 tripping upstairs ; the bone yields in con- 
 sequence, and the patient falls to the ground. The line ol 
 fracture may be transverse or oblique, and is mainly intra- 
 capsular. 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 or 
 injudicious manipulation 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 fragment, which is drawn upwards 
 by the glutei, recti, and hamstring muscles, and rotated outwards 
 
 Pig. 151. — Intracapsu- 
 lar Fracture of the 
 Cervix Femoris. 
 
INJURIES OF BONES— FRACTURES 
 
 47' 
 
 and somewhat backwards, so that the fractured surface looks 
 almost directly forwards. 
 
 The Method of Union in these cases depends to a large extent 
 upon the general condition of the individual. If of a healthy 
 temperament, and without any chronic pulmonary affection, so 
 that he can be kept in the recumbent posture for six or eight 
 weeks, bony union may certainly occur, in spite of the fact 
 that at first synovial fluid finds its way between the fractured 
 surfaces. The main process of repair takes place from the lower 
 end, but little callus being formed from the head of the bone, the 
 vascular supply being only just sufficient to maintain its vitality. 
 If, however, the patient is feeble and weakly, and especially if the 
 subject of chronic bronchitis and emphysema, the prognosis is by 
 no means good, since hypostatic pneumonia and extensive bed- 
 
 A B 
 
 Fig. 152. — Extracapsular Fracture of Cervix Femoris. 
 
 A, From behind, showing detachment of both trochanters ; B, on section, 
 
 showing impaction of head and neck into base of trochanter, which also is 
 
 detached, 
 sores 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, the patient henceforth walking with 
 the assistance of a stick or crutch. The prognosis is, of course, 
 much improved by the presence 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 re- 
 flected fibres from the capsule also improves the outlook. 
 
 Extracapsular Fracture of the cervix femoris (fracture near the 
 trochanter) is an absolute misnomer, since the capsule extends 
 to the shaft of the bone along the anterior intertrochanteric line, 
 and leaves no portion of the neck uncovered in this situation. 
 
472 A MANUAL OF SURGERY 
 
 The line of fracture is placed in front, either along the attachment 
 of the capsule or within it, and is really only extracapsular 
 behind ; sometimes, moreover, the shaft itself is considerably 
 encroached on. The great trochanter is often involved in the 
 fracture, being splintered or detached, and the lesser trochanter 
 may be split off with a portion of the shaft, so that the bone is 
 broken into at least three different fragments (Fig. 152). 
 
 Mechanism. — This fracture is usually the result of direct 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, being more or less crushed and 
 comminuted ; the whole neck then yields, and the severed head 
 and neck are forcibly impacted into the junction of the trochanter 
 and shaft (Fig. 152, B). The majority of these cases are thus 
 primarily impacted, continuation of the violence producing dis- 
 impaction, coupled either with detachment of one or both tro- 
 chanters, or with comminution of the great trochanter. A similar 
 result may follow from the inflammatory exudation causing a late 
 separation of the impacted parts, or from injudicious manipulation. 
 
 The displacement is much the same as in the former variety ; 
 the upper fragment remains in statu quo, whilst the lower is 
 drawn up and everted, only to a greater extent. Shortening 
 may at first be slight, but is likely to increase at the end of 
 a few days, as a result of disimpaction of the fragments, or 
 from the yielding of the reflected fibres of the capsule, or from 
 the tonic action of the muscles. Later on, moreover, the shorten- 
 ing may again increase from a rapid absorption of the neck, which 
 occasionally follows this accident, or is possibly due to the super- 
 vention of chronic traumatic arthritis. 
 
 The Signs and Symptoms of these two fractures may well be 
 considered together, the points of similarity and contrast being in 
 this way more effectually emphasized. 
 
 (a) The signs of local trauma, viz., pain, bruising, and swelling, 
 may be present in both ; but whilst slight in the intracapsular 
 variety, they are very marked in the extracapsular. It must not 
 be overlooked, however, that even in the former the patient may 
 fall on the affected hip after the fracture has occurred, and thus 
 cause a considerable amount of bruising. 
 
 (b) Crepitus is evident in the unimpacted forms of each ; but it 
 is unnecessary and, indeed, extremely unwise to elicit it by forcible 
 manipulation, especially in the intracapsular variety. 
 
 (c) Loss of power of the limb exists to a variable extent, and 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 displace- 
 
INJURIES OF BONES— FRACTURES 
 
 47; 
 
 ment is accredited to the natural weight of the limb, to the greater 
 fragility of the back of the cervix, causing it to be more com- 
 minuted 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. In the latter case 
 the shortening usually attains its maximum — viz., il to 2h, or 
 even 3 inches — at once ; but such is not always the case in the 
 former. 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 im- 
 
 Fig. 153. — Nelaton's Line and Bryant's Measurement for ascertaining 
 Position of Great Trochanter. 
 
 portance. It is raised above its ordinary level and everted ; it is 
 approximated to the middle line of the body and to the anterior 
 superior iliac spine, and rotates in the arc of a smaller circle than 
 usual, the radius being the thickness of the trochanter alone, 
 instead of including also the length of the neck. The demonstra- 
 tion of this position is most important, and, amongst others, the 
 following tests are employed : 
 
 Nelaton's line (Fig. 153) 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 abduc- 
 tion or adduction is present, the top is situated slightly above or 
 
474 A MANUAL OF SURGERY 
 
 below the line. Definite elevation of the bone above the line 
 indicates shortening of the limb due to dislocation backwards, 
 fracture of the neck, or absorption of the neck from disease. 
 
 Bryant's Test Line (Fig. 153). — In this the patient lies 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. 
 
 Morris's bitrochanteric 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. 
 
 One other change in the great trochanter may be noted in the 
 extracapsular form of fracture, which can be utilized as a useful 
 diagnostic feature between it and the intracapsular variety, viz., 
 the great amount of thickening of the process which is always pro- 
 duced, owing to the excessive 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 ilio- 
 tibial band) is given as a characteristic feature of these fractures. 
 
 Diagnosis. — Simple unimpacted fractures are readily detected, and 
 there can be but little difficulty in distinguishing the two forms, 
 either from one another or from other injuries. The fact that an 
 impacted fracture has occurred can also be easily made out as a 
 rule, the pain, eversion, and shortening sufficing to indicate its 
 existence ; but it is often very difficult to say which of the two 
 forms of fracture is present, especially if the surgeon is not called 
 till late in the case. The character of the accident and the age 
 of the patient must be taken into account, whilst the existence of 
 Assuring or thickening of the trochanter, or an excessive amount 
 of shortening, may indicate that the lesion has been extracapsular. 
 A severe contusion of the hip, which may be associated with marked 
 eversion, is known from a fracture by the absence of shortening 
 and crepitus ; there is no displacement of the trochanter, which 
 rotates in a normal manner. The shortening which sometimes 
 follows, owing to subsequent atrophy of the neck, may, however, 
 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 
 with antecedent shortening and marked bony crepitus, there may 
 be no history of accident, and no acute eversion, pain, or loss of 
 power ; possibly the existence of similar disease in other joints 
 
INJURIES OF BONES— FRACTURES 
 
 475 
 
 may assist the surgeon, whilst osteo-arthritis of the hip usually 
 results in prominence of the trochanter, and not in flattening, as 
 occurs after fracture. Moreover, the fascia 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. A Thomas's 
 splint should be fitted as early as possible, and the patient 
 encouraged to get about on crutches. 
 
 Fig. 154.- 
 
 -Liston's Splint padded and applied. 
 a. Perineal band. 
 
 In a healthy individual with good physique, where bony union 
 may be expected, the patient is kept at rest in bed for six or 
 eight weeks, by means of Liston's splint (Fig. 154). This needs 
 careful adjustment, but is satisfactory in its results when properly 
 applied. It should reach from the axilla to about 6 inches below 
 the ankle, and is fixed to the leg and body either by bandages, or 
 much better by two broad sheets, which first firmly envelop the 
 splint, and are then passed round the body, and finally secured by 
 pins to the portion surrounding the splint. Carefully padded 
 poroplastic foot-pieces are placed on either side of the ankle so as 
 to diffuse the pressure, and a handkerchief passed round the foot, 
 and through the prongs at the end of the splint, fixes it in the 
 desired position. A well-padded perineal band is next applied, 
 taking its purchase from the tuber ischii, and with its free ends 
 passed through the two holes at the upper extremity of the splint ; 
 by tightening and tying these two together, the upper end of the 
 splint is steadied. Extension of the limb is obtained by an elastic 
 
476 A MANUAL OF SURGERY 
 
 accumulator, or by weight and pulley acting from the knee in the 
 usual way. Finally, the sheets or bandages are adjusted, and the 
 lower end prevented from moving laterally or rotating by slipping 
 it into a slot between two rectangular plates of metal screwed to 
 a substantial wooden base, which rests on the bed. The handker- 
 chief and perineal band will need occasional tightening to maintain 
 the required position, and the latter must be renewed from time 
 to time for purposes of cleanliness, and the parts well powdered 
 with boric acid. At the end of six weeks or so the pelvis should be 
 encased in poroplastic material or plaster of Paris, and the 
 patient allowed to get about on crutches, or a Thomas's splint 
 applied. 
 
 No attempt should be made to disimpact fractures in old people ; 
 rest and quiet are maintained by applying a long splint without 
 extension, and bony union usually follows. 
 
 In other cases it may suffice to simply lay the limb on a bed 
 between sandbags, and to make extension from the foot. The leg 
 is first swathed with a boracic lint bandage, and then a piece of 
 broad adhesive plaster is applied on either side of the limb, reach- 
 ing nearly as high as or above the knee, and with a loose stirrup 
 4 or 5 inches long below the foot ; the plaster is secured by one or 
 two strips of strapping f inch wide wound obliquely round the 
 limb above and below, and by a calico bandage. In the stirrup a 
 cross-piece of wood, rather broader than the ankle, is inserted, and 
 a knotted cord carried through a hole in it. The cord is passed 
 over a pulley fixed to the end of the bed, and to its end is attached 
 a weight, varying with the requirements of the case ; the lower 
 portion of the bed is usually raised by placing the legs on blocks, 
 so as to utilize the weight of the body as a counter-extending force. 
 As the continuous application of a heavy weight may stretch the 
 ligaments of the knee joint, it is usually advisable to distribute a 
 part of the traction above the knee. Hodgen's splint, as described 
 below, may also be used in these cases. 
 
 Treatment of Extracapsular Fracture. — The long splint with 
 extension will sometimes suffice for this condition, good bony 
 union usually occurring, though with some shortening. In other 
 cases it may be advisable to make extension from the knee, and 
 to keep the limb slightly flexed, as on a double inclined plane. 
 Probably treatment is best carried out by the use of the splint intro- 
 duced by Dr. Hodgen, of St. Louis, U.S.A., the value of which 
 was first demonstrated in this country in the theatre of Guy's 
 Hospital by the inventor in 1879. For our description of it we 
 are indebted to Mr. Golding Bird. It is made of stout iron wire, 
 quite rigid, and is in the form of the letter U, the outer 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. 
 
INJURIES OF BONES— FRACTURES 
 
 477 
 
 The sides taper with the limb, and should be f 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 is placed 
 on the slant, and should correspond to Poupart's ligament ; two 
 simi'ar arches are placed at equal points lower down. The splint 
 is bent at the knee to about an angle of 130 . 
 
 Before applying the splint, an ordinary extension stirrup should 
 be attached to the limb, and a piece of wood introduced therein wide 
 enough to take any pressure off the malleoli ; to the wood is tied a 
 piece of stout cord. 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 
 
 Fig. 155. — Hodgen'3 Splint applied. 
 
 spot to which each is to be applied. The splint is then adjusted, 
 the top of the outer bar resting against the anterior superior 
 spine, and the inner bar against the adductor tendon. The 
 strips of flannel are then raised in succession, and, being 
 lapped over the bar, are pinned or stitched there, so that when 
 completed the limb lies in a flannel trough, from which only 
 the upper surface projects, and there should be an interval of 
 fully an inch between Poupart's ligament and the upper crossbar. 
 The short cord already mentioned as being attached to the stirrup 
 is then securely tied to the lower end of the splint. Cords are 
 now fixed to the hooks, two of which are soldered to each side of 
 the splint, the lengths of the cords being such that, if they were 
 raised and made taut with the finger, the finger would be about 
 
478 A MANUAL OF SURGERY 
 
 8 or 10 inches above the splint. The two cords are then brought 
 together over the limb, and to them is tied another stout cord, 
 which passes over a pulley attached to a vertical post at the 
 end of the bed, and is weighted to a sufficient extent. The angle 
 required to make satisfactory extension is determined partly by the 
 position of the limb, partly by the sensations of the patient. The 
 limb when the weight is applied should lie free of the bed, even to 
 its extreme upper limit. No bandages are required ; the limb lies 
 in the obliquely-set flannel trough, which is maintained in position 
 by its friction against the limb ; the splint itself is pulled upon by 
 the extending force, and this is transmitted to the limb through 
 the stirrup cord attached to the lower end of the splint. If 
 correctly applied, this stirrup cord is taut ' like a harp string '; 
 any slipping of the extension or of the apparatus is indicated by 
 laxity of this cord, and involves readjustment. Some authorities, 
 however, recommend that the thigh should be enclosed in Gooch 
 splinting, a narrow piece in front between the bars, and a broader 
 piece behind encircling the limb. These are well padded and 
 bandaged on, the bandages extending over the whole length of the 
 apparatus ; finally, starch is rubbed in so as to fix it more firmly. 
 When impaction has occurred in young and active individuals, 
 it is quite justifiable to give an anaesthetic, and forcibly break it 
 down, so as to prevent subsequent shortening. 
 
 2. Fracture of the Great Trochanter is very rare, and always 
 due to direct violence ; in the young it occurs as an epiphyseal 
 lesion. The trochanter, or a portion of it, is entirely separated 
 from the rest of the bone without any loss of the continuity of the 
 shaft. Independent movement of the fragment with crepitus is 
 usually obtainable ; and if the displacement is at all marked, an 
 operation to fix it by means of a plated screw or ivory peg should 
 be undertaken. 
 
 3. Fracture through the Great Trochanter (the per-trochantcric 
 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. 
 The lower fragment, including the lesser trochanter, is drawn 
 upwards and backwards towards the sciatic notch, and forms a 
 projecting mass behind, somewhat simulating a dislocation ; the 
 tip of the trochanter can, however, be felt separately, not moving 
 with the shaft. Such cases may be treated by extension with 
 the long splint, or perhaps better by Hodgen's apparatus. 
 
 4. Separation of the Upper Epiphysis of the Femur. — The upper 
 cartilaginous end of the femur in infants includes not only the 
 head, but also both trochanters, and there is no case on record of 
 complete detachment of this portion. Ossific centres early appear 
 for each of these three projections, and by the rapid growth 
 upwards of the shaft, they are separated from each other by the 
 
INJURIES OF BONES— FRACTURES 
 
 479 
 
 fourth year, the neck thus being really constituted as an outgrowth 
 of the shaft. The epiphysis of the head has been completely 
 detached in a considerable number of cases, but the accident is not 
 so common as in the humerus, owing to the protection given by 
 the depth of the acetabulum. The phenomena closely simulate 
 those of an intracapsular fracture, but are less obvious. Impair- 
 
 Fig. 157.- — Fracture of Lower Third 
 of Femur, showing Displacement 
 of Lower Fragment Backwards 
 (From Gray's 'Anatomy.') 
 
 Fig. 156. — Fracture of Utper Third 
 of Femur, showing Displacement 
 of Bone. (From Gray's 'Anatomy.') 
 
 ment of growth may follow, and possibly the shape of the head 
 and neck may be so altered subsequently as to simulate the con- 
 dition known as coxa vara. Treatment of the lesion is by exten- 
 sion, and possibly the use of the long splint. 
 
 Fractures of 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 
 
4 8o A MANUAL OF SURGERY 
 
 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. 
 
 In almost every case displacement occurs, the direction and 
 amount of which depends not only on the line of fracture, but 
 also on the situation. In the upper third (Fig. 156), the small 
 upper 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 hamstrings and adductor muscles, 
 marked eversion also resulting partly from the weight of the foot, 
 and partly from the action of the adductors ; but such a com- 
 plicated displacement is not always present. 
 
 In the middle third, if due to direct violence, the line of fracture 
 slants from above downwards and backwards, causing a simple 
 over-riding of the fragments, or an angular deformity. The lower 
 fragment is drawn upwards and inwards, either in front of or 
 behind the upper fragment, and is usually everted. The upper 
 fragment is sometimes tilted forwards. If due to direct violence, 
 the fracture is more often transverse, and any form of displace- 
 ment may then occur. 
 
 In the lower third the fractures often arise from direct force, and 
 are transverse ; the lower fragment may then be tilted backwards 
 by the gastrocnemii muscles, and compress or rupture the popliteal 
 vessels, perhaps causing gangrene (Fig. 157). Oblique fractures 
 from indirect violence, sloping from above downwards and for- 
 wards, are also met with ; the upper fragment is driven into the 
 substance of the quadriceps muscle and may become fixed in it, 
 projecting immediately beneath the skin, whilst the lower frag- 
 ment is drawn up behind. If such a case is left unreduced, 
 ununited fracture is likely to ensue ; the knee-joint is generally 
 penetrated by the lower end of the upper fragment. 
 
 Treatment. — In the upper third, where the upper fragment is 
 tilted forwards, constituting a projection under the skin, and when 
 it is 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 brought 
 into the same axis as the upper. Manipulation will usually 
 correct any lateral displacement. The limb must be confined 
 in this position by some form of inclined plane, such as a Mac- 
 intyre's splint, with a long thigh-piece, and with small straight 
 wooden splints or a piece of Gooch's splinting fixed, if necessary, 
 to the front and outer sides of the limb, over the seat of fracture. 
 The 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 pre- 
 cautions are not taken, an ununited fracture, with the upper frag- 
 ment in front of the lower, is likely to occur. Hodgen's apparatus 
 also answers admirably in these cases. 
 
INJURIES OF BONES— FRACTURES 481 
 
 In the middle third of the thigh, where the upper fragment can 
 be controlled by splints, shortening is prevented by simple, exten- 
 sion (p. 476), the thigh being surrounded by pieces of Gooch's 
 splinting, which grasp the muscles and keep the parts at rest. 
 The limb is then placed between sandbags, or secured on a 
 Liston's splint. Where the fracture is oblique, with a good deal 
 of tendency to overlap, Hodgen's apparatus should be utilized. 
 
 In the lower third, if there is any tendency to displacement of 
 the lower fragment backwards, a Macintyre's splint, 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 if the upper fragment projects anteriorly beneath the skin 
 through the quadriceps, operation alone holds out any prospect 
 of bringing the parts into apposition, the muscular fibres being 
 divided sufficiently to allow the projecting end of the bone to be 
 replaced, and if necessary wired or pegged. In other cases the 
 ordinary long splint or Hodgen's will be required. 
 
 In children, Bryant's plan of treatment 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 splints, thus obtaining extension by utilizing the 
 weight of the body, whilst the bandages, etc., are kept from being 
 soiled. If a long splint is used for children, a double one (e.g., 
 Hamilton's splint) with a crossbar below is the best. Plaster of 
 Paris or starch bandages may be early applied in adults, but only 
 in the later stages in young children, as they are difficult to keep 
 clean. 
 
 Fractures of the Lower End of the Femur. 
 
 1. Transverse Supracondyloid Fracture is practically identical 
 with that involving the lower third of the femur ; the lower frag- 
 ment is rotated backwards by the action of the gastrocnemii, thus 
 endangering the integrity of the popliteal vessels, and predisposing 
 to non-union, if the deformity is overlooked. 
 
 2. T- or Y-shaped Fracture of the Condyles. — In this a trans- 
 verse fracture is complicated by a fissure, which runs into the 
 joint, separating the two condyles. The symptoms are much 
 the same as the above, but the joint is distended with blood, the 
 bone may feel broader than usual, and crepitus may be detected. 
 The Treatment is the same as for transverse fracture. 
 
 3. Separation of either Condyle always results from direct 
 violence, the line of fracture being oblique. There is no shorten- 
 ing, but the leg may be deflected towards the side injured, and 
 the joint is distended with blood. It may move separately from 
 the shaft, and give rise to crepitus. Treatment. — Reposition is 
 easily effected when the limb is slightly flexed, and it is best put 
 up in this position. 
 
 Occasionally a small portion of the condyle may be detached 
 
 3i 
 
4 82 A MANUAL OF SURGERY 
 
 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. 
 
 4. The Lower Epiphysis of the Femur is separated from the 
 shaft in young people; it is net a very rare accident, and closely 
 simulates in its signs those of a transverse fracture, even occasion- 
 ing gangrene in some cases. The epiphysis is generally displaced 
 forwards by the traction of the quadriceps on the tibia, and the 
 vessels are then compressed by the lower end of the diaphysis. 
 Suppuration occurs in a fair proportion of the cases. This con- 
 dition has been mistaken for disease of the knee-joint. Treat- 
 ment. — 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 6o°, and laid on its outer side 
 with an icebag applied. Passive movement is carefully com- 
 menced in a fortnight. 
 
 5. Longitudinal and Spiral Fissures are met with in the femur, 
 running down to the knee-joint, but causing no characteristic 
 symptoms beyond pain and haemarthrosis. Early passive move 
 ment is necessary to prevent impairment of function. 
 
 Fractures ef the Patella. 
 
 The patella is broken in two distinct ways, viz., by muscular 
 force and by direct violence, and the conditions produced are so 
 different that a separate description is necessary. 
 
 1. Fractures hy direct violence may traverse the bone in any 
 direction, but are most often vertical or star-shaped, and possibly 
 comminuted. They are frequently incomplete, i.e., mere fissures 
 of the front of the bone, and as a rule the fibrous aponeurosis or 
 capsule covering it is uninjured, thereby preventing any displace- 
 ment of fragments. There is a good deal of subcutaneous bruising, 
 and perhaps some effusion into the joint, whilst on careful palpa- 
 tion the fissure may be detected. Crepitus can be obtained if 
 the fracture is complete. Treatment consists in keeping the 
 limb at rest on a back-splint, and perhaps applying evaporating 
 lotions. Passive movements must be commenced early where 
 there has been much effusion into the joint. 
 
 2. Fractures due to muscular force constitute a very different 
 class of injury, since they are always transverse, usually complete, 
 and also involve the fibrous aponeurosis, so that considerable dis- 
 placement 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 of its articular surface ; in this position any sudden 
 
 
INJURIES OF BONES— FRACTURES 
 
 483 
 
 and violent contraction of the quadriceps, as in attempting to 
 recover one's equilibrium after having slipped, takes the hone 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 bone yields subsequently, although 
 perfect functional repair has been obtained in that first broken. 
 The fragments are often almost equal in size (Fig. 158), but 
 may vary widely ; and either of them may be again divided 
 vertically, or comminuted. 
 
 The Signs of this fracture are very evident, consisting 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 some- 
 times brought into apposition with crepitus (Figs. 158 and 159). 
 
 Fig. 158. — Fracture of Patella, 
 and Separation of Fragments. 
 (From Gray's ' Anatomy.') 
 
 Fig 159 — Appearancf of 
 Knee after Fracture 
 of Patella. 
 
 This displacement, at first due to muscular action, is maintained 
 by the effusion of blood, as also later by synovial exudation. 
 Union by bone is rarely obtained under ordinary circumstances, 
 a fact explained partly by the separation of the fragments, and 
 partly by 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 
 may be 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 often very weak in consequence. 
 
 The Treatment of these cases has been a matter of much 
 discussion, and many plans have been adopted, which may 
 
 31 — 2 
 
484 A MANUAL OF SURGERY 
 
 be grouped under three headings, viz., treatment by retentive 
 apparatus, by subcutaneous operation, or by the open method. 
 
 1. Simple retentive apparatus may be employed in cases where 
 the fragments are not widely separated, and can be readily 
 brought into contact and maintained in apposition. 
 
 Some surgeons depend mainly upon plaster of Paris to effect 
 this. If there is but little effusion, the limb is extended, swathed 
 in cotton-wool and a flannel bandage, and over this the plaster 
 casing is applied. As the apparatus becomes loose from muscular 
 atrophy, it will need readjustment. The patient is kept in bed 
 for three or four weeks, but the plaster is retained for as many 
 months, and after that a knee support, such as the Middlesex 
 splint (vide infra), is kept on till twelve months have elapsed. 
 Where there is much effusion after the accident, the limb is 
 placed on a back-splint and kept cool by ice or evaporating lotion, 
 until the fluid has been absorbed ; or the joint may be aspirated 
 in order to hasten matters. The plaster is then applied, and the 
 same routine followed. The chief objection to this plan is the 
 enclosure of the limb in the plaster case, so that the muscles and 
 joint cannot easily be got at for purposes of massage. 
 
 In the so-called Middlesex plan of treatment a large piece of 
 moleskin plaster is placed over the front and sides of the extensor 
 surface of the thigh, reaching halfway up to the groin, and terminat- 
 ing below in two lateral elongated ends or tags, to which elastic 
 traction is applied. The limb is put on a back-splint, with a foot- 
 piece, beneath which the elastic accumulator is firmly tied. 
 Removal of the effusion in the joint may be hastened by the 
 use of the aspirator. At the end of about six weeks the patient is 
 allowed to get about in a plaster of Paris casing, and then, about 
 three months after the accident, a special knee-splint is substituted, 
 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. In this method of treatment it 
 is probable that only fibrous union is obtained. 
 
 2. To ensure more accurate apposition and a firmer union, and 
 yet to avoid the risks necessarily associated with laying the joint 
 open, various subcutaneous operations have been adopted, (a) Barker 
 recommends antero -posterior suture of the bone (Fig. 160). 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, 
 
INJURIES OF BONES— FRACTURES 
 
 485 
 
 and by tightening and twisting the wire the fragments are brought 
 into apposition. The ends are cut off and pushed back under the 
 skin. The punctures are treated antiseptically, and the limb 
 placed on a back-splint for a week or so, when passive movement 
 is commenced, the patient being allowed to walk about at the end 
 of the second week, and discarding all apparatus at the end of 
 five weeks, (b) Circumferential suture (introduced originally by 
 Butcher, of Liverpool) is also practised (Fig. t6i), the wire in this 
 case passing round the bone from side to side. A somewhat 
 longer period of after-treatment is needed in these cases, (c) Mayo 
 Robson, of Leeds, inserts knitting needles through the muscle 
 and tendon above and below the fragments, and draws them 
 together by elastic bands passed over the ends (Fig. 162). 
 
 Necessarily, a certain element of risk is admitted in any of 
 these subcutaneous operations, and the surgeon has to ask himself 
 whether he is doing the best for his patient by utilizing such 
 proceedings, granting that it is advisable to interfere at all. 
 Personally, we are of opinion that, if it be justifiable to incur any 
 risk, it is best to proceed by the open method, since in none of 
 
 Fig. 160. — Barker's 
 Method of Sub- 
 cutaneous Suture 
 after Fracture of 
 Patella. 
 
 Fig. 161. — Circumferen- 
 tial Suture for Frac- 
 ture of Patella. 
 
 Fig. 162. — Mayo Rob- 
 son's Method of 
 dealing with frac- 
 TURED Patella. 
 
 the others can the fragments be brought into accurate apposition, 
 owing to the impossibility of removing the interposed portion of 
 fibrous capsule, which is always curled in over one of the broken 
 surfaces, whilst the joint cavity cannot be cleared of the blood- 
 clot which may have collected within it. Impressed by the 
 confidence derived from a thorough and efficient application of 
 aseptic principles, we cannot but conclude that, if it is desirable 
 to do more in a case of fractured patella than apply mere retentive 
 apparatus, the patient's welfare is best consulted by adopting — 
 
 3. The open plan of treatment, advocated and perfected by Lord 
 Lister. It consists in freely exposing the interior of the articula- 
 tion, clearing the joint of all blood-clot, removing all tags of fascia 
 or aponeurosis, and wiring the fragments securely together. 
 
486 
 
 A MANUAL OF SURGICKY 
 
 No surgeon should attempt this operation unless well assisted 
 and thoroughly an fait with the details of antiseptic work. At 
 King's College Hospital this practice is now almost exclusively 
 followed, and the results, at any rate in the more recent cases, are 
 most satisfactory, no instance of serious mischief from the opera- 
 tion having arisen for the last fifteen years or more. A longi- 
 tudinal incision is sometimes adopted, although a horseshoe- 
 shaped flap is more frequently dissected up or down, exposing 
 the bone. All blood-clot is removed, and the fractured surfaces 
 cleared of all clot and fibrous shreds, which are very often 
 adherent. Tracks for the wire sutures are now made by a 
 bradawl, extending from the upper or lower end through the 
 centre of the bone, so as to emerge on the fractured surface just 
 in front of the articular cartilage (Fig. 163); should the awl 
 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 periosteum, so as to keep it from 
 projecting under the skin and causing irri- 
 tation. A second wire is sometimes needed 
 in order to prevent rotation of the fragments. 
 The wound is closed, and the limb kept on 
 a Gooch's splint for eight days, when passive 
 movement is commenced, and by the end of 
 a fortnight the patient is allowed to walk in 
 the simpler cases ; but in complicated frac- 
 tures and in elderly people it is advisable to 
 keep the limb immobilized for a longer period. 
 It is perhaps advisable not to undertake this 
 operation immediately after the accident. The 
 limb should be kept at rest on a back-splint, and an icebag applied 
 for a week or ten days, so as to allow the joint to recover from the 
 effects of the injury it has sustained ; there is then much less risk 
 of septic complications. 
 
 In old cases, where the fibrous union has stretched and the utility 
 of the limb is seriously impaired, the open operation holds out the 
 only hope of helping the patient, although it is always a matter of 
 considerable difficulty. The fibrous tissue must be dissected 
 away, and the ends of the bones freshened, if need be, with the 
 saw. To obtain apposition, the upper fragment must be freely 
 detached from the femoral condyles, to which it is very often 
 adherent, and the rectus muscle, which is secondarily contracted, 
 may need to be partially divided. The limb should be well raised 
 
 Fig. 163. — Position 
 of Silver Wire in 
 Open Operation 
 for Fractured 
 Patella. 
 
INJURIES OF BONES— FRACTURES 4S7 
 
 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 absolutely brought together, the 
 same treatment may be adopted, and the patient allowed to get 
 about with silver wires between the fragments ; the quadriceps is 
 stretched by this means, and a subsequent operation may prove 
 successful in gaining bony union. 
 
 Fractures of the Leg. 
 
 In the leg fractures may be due to direct or indirect violence, 
 and may involve either the tibia or fibula alone, or both bones. 
 
 Fractures of the Tibia alone. — Several varieties are described. 
 (a) The upper end is usually broken as a result of direct violence, 
 the line of fracture being transverse ; it is by no means a common 
 accident. 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, (b) Fracture of the 
 shaft of the tibia, apart from the fibula, is usually caused by direct 
 violence. It is transverse in the upper part of the bone, and 
 oblique below (Plate X.). 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 down, and then the limb may be put up in plaster. If the 
 bone has been comminuted, treatment will be more protracted, 
 (c) The internal malleolus is occasionally separated as the result of 
 direct injury, apart from any other osseous lesions, constituting 
 what is known as ' Wagstaffe's fracture.' There is comparatively 
 little displacement, 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 the application of lateral splints. If there 
 is any difficulty in keeping the parts in apposition, an incision 
 should be made, and the malleolus wired or pegged to the tibia. 
 
488 A MANUAL OF SURGERY 
 
 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). Sometimes the diagnosis is 
 extremely uncertain, and then the X rays prove useful. Treat- 
 ment 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 according to the character 
 of the violence, although the obliquity is most frequently directed 
 downwards, forwards, and inwards. The lower fragment is gener- 
 ally drawn upwards on account of the contraction of the powerful 
 calf muscles, and often rotated outwards from the weight of the 
 foot ; hence there is well-marked shortening, which can usually 
 be overcome by traction. 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 oblique fragment of the tibia, usually the upper, 
 piercing the skin. Skiagraphy is exceedingly useful in enabling 
 one to decide as to the character of the lesion, and the skiagrams 
 should be taken both from the front and from the side, as the 
 appearances are often very different (compare Plates XXII. and 
 XXIII.). 
 
 The fracture of the tibia has been proved by skiagraphy to be 
 frequently of the bec-de-fiute type, and is then probably always due 
 as much to forcible torsion of the limb as to vertical strain. The 
 rotation is a very important element in these cases, and the lower 
 end of the upper fragment rides prominently forwards (the ' riding 
 fragment '). The shortening is sometimes less marked than in 
 simple oblique fractures, but th?re is much greater difficulty in 
 getting satisfactory approximation of the fragments, even after 
 freeing the ends of the tibia by operation. This difficulty is 
 probably in most cases due to the broken ends of the fibula be- 
 coming engaged in the fibro-muscular tissues around it, and will 
 necessitate an incision over this bone in order to free them. 
 
 Treatment. — In the simpler cases reduction is 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 
 into position. The tendo Achillis may, if necessary, be divided. 
 It will usually suffice to put up the limb in a pair of side-splints, 
 such as Cline's, the longer one with the foot-piece being intended 
 
PLATE XXII. 
 
 Fracture of both Bones of the Leg, seen from in front. 
 
 To ;acc p. 488.] 
 
PLATE XXIII. 
 
 The same Fracture as in Plate XXII., seen from the inner side. 
 From a study of the two skiagrams it will be noticed that both lower fragments 
 have been displaced outwards, with but little alteration in their antero- 
 posterior axes. 
 
 Tofolltnv Plate XXII. ] 
 
INJURIES OF BONES— FRACTURES 489 
 
 for the outer side. In other cases it may be better to apply a broad 
 posterior splint with a rectangular foot-piece, e.g., Macintyre's, 
 and two lateral splints ; or the old-fashioned half-box splint may 
 be employed. Some surgeons recommend an anterior wire splint, 
 extending from above the knee to the foot, the leg being subse- 
 quently slung in the flexed position. This maybe advantageously 
 modified by combining it with an additional casing of plaster of 
 Paris. Whatever 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 subcutaneous surface of the internal malleolus, 
 and the inner border of the patella, are in the same line, 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 plaster, which must be retained for at least another 
 month, and even then a good deal of lameness is likely to persist, 
 which will need subsequent massage. 
 
 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, we have no 
 doubt that the suggestion to cut down on, and wire, screw, or peg 
 the fragments together, is fully justifiable in the hands of skilled 
 surgeons. In the spiral cases the operation may also have to 
 include an incision to free and fix the fibula. 
 
 Fractures in the neighbourhood of the Ankle-joint are usually 
 produced by indirect violence, the foot slipping, 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. 
 
 1. Displacement of the Foot outwards is by far the most common 
 variety, constituting what is known as Pott's Fracture. It usually 
 results from the patient slipping on the inside of the foot, as from 
 off a kerbstone. The sudden abduction 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 thereby driven against the inner aspect of the external malleolus, 
 and tends to displace that portion of bone outwards. The force 
 is thence transferred up the fibula, which bends and breaks at its 
 weakest spot — that is, about 3 inches above the tip of the 
 malleolus — the upper end of the lower fragment being displaced 
 inwards towards the tibia. Where the inferior interosseous tibio- 
 fibular ligament remains intact, the foot itself cannot be displaced 
 upwards, but is merely rotated outwards. 
 
 The amount of injury inflicted on the tissues of the foot or on 
 the bones of the leg warrants us in describing at least four dis- 
 
490 
 
 A MANUAL OF SURGERY 
 
 tinct lesions to which the term Pott's fracture may be more 
 or less accurately applied, (a) In the first degree, the fibula is 
 broken, and on the inner side merely the internal lateral ligament 
 is torn through (Fig. 164) ; the intact malleolus can then be felt 
 projecting beneath the skin. (b) In the second degree, the 
 malleolus itself is torn off, and a distinct sulcus can be felt be- 
 tween it and the lower end of the tibial shaft (Fig. 165). (c) The 
 third degree is a much more serious lesion. The interosseous 
 tibio fibular ligament yields more or less completely, or the flake 
 of bone to which it is attached is torn off; the foot, carrying with 
 
 Fig. 164. — Ordinary Pott's Fracture 
 with Rupture of internal Lateral 
 Ligament. 
 
 Fig. 165. — Pott's Fracture 
 with Internal Malleolus 
 torn OFF. 
 
 it the lower portion of the fibula and the superficial flake of the 
 tibia, which has been detached, is displaced firstly outwards, and 
 so long as the upper surface does not clear the lower articular 
 surface of the tibia, there is merely lateral displacement with 
 marked abduction of the foot and increased breadth of the ankle 
 (Plate XXIV.). 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 backward displace- 
 ment is added, causing great eversion of the foot and deformity of 
 the ankle. This latter type is sometimes known as Dupiiytren s 
 Fracture . On the inner side either the ligament or the .malleolus 
 
PLATE XX. ' 
 
 Dupuytren's Fracture, with well-marked Displacement outwards of 
 the Foot, as well as of the Lower Fragment of the Fibula and 
 the Internal Malleolus. (Skiagram taken from in front.) 
 
 To face p. 490. ) ' 
 
INJURIES OF BONES—FRACTURES 
 
 491 
 
 may yield (Fig. 166). (d) The fourth degree 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 (Fig. 167). In this variety, 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 rectification, considerable 
 deformity results. In rare instances, the lower end of the tibia 
 may project through the skin, thus rendering the fracture com- 
 pound. 
 
 In almost all of these varieties the ankle joint itself is opened, 
 
 Fig. 
 
 166. — Dupuvtren's 
 Fracture. 
 
 Fig. 167.— Fracture of Lower End of 
 Fibula and Tibia simulating Pott's 
 Fracture 
 
 and this, combined with the amount of .bleeding that occurs into 
 tendon sheaths and muscles around, and the difficulties often 
 associated with fixation of the fragments, explains why the results 
 of these cases are frequently so unsatisfactory. Should union 
 occur with the foot in a false (i.e., everted) position, a large mass 
 of callus develops between the shaft of the tibia and the malleolus. 
 2. Displacement of the Foot inwards. — When the patient slips 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 ligament, 
 
492 
 
 A MANUAL OF SURGERY 
 
 which acts as a fulcrum, the fibula yields at the same spot as in 
 Pott's fracture. The foot is displaced inwards, and perhaps 
 slightly 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. 569). 
 
 Treatment. — In reducing these fractures, traction should be 
 made upon the foot after the tension of the calf muscles has been 
 relieved by flexing the knee, or by tenotomy of the tendo Achillis ; 
 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 ; (b) the heel must not project unduly backwards ; 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 splints is generally sufficient to 
 steady the parts. Some cases are better treated, however, by a 
 Dupuytren's splint (Fig. 168), which is really a Liston's splint on 
 a small scale. It reaches from the knee to below the sole of the 
 foot, and is placed on the inner side of the limb, the patient 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 
 
 Fig. 168. — Dupuytren's Splint applied for Pott's Fracture. 
 (Tillmanns.) 
 
 to the limb. Any tendency to backward displacement of the heel 
 may be counteracted by the use of a Macintyre's back-splint, or 
 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 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 foot. 
 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 
 
INJURIES OF BONES— FRACTURES 493 
 
 behind the heel, which is thus lifted forwards. As soon as 
 possible, the limb should be put up in water-glass or plaster of 
 Paris. 
 
 In the simpler forms, early massage may be employed, and then 
 all the retentive apparatus necessary is some adhesive plaster 
 applied so as to cover in and encase the foot and ankle. In the 
 more difficult cases, where there is considerable displacement 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-divide the fibula, and to excise a V-shnped portion 
 of bone from the tibia extending into the ankle joint, so as to 
 enable the malleolus to be brought in contact with the shaft. 
 
 Fracture of the Os Calcis may result trom direct violence, such 
 as a blow or fall on the heel, or possibly from muscular action, the 
 epiphysis being then separated, or the shell of bone into which 
 the tendo Achillis is inserted being torn off. The fragment thus 
 separated is displaced upwards by the contraction of the calf 
 muscles, and the resulting deformity is very evident. If the line 
 of fracture passes through the body of the bone there may be 
 no displacement, owing to the attachment of the interosseous and 
 lateral ligaments ; but should the sustentaculum tali be broken, 
 the arch of the foot may be more or less flattened. When due to 
 a fall from a height, the bone is often comminuted and the foot 
 much bruised and swollen. Treatment consists in immobilizing 
 the foot in a plaster case if there is no displacement ; but where the 
 posterior part of the bone is drawn upwards, it must be approxi- 
 mated 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. 
 
 Fracture of the Astragalus is usually due to falls on the foot 
 from a height, or from direct violence applied 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 back- 
 wards, making a marked projection beneath the skin. In a case 
 recently under our care at hospital, the patient had fallen down a 
 lift, alighting on his feet ; both astragali were smashed, and this 
 probably saved his life. 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. Treatment 
 consists either in immobilization, which is likely to be followed by 
 stiffness of the ankle, or in bad cases by excision of the bone or of 
 projecting fragments. 
 
 Occasionally in less severe accidents the bone merely splits 
 across, the lesion being usually situated about the neck. Such is 
 
494 A MANUAL OF SURGERY 
 
 due either to the weight of the body flattening out the arch of the 
 bone beyond the limits of elasticity, or if the foot is dorsi-flexed 
 to penetration of the bone by the anterior edge of the tibia, im- 
 paction being even produced in this way. Massage and early 
 mobilization should be employed in such cases. 
 
 Other bones of the tarsus are occasionally fractured, but these 
 lesions require no detailed description. 
 
CHAPTER XVIII. 
 
 DISEASES OF BONE. 
 
 Inflammation of Bone. 
 
 In order to assist our readers to correctly understand the subject 
 of inflammation in bone, we must call to mind a few facts relative 
 to its constitution and growth. 
 
 Bones are divided into the long, the short, and the flat, each of 
 these consisting of compact and cancellous tissue in varying 
 amounts. In the short bones there is but a thin layer of compact 
 tissue surrounding 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 limiting plates, separated by 
 a layer of cancellous tissue of varying thickness (known in the 
 skull as the diploe). In long bones the shaft consists of a peri- 
 pheral tube of compact structure, surrounding a space which is 
 normally hlled with medulla, and known as the medullary canal ; 
 at each end it gradually merges into a larger mass of loose 
 cancellous tissue, the interstices of which are similarly packed 
 with vascular fatty medulla, which apparently performs the 
 function not only of maintaining the nutrition of the bone, but 
 also of elaborating the blood. Prolongations from the medulla, 
 moreover, extend into the Haversian canals, and are thence con- 
 tinuous with the periosteum, so that the mineral skeleton has 
 incorporated within it a vascular fibro-cellular mass which 
 permeates its whole structure. It must be clearly remembered 
 that there is normally no open hollow space, and therefore no 
 endosteum or internal lining membrane (except in bones con- 
 taining cavities, such as the mastoid cells or frontal sinuses). 
 
 The vascular supply of a bone is derived (a) from the 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 (b) from 
 the periosteum, air exceedingly vascular ensheathing membrane, 
 from which small vessels pass perpendicularly into the Haversian 
 canals, and thus establish a communication between the two 
 
49 6 A MANUAL OF SURGERY 
 
 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 in- 
 flammatory mischief; if the thrombus becomes infected, and so 
 disintegrated, pyaemia is very likely to ensue. 
 
 The growth of bone manifests itself in three different ways : (i.) It 
 increases in length from the shaft side of the epiphyseal cartilage, 
 the epiphysis itself growing but little. In the upper limb the 
 chief increase in length occurs at the shoulder and wrist, whilst 
 in the leg it is mainly evident on either side of the knee-joint, and 
 this in spite of the fact that the so-called nutrient arteries are 
 directed away from these points ; this would tend to indicate that 
 the importance of these vessels in supplying nutrition to the bones 
 has been much over-rated, (ii.) Increase in breadth is produced 
 by new formation of bone from the deeper layer of the periosteum, 
 which contains many yellow elastic fibres, and a large number of 
 angular nucleated cells, or osteoblasts, which are presumably the 
 bone-forming agents, (iii.) A bone increases in density by a new 
 deposit of osseous tissue around the Haversian canals and cancel- 
 lous spaces. 
 
 In considering the inflammatory affections of bones, it must 
 always be kept in mind that the essential pathological phenomena 
 (viz., hyperemia, exudation, and tissue changes, active or passive) 
 are similar to those manifested in any other vascular structure, 
 but that the resulting effects are modified by the limited space in 
 which the vessels lie, and the resisting character of the surround- 
 ing osseous tissue. Hence any acute inflammation, resulting in 
 rapid vascular 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 osteoporosis or rarefaction of the bone results, 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 osteo- 
 sclerosis, or condensation, is most likely to result. Tubercle in 
 bones, as elsewhere, causes primarily rarefaction of the tissue 
 attacked, though sclerosis may be associated with or follow it, 
 and the chronic pressure of tumours or aneurisms leads to rarefac- 
 tion and atrophy locally, although a certain amount of sclerosis 
 may be induced around. 
 
 One more general fact must be noted, viz., that it is very rare 
 for any inflammatory process to affect solely one element of a 
 bone. The continuity of the vascular supply explains why a 
 periostitis is usually or almost invariably associated with inflam- 
 mation of the subjacent bone, and why an osteomyelitis is never 
 limited to the medullary cavity. 
 
DISEASES OF BONE 497 
 
 Terminology. — Many different terms have been applied to these 
 pathological processes, and much needless confusion introduced 
 thereby into a subject at all times somewhat complicated. 
 Especially is this the case in inflammatory affections of cancellous 
 or compact bone, the terms ' osteitis ' and ' osteomyelitis ' being 
 used with very little precision. All inflammation of bone occurs 
 in connection with the vascular tissue permeating its structure, 
 and hence, as this is everywhere connected with the medulla, 
 all such processes might be described as forms of osteomyelitis. 
 This term is, however, limited to the affections of the medulla 
 of long bones, whilst the term ' osteitis ' is applied to those 
 occurring in the compact tissue of the shaft of long bones, or in 
 the cancellous tissue at the ends of long bones, or in the interior 
 of short bones, and with such limitations we shall comply here. 
 Then, moreover, the results of disease have been often confounded 
 with the pathological processes leading to them, and the clinical 
 conditions — caries, necrosis, and sclerosis — are described as distinct 
 diseases ; we shall endeavour to avoid this source of error by pre- 
 facing our description of the diseases with a few remarks on each 
 of these clinical conditions. 
 
 Necrosis, or death of bone, may occur in a variety of forms, 
 and from many different causes, e.g. : (a) From acute localized 
 suppurative periostitis, the sequestrum, or dead mass, being then 
 simply a superficial plate or flake of the compact exterior (Fig. 169); 
 (b) from acute idiopathic infective osteomyelitis (acute panostitis 
 or acute necrosis), 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 efficiently 
 treated (Figs. 171 and 172) ; (c) from acute septic osteomyelitis, 
 usually traumatic in origin, the sequestrum being annular in 
 shape, and involving more of the interior of the bone than 
 of the exterior (Fig. 173 ) ; (d) from acute or subacute septic 
 osteitis of cancellous bone, the sequestra being small spicu- 
 lated fragments of the bony cancelli which have, escaped 
 absorption by the granulation tissue always forming in such a 
 process ; (e) from tuberculous disease of cancellous tissue, the 
 sequestrum being light and porous, often infiltrated with curdy 
 material, and rarely separated completely from surrounding parts ; 
 (/) from syphilitic disease of cancellous or compact tissue, usually 
 resulting from excessive sclerosis, or gummatous disease of the 
 periosteum which has become septic ; (g) from the action of local 
 irritants, e.g., mercury, or phosphorus fumes gaining access to the 
 interior of the teeth ; (h) occasionally as a simple senile loss of 
 nutrition, as in senile gangrene ; and (i) 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 en one of the condyles. 
 
 32 
 
498 A MANUAL OF SURGERY 
 
 The separation of sequestra is always brought about by a process 
 analogous to that by means of which sloughs and gangrenous 
 materials are cast off from the body, viz., by complete absorp- 
 tion if small, aseptic, and surrounded by sufficiently vascular 
 tissue ; by absorption of as much as possible, in larger aseptic 
 masses, granulation tissue invading and replacing the dead mass, 
 and a line of separation forming as a result of defective nutrition 
 of the most advanced layer ; or, if septic, an active rarefying 
 inflammation occurs in the neighbouring living tissue, which in 
 time breaks down, and so sets free the dead mass. (See in more 
 detail at p. 69.) From the eroding action of the granulation 
 tissue, the under surface of the sequestrum is always hollowed 
 out, and, as it were, worm-eaten in appearance. Where sepsis is 
 present, the process is more active, and is completed more rapidly, 
 though with greater risk to the patient. 
 
 Caries, or, as it is sometimes called, osteoporosis, or rarefaction of 
 bone, is a clinical condition resulting from inflammation, and con- 
 sisting in 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 in- 
 flammatory process, e.g., during the early stage of repair in a 
 fracture ; (b) from acute or subacute septic or infective inflamma- 
 tion of cancellous tissue ; (c) from tuberculous affections of the 
 cancellous tissue or periosteum ; (d) from syphilitic disease of the 
 medulla or of the under surface of the periosteum. 
 
 Pathologically, it is characterized by the replacement of the 
 medulla by granulation tissue, which usually contains some large 
 multi-nucleated cells, or osteoclasts, and these seem to be closely 
 connected with the removal of the bone, though we are at present in 
 ignorance of the manner in which this is effected. The cancellous 
 tissue becomes hollowed out to accommodate these granulations, 
 and the osteoclasts are usually found occupying shallow depres- 
 sions known as ' Howship's lacunae.' In tuberculous and syphilitic 
 lesions the bone corpuscles undergo fatty degeneration. 
 
 Certain terms are used to indicate the characteristics observed 
 in particular cases. By Caries sicca is meant that the process 
 occurs without suppuration ; in C. suppurativa pus is always 
 present ; in C. fungosa the granulation tissue is exceedingly abun- 
 dant, especially in tuberculous disease of the articular ends of 
 bones ; in C. necrotica necrosis is associated with caries, the 
 sequestra consisting either of spiculated fragments, or in tuber- 
 culous disease of larger masses. 
 
 If caries is recovered from, a subsequent condition of sclerosis 
 usually follows, with loss of substance and often deformity. 
 
 Sclerosis of bone (osteosclerosis) is invariably the result of some 
 chronic inflammatory affection, e.g., (a) chronic periostitis, whether 
 simple or syphilitic ; (b) chronic osteomyelitis, simple, tuber- 
 culous, or syphilitic ; or (c) chronic osteitis of the compact bone, 
 
DISEASES OF BONE 49g 
 
 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. 
 
 (b) Acute diffuse, always associated with or secondary to 
 
 acute infective osteomyelitis. 
 
 (c) Chronic simple, or hyperplastic. 
 
 (d) Chronic tuberculous. 
 (V) Chronic syphilitic. 
 
 II. Osteitis, or inflammation of compact bone, which is always 
 
 associated with and secondary to either periostitis or 
 osteomyelitis, and so will not be described separately. 
 The acute form results in necrosis, the subacute in 
 osteoporosis, and the chronic in sclerosis, except in 
 tuberculous disease. 
 
 III. Osteomyelitis, or inflammation of the medulla of long 
 
 bones : 
 
 (a) Acute septic (traumatic). 
 
 (b) Acute infective (idiopathic = acute panostitis). 
 
 (c) Subacute simple or infective, e.g., after fractures, or 
 
 during the separation of sequestra, resulting primarily 
 in rarefaction, but finally in sclerosis. 
 
 (d) Chronic simple, tuberculous or syphilitic, usually causing 
 
 general enlargement and sclerosis of the bone, even 
 if locally some rarefaction is present. 
 
 IV. Inflammation of the Cancellous Tissue (Osteitis) may 
 
 similarly be : 
 
 (a) Acute septic or traumatic. 
 
 (b) Acute infective. 
 
 (c) Subacute simple or septic. 
 
 (d) Chronic simple, syphilitic, or tuberculous. 
 
 When limited to the articular end of a bone in a young person, 
 this is sometimes termed Epiphysitis. 
 
 It is unnecessary to describe in detail all these conditions, since 
 many of the divisions overlap, and hence we shall group together 
 
5°o 
 
 A MANUAL OF SURGERY 
 
 the various acute and chronic affections in order to indicate the 
 clinical signs and symptoms. 
 
 Acute Inflammations of Bone. 
 
 i. Acute Localized Periostitis usually arises as a result of 
 traumatism applied directly to the bone, with or without an open 
 wound ; it may also be determined by general conditions, such as 
 rheumatism, gout, and pyaemia, or by an extension of inflam- 
 matory mischief, as in an alveolar abscess. 
 
 Pathologically, the process consists of hyperemia of and exuda- 
 tion into the periosteum, which becomes swollen, turgid, and 
 thickened. This may be followed in due course by resolution, or 
 may leave the bone thickened and in a condition of chronic inflam- 
 mation ; or suppuration may ensue, and with it usually a limited 
 
 ffi 
 
 Fig. 169. — Superficial Necrosis resulting from a Localized Periostitis 
 (Diagrammatic). 
 
 A represents the necrosed tissue lying in continuity with the surrounding living 
 bone ; the periosteum is stripped up from it, and has an opening through 
 which the pus has been discharged. B shows a later stage, in which the 
 sequestrum is being separated by a process of rarefying osteitis in the 
 immediately contiguous living bone, whilst an involucrum, or sheath of 
 new bone, is formed from the under surface of the periosteum ; a cloacal 
 aperture remains in the involucrum for the escape of discharges. C shows 
 the condition of affairs after the sequestrum has been removed. 
 
 superficial necrosis. In the last event pyogenic organisms of no 
 great virulence must 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 auto-infection may occur. The in- 
 flammatory 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 
 
DISEASES OF BONE 501 
 
 around them, and finally pulled out from the osseous canals by 
 the tension of the subperiosteal effusion and by the peptonizing 
 power of the bacterial products. Consequently, the vitality of the 
 superficial layer of bone is destroyed for an area corresponding 
 almost exactly to that from which the periosteum has been 
 stripped (Fig. 169, A). 
 
 As soon as tension has been relieved by the escape of the pus, 
 repair commences. Where the mischief is very slight and super- 
 ficial, the involved bone may entirely recover, or even small 
 necrotic portions be absorbed. If the dead portion of bone is 
 more extensive, it will be separated from the subjacent living 
 tissues by one of the processes already described (p. 498), whilst 
 from the under surface of the stripped-up periosteum a casing of 
 new bone is developed, constituting 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 cloaca through which the discharge passes, and 
 corresponding in position to the openings in the periosteum and 
 skin made by Nature or the knife (Fig. 169, 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, whilst the skin over it becomes red and cedematous. 
 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 
 through 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 ascer- 
 tained by moving it with a probe within the osseous cavity, which 
 is now lined on the inner aspect with granulation tissue. 
 
 Treatment. — Rest, elevation of the limb, leeches, and fomenta- 
 tions are usually relied on locally in the early stages, whilst a 
 good purge and specific anti-diathetic remedies may be used 
 generally. If, however, the affection is not readily checked, 
 and suppuration threatens, a free aseptic incision down to the 
 bone is the best means of preventing necrosis. Should an abscess 
 form, it must be opened early, and possibly by this means death 
 of the bone may be obviated or limited. When necrosis has 
 occurred, the parts must be carefully dressed and kept aseptic, 
 until the sequestrum is detached. An incision is then made over 
 the involucrum, the periosteum stripped from it, one of the cloacae 
 enlarged, and the dead bone removed. The cavity will now rapidly 
 
502 A MANUAL OF SURGERY 
 
 fill up with granulations, and heal completely. In many cases 
 recovery may be expedited by chiselling away those portions of 
 dead bone which must ultimately be separated without waiting 
 for the tardy process of Nature ; this should not be undertaken 
 until the destructive changes have ceased, and then only to a 
 limited extent. The dead bone is recognised from the living by 
 its white appearance and by not bleeding when cut. 
 
 2. Acute Infective Osteomyelitis (Syn. : Acute Necrosis, Acute 
 Diffuse or Infective Periostitis, Acute Diaphysitis, Acute Panostitis). 
 — This disease usually occurs in children, often of a tuberculous 
 inheritance, and not unfrequently follows one of the exanthemata 
 (e.g., measles or scarlet fever). It generally commences before 
 the age of puberty, and is an affection of the gravest import ; the 
 multiplicity of names attached to it suggest quite accurately that 
 its manifestations may be very diverse in character. 
 
 Pathology. — The patients are always in a state of depressed 
 general health, so that their germicidal powers are considerably 
 diminished. Moreover, spots of localized ulceration are often 
 present in the throat, mouth, or intestines, which give a ready 
 entrance for micro-organisms into the system. Evidently some 
 of these must be circulating within the blood, ready to attack any 
 area of diminished tissue resistance. A slight injury in the shape 
 of a strain or a wrench, which is often entirely overlooked or for- 
 gotten, may suffice to determine the commencement of an in- 
 flammatory process which rapidly spreads by continuity of tissue, 
 until perhaps the whole structure of the bone may be affected. 
 
 The majority of the ligaments and not a few tendons are 
 inserted into the epiphysis, and it is not difficult to appreciate 
 the fact that articular strain must be mainly felt in the juxta- 
 epiphyseal region, i.e., immediately beyond these insertions. It 
 has been already mentioned that the traumatic separation of 
 epiphyses is liable to be followed by suppuration, even in healthy 
 children, and it is easy to understand that in an unhealthy child 
 a very slight injury in the epiphyseal region may determine a 
 similar process. 
 
 The disease almost always starts in the soft vascular tissue on 
 the shaft side of the epiphyseal cartilage, but occasionally it com- 
 mences in the epiphysis itself at the margin of the ossifying centre, 
 and in a few instances (mainly amongst young adults) it may be 
 preceded by a patch of localized periostitis, suggesting that an 
 acute infection ha^ supervened upon a subacute periosteal focus. 
 The bacteria, once admitted, grow and multiply rapidly, and give 
 rise to inflammatory phenomena, the nature and extent of which 
 depend largely on the exact situation of the infective focus, the 
 amount of resistance offered by surrounding tissues, and the 
 virulence of the organisms. As in any other part of the body, the 
 trouble is most likely to travel along the line of least resistance, 
 i. If the process commences in the periphery of the juxta- 
 
DISEASES OF BONE 
 
 So.? 
 
 epiphyseal region close to the periosteum, the line of least resist- 
 ance will be towards that structure, and hence a sub -periosteal 
 abscess may form, whilst the central portions of the bone may 
 escape almost entirely. The extent of this abscess depends 
 mainly upon the virulence of the 
 bacteria, but considerable portions of 
 the diaphysismaybe denuded, resulting 
 in extensive necrosis, which, however, 
 involves the superficial rather than the 
 deeper parts. It rarely extends to the 
 neighbouring joint owing to the close 
 bond of union which exists between 
 the diaphyseal periosteum and the 
 epiphyseal cartilage. In this variety 
 an early incision to let out the pus 
 may suffice to prevent necrosis, or, at 
 any rate, to limit it. The constitu- 
 tional symptoms will be less severe 
 than in other varieties ; there is less 
 likelihood of the development of 
 pyaemia, and the toxic fever soon dis- 
 appears after the removal of the pus. 
 Subsequently the same course of 
 events occurs as in the localized 
 variety of acute periostitis — viz., an 
 involucrum forms, perforated by one 
 or more cloacae, and the sequestrum 
 in time separates. FlG - 170. —Acute Osteo- 
 
 A good illustration of this type is pyelitis of the Lower 
 , & , . . ;1 ■ .-,- End of the Femur in a 
 
 to be found in the acute periostitis Child of Nine Weeks. 
 which affects the lower end of the femur. (After Lexer.) 
 It almost always starts posteriorly, IC internal condyle ; K, centre 
 stripping the thin periosteum off the of ossification in epiphysis; 
 back of the bone as far as the bifurca- A, abscess cavity in epiphyseal 
 
 tion of the linea aspera. Its prefer- lin f ; S ' sequestrum; I, in- 
 
 r . . . . r . . , , f j volucrum. 
 
 ence tor this situation is evidently due 
 
 to the fact that strains upon the knee-joint are mainly experienced 
 
 when the limb is hyper-extended, and that such strain is directed 
 
 to the posterior ligaments, and hence the posterior portion of the 
 
 epiphyseal line is likely to suffer. An abscess forms, and inasmuch 
 
 as it lies deeply and its origin is not easily recognised, it is allowed 
 
 to progress for some time, one result being that the osteogenetic 
 
 powers of the periosteum are destroyed, so that an involucrum 
 
 rarely forms in this particular example of necrosis. Removal of 
 
 the sequestrum is also difficult from anatomical reasons, and hence 
 
 amputation is sometimes required. 
 
 2. Should the process start in the centre of the juxta-epiphyseal 
 
504 A MANUAL OF SURGERY 
 
 region, it may spread in several directions, and the results vary 
 considerably. 
 
 (a) The process may reach the periosteum first and then the 
 phenomena of a diffuse sub-periosteal abscess, as indicated above, 
 with the addition of the symptoms due to its deeper origin, will 
 manifest themselves. This is, perhaps, the most usual course for 
 the disease to take. 
 
 (b) Less frequently the infection extends along the medullary 
 cavity and gives rise to the most typical form of osteomyelitis 
 (Fig. 170). The medulla becomes intensely hypersemic ; the 
 veins are thrombosed ; localized foci of suppuration and gangrene 
 appear ; and in consequence of the increased pressure infective 
 emboli are likely to be detached and pyaemia to follow. Even if 
 the latter does not occur, the general condition is profoundly 
 affected by the absorption of toxins. Suppuration also occurs 
 beneath the periosteum, although the amount of pus may not be 
 great at first; but the membrane is stripped up from the diaphysis, 
 perhaps to such an extent as to involve the whole length and 
 circumference of the shaft. Unless prompt measures are taken to 
 limit the progress of the disease, necrosis is certain to follow, 
 usually implicating the whole thickness of the diaphysis, and 
 sometimes extending along its whole length. In fact, the whole 
 diaphysis is occasionally found lying loose in an abscess cavity, 
 the two epiphyses having been previously separated. 
 
 (c) It has been already mentioned that, owing to the intimate 
 connection between the periosteum of the diaphysis and the 
 epiphyseal cartilage, the neighbouring joint usually escapes infec- 
 tion. Should, however, the epiphyseal line be within the joint, as 
 in the hip, it must perforce become the seat of an acute infective 
 arthritis as soon as the bacteria reach its periphery. The elbow- 
 joint is similarly liable to suffer when bacteria attack the upper 
 end of the ulna, since the epiphysis is a mere flake of bone and the 
 greater part of the olecranon is derived from the shaft. Sometimes 
 the junction cartilage is softened and destroyed by the organisms, 
 so that the inflammation spreads through the epiphysis to the 
 articular cartilage, which is eroded, and the joint opened. Occa- 
 sionally the pus burrows along the soft tissues outside the bone, 
 as along the biceps groove into the shoulder-joint. 
 
 In infants, where there is little or no bone, the cartilage may be 
 rapidly destroyed, and an opening made through it into the joint, 
 giving rise to what was described by Sir Thomas Smith as the 
 acute arthritis of infants. 
 
 (</) When the infecting organisms are of a mild type and the 
 patient's health not much depreciated, the process may not spread 
 far from the spot first involved, but may give rise to a chronic 
 abscess in the bone in that situation. Naturally this is not likely 
 to occur, except in regions where large masses of cancellous tissue 
 exist, as, for instance, the head of the tibia. It must not be for- 
 
DISEASES OF BONE 
 
 5°5 
 
 gotten, however, that certain epiphyses occur away from joints, 
 and chronic abscesses in such situations as the great trochanter 
 may be explained on these grounds. A similar condition is some- 
 times due to tubercle (p. 519), but of course the organisms found 
 in the pus are different, whilst the tuberculous variety is probably 
 more chronic ; otherwise the results of the process, clinical and 
 pathological, are alike. 
 
 The organism generally found in this disease is the Staphy- 
 lococcus pyogenes aureus, but occasionally others are responsible 
 
 Fig. 171. — Diagram of Massive Necrosis after Acute Osteomyelitis. 
 
 (Billroth.) 
 
 In A (early) the necrosed tissue, though continuous above and below with the 
 healthy bone, is surrounded by a cavity formed by the stripping up of 
 the periosteum, and from it two sinuses pass to the exterior ; in B (late) 
 the sequestrum is supposed to have been loosened and removed, and the 
 cavity remaining is lined by granulation tissue, and surrounded by a thick 
 involucrum of new bone, in which two cloacae exist. 
 
 for it, and the symptoms vary somewhat with the causative 
 microbe. Thus, if due to the Staph, pyog. albus, the process is 
 less acute ; a good deal of brawny infiltration of the periosteum 
 ensues, and necrosis is more easily prevented by early treatment ; 
 this variety is sometimes termed ' periostitis albuminosa.' The 
 Streptococcus pyogenes, if present at all, is only found in young 
 children, and the resulting necrosis is often less extensive. The 
 
506 A MANUAL OF SURGERY 
 
 Pneumococciis has also been discovered in this disease, as well 
 as the Bac. coli communis, which latter only occurs in association 
 with other organisms ; the resulting pus is very foul. 
 
 Clinical History. — The disease usually commences abruptly 
 with a rigor, followed by high fever and severe pain in the limb, 
 which soon becomes swollen, brawny and congested. It may at 
 first be mistaken for an acute attack of rheumatism, although the 
 fact that the inte^articular portion is affected, and not the articula- 
 tion, should readily prevent this error. The pain is of an extremely 
 severe nature, so that the child screams whenever the limb or even 
 the bed is touched. 
 
 Should the trouble be mainly limited to the periosteum, 
 evidences of its being stripped off the bone, and of the accumu- 
 lation of pus beneath it, soon show themselves. An abscess 
 forms which may quickly transgress its periosteal boundary and 
 burrow under fascial or muscular planes ; its limitation to the 
 diaphysis has been already explained ; but, although the neigh- 
 bouring joints may escape infection, they are very likely to suffer 
 from a serous exudation, and subsequently some limitation of 
 movements may be observed. Sooner or later the abscess bursts 
 or is opened, giving exit to a larger or smaller amount of pus, and 
 the subjacent bone is found bare and apparently dead. Possibly 
 the relief of tension may suffice in such cases to limit the mischief, 
 the periosteum again becoming adherent to the bone, and a cure 
 being established without extensive necrosis. More frequently a 
 considerable portion of the shaft loses its vitality, and has to be 
 separated in the manner already described, whilst an involucrum 
 forms around it from the periosteum (Figs. 171 and 172). If no 
 septic organisms have been admitted, no fever or bad constitutional 
 symptoms need be expected during this later stage. Sometimes 
 the process is so acute as to cause actual sloughing or disintegra- 
 tion of the periosteum, so that its osteogenetic powers are destroyed, 
 and subsequent repair becomes difficult or impossible. 
 
 When the medulla itself is more especially involved, the symp- 
 toms of pyaemia or of severe toxaemia become very prominent, 
 and the child may die from this cause before the local mischief has 
 been able to advance very considerably. The pain will continue 
 to be of a severe character, although the patient's perceptions may 
 be so blunted by the toxic condition that it lies more or less un- 
 conscious. The swelling of the limb is not so great as in the 
 former type, but the mischief may be very extensive, and although 
 there is no great collection of pus beneath the periosteum, yet 
 it may be stripped up along the whole length of the shaft, and even 
 detached from the epiphyses at each end. Should the child not 
 die of toxaemia, extensive destruction of bone is certain to result. 
 
 When the epiphysis is attacked, the symptoms commence in 
 the same way, but are likely to be followed by those of an 
 acute suppurative arthritis (p. 578). This affection is sometimes 
 
DISEASES OF BONE 
 
 507 
 
 termed acute epiphysitis. It is almost limited to infants and very 
 young children, and is said to occur most frequently in the sub- 
 jects of inherited syphilis. The head of 
 the humerus and the upper and lower 
 ends of the femur are the parts most 
 commonly involved. In some of these 
 cases the ligaments are so seriously 
 weakened and relaxed that a loose flail- 
 joint results. 
 
 In the milder types of osteomyelitis, 
 the patients complain of severe pain at the 
 end of some bone (one type of growing 
 pain), and this may be attended by some 
 degree of fever and of local disability. 
 The symptoms may quiet down after a 
 time and no harm result, but in some 
 cases the growth of the bone will be 
 checked or entirely stopped. In other 
 patients a subacute or chronic abscess may 
 form and perhaps come to the surface, 
 and on opening it a sinus is found leading 
 to the interior of the bone, in which a 
 sequestrum of cancellous tissue is found. 
 
 The Prognosis of the acute form is 
 always somewhat grave. Life may be 
 threatened by pyaemia or toxaemia in the 
 early stages, whilst later on hectic, amyloid 
 disease of the viscera, and exhaustion, may 
 terminate the case if sepsis has been ad- 
 mitted. 
 
 The utility of the limb may be unim- 
 paired if the disease has not been too ex- 
 tensive, and if prompt treatment has been Fi( . _ Necrosis fol . 
 adopted ; but if neighbouring joints are LOWING acute Osteo- 
 affected by a suppurative arthritis, or if myelitis. (From Speci- 
 the osteogenetic powers of the. periosteum MEN j n College of 
 have been destroyed by the acuteness of Surgeons' Museum.) 
 the process, amputation may be required. The irregular new bone of 
 In cases which have recovered, excessive ^™S, J j£ 
 growth of the bones sometimes follows, tions of the sequestrum, 
 owing to the long-standing hyperaemia of 
 
 the part ; but if the epiphyseal cartilage has been much affected 
 the limb may be stunted in its subsequent development. 
 
 Treatment.— Prompt surgical interference must be adopted in 
 order, if possible, to cut short the malady. As soon as the local 
 pain and high fever give evidence that this affection is present, 
 a free incision should be made in the long axis of the limb 
 through the periosteum, whether pus can be detected or not. The 
 
508 A MANUAL OF SURGERY 
 
 surgeon will then proceed to carefully investigate the condition 
 of the bones by inspection and the use of the finger and probe, 
 and his further proceedings will to a large extent depend upon 
 what is thus found. 
 
 If the suspicions as to the existence of osteomyelitis are thereby 
 confirmed, the most vigorous surgical treatment is demanded, for 
 if the teachings of pathology are to be depended on, it is certain 
 that no good can follow any half measures which stop short of 
 the medullary canal. As a rule, the surgeon will find himself in 
 the neighbourhood of the epiphyseal cartilage, and if the case has 
 been taken in hand early, it is possible that the mischief will be 
 quite limited ; all that is then required is to scrape or gouge 
 away the softened and hyperaemic bone at the end of the diaphysis, 
 together with any necrotic tissue which may be present, taking the 
 greatest care not to encroach on the epiphyseal cartilage. The 
 cavity thus formed is thoroughly washed with, an antiseptic, 
 and perhaps swabbed out with pure carbolic acid ; a drain-tube 
 is inserted, and in all probability recovery will rapidly ensue. 
 
 If the case has gone further, the periosteum will be found 
 stripped from the bone for a varying distance, and possibly the 
 epiphysis partially or completely separated. Under these circum- 
 stances it is always necessary to open up the medullary canal 
 by removal of part of the compact bone, so as to allow the 
 hyperaemic and gangrenous fatty tissue contained therein to be 
 scraped out, and this proceeding may involve a considerable 
 portion of the shaft. When grave constitutional phenomena are 
 present, associated with loosening of the epiphysis, it will often 
 be found expedient to amputate in order to prevent death from 
 toxaemia. 
 
 If the periosteum has been more extensively involved, and a 
 large amount of bone, possibly the whole diaphysis, denuded, 
 two courses are open to the surgeon : either to remove the 
 whole necrosed area at once, or simply to relieve tension and 
 wait for an involucrum to form before taking away the sequestrum. 
 The great advantage of the former plan consists in the immediate 
 extirpation of the infective focus, thereby diminishing the risks 
 of pyaemia or toxaemia, and preventing the necessity for further 
 operative proceedings. On the other hand, it is claimed that the 
 continued presence of the sequestrum is beneficial, in that it 
 stimulates the periosteum to new formation of bone, and hence it 
 should not be removed until a sufficient involucrum has formed. 
 The practice usually adopted is. as follows : For the femur and 
 humerus sequestrotomy should be delayed ; immediate removal 
 would lead to hopeless shortening and crippling of the limb. For 
 the bones of the forearm or leg, immediate removal is perfectly 
 justifiable, since there is always a second bone present to main- 
 tain the length of the limb. Some surgeons have recommended 
 that a bone-graft or suitable rod of celluloid or ivory should be 
 
DISEASES OF BONE 509 
 
 inserted to take the place of the resected diaphysis and stimulate 
 the osteogenetic powers of the periosteum ; there is no objection 
 to such an attempt being made, provided that asepsis is main- 
 tained, but it is very questionable whether much good will follow. 
 
 When there is any doubt as to the actual condition of the bone, 
 and the symptoms indicate that the medulla is not much involved, 
 its immediate removal is undesirable ; the pus is allowed to 
 escape through a free incision, the cavity is well irrigated, and 
 the stripped-up periosteum allowed to fall back upon the bone, 
 and regain adhesions to it, if possible. Drainage is provided for, 
 strict asepsis maintained, and the discharge soon becomes merely 
 serous. A portion of the bone dies, and during its separation 
 from neighbouring parts becomes incased in a newly formed 
 involucrum. When the sequestrum is free — that is, in about five 
 or six weeks — sequestrotomy will be required ; it consists in reflect- 
 • ing the periosteum from the new casing, and in enlarging or 
 uniting one or more of the cloacae, so as to allow the sequestrum 
 to be withdrawn ; it sometimes expedites matters to divide the 
 sequestrum into two portions, and then to deal with each 
 separately. The cavity thus left is well irrigated, and either 
 drained or packed with gauze, so as to allow it to heal from the 
 bottom by granulation. Occasionally the operation for removal 
 of the sequestrum is exceedingly difficult and dangerous, owing 
 to the situation of the sinuses, and in some places, e.g., the 
 posterior aspect of the lower end of the femur, it is almost im- 
 practicable to reach it ; under such circumstances amputation may 
 be preferable. This summary proceeding may also be needed 
 in the course of this disease on account of pyaemia, defective 
 repair, exhaustion from chronic sepsis, or suppuration in a neigh- 
 bouring joint. 
 
 3. Acute Septic Osteomyelitis arises as a result of infection 
 from without, e.g., in cases of compound fracture, and after 
 amputation, excision, or even osteotomy. The organisms present 
 are usually staphylo- or strepto- cocci, together with various 
 non-pathogenic forms. The clinical history of a case involving 
 the shaft of a long bone is as follows : The patient during an 
 attack of septic traumatic fever due to an injury or operation 
 has one or more rigors, which suggest the existence of pyaemia, 
 and is suddenly seized with severe pain in the limb, which 
 becomes intensely sensitive. On examining the wound, the soft 
 parts are found to be unhealthy and infiltrated, the lower end of 
 the bone is bare and yellow, and from the interior projects a 
 stinking mass of gangrenous medullary tissue. Should early and 
 efficient treatment not be undertaken, the patient runs a consider- 
 able risk of succumbing to pyaemia or septic intoxication, whiist 
 a varying amount of the interior of the bone dies (central or 
 tubular necrosis), and a small segment of its whole thickness below, 
 so that the sequestrum which ultimately separates is annular and 
 
S'o 
 
 A MANUAL OF SURGERY 
 
 m 
 
 pi 
 
 conical (Fig. 173). Should the patient survive, the necrotic tissue 
 gradually separates, and during this process a mass of new bone is 
 formed from the under surface of the periosteum, so that the shaft 
 becomes much thickened externally. Hectic 
 fever may supervene whilst this is occurring. 
 The Treatment of this condition has been 
 somewhat modified of late years. Formerly, 
 the only plan adopted was amputation of 
 the limb through the next joint. At the 
 present time one would freely open up the 
 wound as early as possible, flush it out, and 
 then thoroughly scrape away the sloughing 
 medullary tissue from the interior of the 
 bone, subsequently disinfecting the cavity 
 with pure carbolic acid, and placing a drain- 
 tube or gauze wick in it for a few days. A 
 certain amount of necrosis follows, but with- 
 out high fever or toxaemia. Should this 
 treatment fail, amputation may still be 
 resorted to. 
 
 A similar process may also invade the short 
 bones, and the cancellous extremities of long 
 bones, being often secondary to septic ar- 
 thritis, or to a compound fracture involving 
 such parts. The local and general pheno- 
 mena are very similar to those detailed 
 above, except that no large sequestra are 
 formed, the dead bone coming away in small 
 spicules (one form of caries necrotica), whilst 
 the pain and fever are less severe, and there 
 is less likelihood of the development of 
 pyaemia. Treatment consists in free drainage, 
 removal of the septic tissue and efficient 
 purification of the wound. 
 
 We have also seen one or two cases of subacute septic osteomyelitis, 
 involving the shaft of long bones after operation, in which the 
 medulla became profoundly altered in texture, being transformed 
 into granulation tissue, with rarefaction of the bony cancelli ; the 
 process was associated with considerable pain and some amount 
 of constitutional disturbance. No necrosis followed, but amputa- 
 tion was necessary on account of the extent of the disease and the 
 pain. 
 
 Typhoid Osteitis. 
 
 Affections of the osseous system are not uncommon in typhoid fever, and 
 usually come on about the third week or during the early stages of con- 
 valescence. The tibia and ribs are most often affected, and in a large percentage 
 of cases typhoid bacilli, with or without pyogenic cocci, will be found. It is 
 curious to note how long the organisms may lie latent in the tissues before 
 causing an abscess — in one case for seven years. The trouble commences 
 
 '**\V 
 
 V\ 
 
 Fig. 173. — Tubular or 
 Conical Seques- 
 trum from Septic 
 Osteomyelitis 
 after Amputation. 
 
DISEASES OE BONE 
 
 5" 
 
 either as a periostitis or osteomyelitis, subacute in character, and tending to 
 improve for a time, and then relapse. It may easily develop an abscess, and 
 then some amount of necrosis or caries may follow ; thus in a case recently 
 operated on by one of us a considerable sequestrum 
 was removed from the upper third of the femur, 
 whilst in the opposite leg there had been an abscess 
 in a similar position, but without death of bone. 
 The abscess is always subacute, often chronic, 
 and the affected bone may be carious rather than 
 necrotic. On its first appearance the affected 
 limb should be elevated and fomented, and fre- 
 quently the more acute symptoms will yield ; but 
 the part often remains enlarged, swollen and tender, 
 and exacerbations of pain are not unlikely to occur 
 from time to time, sooner or later leading up to the 
 formation of an abscess. When suppuration has 
 occurred, the parts must be freely incised, diseased 
 bone removed, granulation tissue scraped away, and 
 the parts disinfected with liquefied carbolic acid. 
 The wounds are usually found to be extremely 
 chronic and indolent, and may require scraping 
 several times. 
 
 Chronic Inflammation of Bone. 
 
 Chronic Osteoperiostitis. — By this disease 
 is meant a chronic inflammatory condition 
 of the bone, which results in overgrowth, 
 thickening, and condensation. 
 
 Varieties. — (a) It may arise as a localized 
 chronic periostitis, traumatic, rheumatic, or 
 syphilitic in origin, or due to the close 
 proximity of a chronic ulcer ; it is char- 
 acterized by a formation of new bone 
 beneath the periosteum, the so-called node 
 (Fig. 174). The cancelli are arranged at 
 right angles to the surface, in consequence 
 of the new tissue forming around the small 
 vessels, which enter the bone from the 
 under surface of the periosteum. At first 
 this new material is soft and spongy, but it 
 rapidly becomes hard and sclerosed, and a 
 similar condition affects the subjacer.t 
 compact structure, which is thickened and 
 indurated by a new formation around the 
 Haversian canals. If the irritation persists, 
 as in the case of a chronic ulcer, this condi- 
 tion may run on into the following variety. 
 
 (b) The diffuse form of chronic osteo- 
 periostitis usually originates in some deep- 
 seated or central affection, tuberculous or 
 syphilitic in nature, and tends to involve the 
 it is sometimes limited to one or other end. 
 
 Fig. 174. — Chronic 
 osteo - periostitis 
 of Tibia, showing 
 the Fusiform 
 Swelling on the 
 Front of the 
 Bone, consisting 
 of Dense Osseous 
 Tissue, and the 
 Medullary Cavity 
 encroached upon. 
 (Museum of Royal 
 College of Sur- 
 geons.) 
 
 whole bone, although 
 If tuberculous, there 
 
5 i2 A MANUAL OF SURGERY 
 
 may be a small abscess or some central necrosis, and around this 
 focus of prolonged irritation the bone becomes thick and indurated. 
 In the later stages a considerable new formation may occur 
 beneath the periosteum, and even the medullary canal become 
 entirely obliterated. If syphilitic in origin, it may be due to a 
 central gumma, or a general condition of sclerosis may supervene 
 without any special focus. 
 
 The Symptoms consist of deep aching pain in the limb, worse at 
 night, with perhaps tenderness over some particular spot. This 
 latter condition is especially evident in cases where a localized 
 abscess exists in the head of a bone, such as the tibia. On 
 examination the bone is felt to be thickened, and its surface more 
 or less nodulated. If the disease is localized and superficial, a 
 distinct node may be felt, consisting of a hard, fusiform, and tender 
 swelling. Where the enlargement is more general, there is less 
 tenderness, though the pain is constant. 
 
 The Diagnosis of such cases is not always easy, the enlarge- 
 ment of the bone being sometimes mistaken for the early stage 
 of a malignant tumour. The rate of growth will be of little 
 assistance, since it is very variable ; but a tumour may have more 
 defined limits, and its tension is often not the same throughout. 
 Skiagraphy is valuable in this direction, since in simple chronic 
 periostitis the bone is solid and throws a continuous and well- 
 defined shadow, while in malignant diseases a certain amount of 
 soft tissue is sure to be present, either centrally or peripherally, 
 easily penetrated by the rays, and hence leaving gaps in the 
 shadow. If, in spite of such assistance, the case is still doubtful, 
 an exploratory incision will be required. 
 
 The Treatment at first consists in resting the limb, applying 
 counter-irritation (e.g., iodine paint or the actual cautery), and 
 giving iodide of potassium internally. If relief is not thereby 
 obtained, an operation will be necessary. An incision is made over 
 the whole length of the thickened bone, right through the peri- 
 osteum. This membrane is now stripped aside with periosteal 
 detachers, raspatories, etc., and if merely a nodular enlargement 
 is present, the new formation is chiselled away. When the whole 
 thickness of the bone is involved, a gutter or trench must be made 
 by gouge and mallet, extending into the medullary cavity, and its 
 length corresponding to the enlargement. The soft parts are 
 then partially drawn together and the wound dressed. It is 
 advisable to cover it with protective, so that the hollow may fill 
 with blood-clot, and this is then allowed to organize (p. 213 ). 
 If the wound remains aseptic, and enough bone is removed, most 
 satisfactory results follow. In some aggravated conditions, how- 
 ever, which have lasted for many years, amputation is required. 
 
DISEASES OF BONE 
 
 Tuberculous Diseases of Bone. 
 
 Bone may be affected in two ways by tubercle, either the 
 periosteum or the cancellous tissue being primarily involved. 
 
 i. In Tuberculous Periostitis a specific infiltration of the 
 periosteum is met with, consisting of a deposit, partly in that 
 membrane and partly under it, of pulpy granulation tissue con- 
 taining the characteristic miliary tubercles, which are chiefly 
 developed around the vessels passing from the periosteum into 
 the bone. As in tuberculous disease elsewhere, caseation and 
 suppuration are likely to follow, leading to the formation of 
 abscesses which are primarily subperiosteal, and filled with curdy 
 pus ; these in time find their way to the surface, either directly 
 or by more or less tortuous channels, and leave sinuses, extending 
 down to the bone. The final effect of such a condition depends 
 largely on whether the subjacent bone consists of thick or thin 
 compact tissue. If the compact bone is thick, the disease is 
 usually localized to the part first affected, the surface of the bone 
 escaping entirely, except some slight superficial erosion. Occa- 
 sionally, however, the disease may spread along the periosteum 
 for some distance, and even involve a neighbouring epiphysis 
 or joint. If the compact bone is thin, as in the bodies of the 
 vertebrae, the underlying cancellous tissue is almost certain to be 
 secondarily affected, and the changes to be immediately described 
 are produced. 
 
 Clinical History. — In the early stages a somewhat diffuse elastic 
 or pulpy swelling forms over the bone, which is tender and asso- 
 ciated with characteristic bone pain, worse at night. It takes 
 some weeks or months to develop, and on skiagraphy the under- 
 lying osseous tissue may appear quite normal in texture. In the 
 latter stages, when caseation or suppuration is present, the swelling 
 often becomes more defined and its surface nodulated ; it then 
 somewhat resembles an ordinary node, but is usually more 
 irregular in shape, of somewhat unequal consistency, and on firm 
 pressure small portions may be felt to give way. If an abscess 
 forms, the pain becomes greater, but it diminishes as soon as 
 tension is relieved by discharge of the pus. The admission of 
 sepsis, however, increases the trouble. It is probably seen in its 
 most typical form in connection with the ribs. 
 
 Treatment. — In the early stages, constitutional treatment may 
 suffice, together with rest and carefully adjusted pressure, as 
 by strapping with Scott's dressing. The condition, however, 
 demands incision if a neighbouring joint is threatened, or when 
 suppuration has occurred. Free removal of all the granulation 
 tissue and softened bone with a Volkmann's spoon is required, 
 disinfection of the cavity with undiluted carbolic acid, and 
 stuffing it with gauze soaked in an emulsion of glycerine and 
 
 33 
 
5M 
 
 A MANUAL OF SURGERY 
 
 purified iodoform (10 per cenl.), ihe wound being allowed to 
 granulate from the bottom. 
 
 2. Tuberculous Osteitis always arises in cancellous tissue, and 
 it affects the short bones, or the shafts or ends of long ones. 
 
 (a) The short bones of the hands and feet are very liable to this 
 condition. It occurs in weakly children with a tuberculous in- 
 heritance, or in those whose general 
 health has been depressed by one 
 of the exanthemata, or sometimes 
 in those otherwise healthy. Some 
 slight injury may determine the 
 onset of the attack, which fre- 
 quently involves several bones 
 simultaneously. When the pha- 
 langes are involved, the disease is 
 known as Tuberculous Dactylitis. 
 
 Clinical History. — The affected 
 bone becomes slowly enlarged, 
 expanded, and painful, the pain 
 being, however, slight in amount, 
 though generally worse at night 
 This continues for some time, until 
 finally one spot rapidly increases 
 in size, becoming red and tender, 
 and finally an abscess forms, which 
 bursts or is opened, leaving a 
 sinus, down which a probe can be 
 passed into the carious interior of 
 the bone. Occasionally contiguous 
 joints are involved in this process, 
 whilst the tendon sheaths are also 
 liable to be affected ; a large por- 
 tion of the swelling is due to 
 periosteal infiltration (Fig. 175). 
 
 Pathology. — A deposit of tubercle 
 bacilli occurs in or around the 
 bloodvessels in the interior of 
 the bone, which may have been 
 previously rendered somewhat 
 hyperaemic as the result of an 
 injury. The organisms produce 
 their usual effect, viz., transformation of the normal medullary 
 tissue into pulpy granulation tissue containing tubercles, the bony 
 cancelli becoming meanwhile eroded and rarefied, and the bone 
 corpuscles undergoing fatty degeneration (vide Caries, p. 498). 
 Sequestra occasionally form, but more often in adults than in 
 children, owing to the greater density of the bone in the former. 
 They are due to a cutting-off of the blood-supply of a definite 
 
 Fig. 175. — Tuberculous Dac- 
 tylitis. (Royal College of 
 
 Surgeons' Museum.) 
 
 This disease started in the proxi- 
 mal phalanx, and has perforated 
 it anteriorly, the tubercu'ous 
 material having involved the 
 periosteum and tendon sheath, 
 whilst the first inter-phalangeal 
 joint is becoming invaded. 
 There is also a considerable 
 formation of granulation tissue 
 on the dorsal aspect. 
 
PLATE XXV 
 
 Tuberculous Disease of Radius. 
 The patient was a lady over fifty years of age, who had suffered for some months 
 from pain and swelling of this bone. The site and extent of the disease is 
 indicated by the light area in the shadow of the bone. Eventually amputa- 
 tion was required. 
 
 To face p. 514.] 
 
DISEASES OE BONE 
 
 5'5 
 
 portion of the bony tissue, either as a result of tuberculous 
 endarteritis, or from early caseation within the cancel li of the 
 whole of the granulation tissue. The sequestra are usually 
 yellowish white in colour from the presence of the caseating 
 tissue in their substance, and are seldom completely separated 
 from the surrounding bone ; thus, they are often quite clear 
 superficially and laterally, but adherent on the deeper side. 
 When the tuberculous disease does not involve the whole bone, 
 the nearest healthy 'tissue may become sclerosed, and thus one 
 not unfrequently finds a central sequestrum surrounded by 
 rarefied bone which merges into an area of sderosed tissue. 
 When a tuberculous focus becomes septic, the destructive process 
 increases in rapidity, and minute spiculated sequestra often come 
 away in the discharge. The term expansion of bone used above is 
 perhaps scarcely correct, inasmuch as the enlargement is due to 
 absorption on the inner aspect, whilst there is a new formation of 
 bone under the periosteum. Skiagraphy is a useful adjunct in 
 estimating the amount of disease present, since the affected bone 
 is less dense, and consequently light areas appear in the midst of 
 the dark shadow cast by the bone (see Plate XXV.). 
 
 The Treatment of tuberculous dactylitis in the early stages 
 consists in attention to the general health, together with rest 
 locally, and perhaps strapping the parts with Scott's dressing. 
 Should the disease progress in spite of such measures operation 
 must not be unduly delayed, since neighbouring joints and tendon 
 sheaths are very likely to be attacked. An incision is made down 
 to the bone at some suitable spot where tendons or other im- 
 portant structures will not be injured ; the periosteum is divided, 
 and the outer layer of compact bone removed by gouge or 
 trephine, so as to allow the diseased medulla to be, scraped away 
 with a Volkmann's spoon. When all the tuberculous tissue has 
 been eliminated, the cavity thus produced is swabbed out with 
 liquefied carbolic acid, and stuffed with gauze soaked in an 
 iodoform emulsion, in order to ensure healing by granulation. 
 Unless this scraping is thorough, recurrence is very likely to 
 ensue, but the integrity of epiphyses and of articular cartilages 
 must be respected. When an abscess or a sii us exists, the same 
 measures must also be adopted. Not unfrequently the growth of 
 the bone is very considerably hindered either by the disease or 
 by the treatment requisite in order to eradicate it, and the part 
 becomes stunted or deformed in consequence. 
 
 (b) Any of the bones of the tarsus may be involved in exactly the 
 same manner, the clinical history and treatment being identical, 
 although possibly articular lesions are somewhat more common 
 than when the disease is limited to the phalanges. The affected 
 portion of the foot becomes swollen, shiny, and pulpy, since the 
 overlying periosteum is often involved in the process ; and it is 
 sometimes difficult to determine whether the lesion is limited to 
 
 33—2 
 
5"> 
 
 A MANUAL OF SURGERY 
 
 the bones or also involves the joints. In the early stages one 
 part of the foot may he more swollen than another, according to 
 the location of the trouble. The os calcis is most often affected, 
 and afterwards, in order of frequency, come the first metatarsal, 
 astragalus (the head), and scaphoid. When it starts in the 
 astragalus, the swelling occurs below the level of the ankle-joint 
 in front of or behind the malleoli, whilst pressure over the head 
 of the bone gives rise to pain. The foot is usually in a position 
 of equinus, but not to such a marked degree as when the ankle- 
 joint itself is affected ; the subastragaloid movements (inversion 
 and eversion, abduction and adduction) are also considerably 
 limited, or may' be absent. An examination of the accompanying 
 illustration (Fig 176) will explain the fact that tuberculous disease 
 
 Fig. 176. — Arrangement of Synovial Membranes of Foot. 
 
 1, Posterior calcaneo-astragaloid, behind the interosseous ligament ; 2, anterior 
 calcaneo-astragaloid and astragalo-scaphoid ; 3, calcaneo-cuboid ; 4, cubo- 
 metatarsal ; 5, the large common sac between scaphoid and cuneiform, 
 between the cuneiform, and between the cuneiform and second and third 
 metatarsals ; 6, between the internal cuneiform and first metatarsal 
 
 starting in the astragalus is very likely to involve the ankle-joint, 
 or to spread to the os calcis or scaphoid. Disease of the os calcis 
 leads to more limited swelling of the back of the foot on one or 
 both sides of the heel ; the movements of the ankle will not be 
 impaired, although walking is painful, and hence the patient 
 limps, treading only on the toes. Further forwards tuberculous 
 disease is most likely to start in or around the scaphoid, the 
 bulbous swelling of the foot being then shifted anteriorly, and 
 the movements of the ankle remaining unimpaired. The prognosis 
 is much worse when the disease attacks the inner half of the foot, 
 comprising the astragalus, scaphoid, cuneiform, and three inner 
 metatarsal bones, owing to the arrangement of the synovial 
 membranes, than when it affects the outer segment consisting of 
 the cuboid and two outer metatarsals, which are excluded from 
 
DISEASES OF BONE 
 
 5'7 
 
 the general synovial membrane, and are thus more amenable to 
 treatment. 
 
 Sooner or later suppuration occurs with increased pain, and, 
 should the sinus which results from opening the abscess become 
 septic, the trouble is sure to spread much more rapidly, and the 
 prognosis becomes increasingly grave. 
 
 Treatment is conducted according to the rules which always 
 guide us in that of tuberculous disease. In the early stages the 
 foot and ankle arc immobilized, and preferably in plaster of Paris 
 or water-glass. The child is sent to the seaside, and plenty of 
 good food administered, and it is not allowed to walk until all 
 pain has ceased; even then the plasler case must be retained until 
 
 Fig. 177. 
 
 -Chronic Abscess in the Lower End of the Tibia. 
 (Kings' College Museum.) 
 
 the swelling has entirely disappeared. It is wise to remove the 
 plaster every month or two for inspection and readjustment. 
 
 Should the disease persist in spite of such treatment, or should 
 suppuration occur, removal of the tuberculous tissue by operation 
 may be required. If the os calcis alone is involved, it will usually 
 suffice to open well into it either from one or both sides, to scrape 
 out its interior and then pack it with iodoform and gauze after 
 disinfecting it with liquefied carbolic acid. Decalcified bone chips 
 mixed with iodoform have been packed into the cavity in order 
 to hasten bony consolidation, but not with much success ; in any 
 case the interior of the bone becomes occupied by fibrous tissue, 
 with perhaps a few bony spicules, and a marked permanent 
 
5«8 
 
 A MANUAL OF SURGERY 
 
 depression always remains at the site of operation. Excision of the 
 os calcis was formerly practised, but is not to be recommended, 
 since even if performed subperiosteally, the power of repair 
 that remains is very slight. If the disease mainly affects the 
 astragalus, it may suffice to remove it entirely, neighbouring 
 articulations being curetted, if need be ; but probably the disease 
 will have spread so far that amputation will be required, and then 
 Syme's operation is better than methods such as Pirogoff's, which 
 retain any portion of the tarsus. Disease of the cuboid and outer 
 half of the foot in front of the os calcis can often be dealt with 
 
 B 
 
 ^f7 
 
 p£$fcu ^ 
 
 Fig. 178. — Lower End of Tibia affected with Tuberculous Disease. 
 (From King's College 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. 
 
 efficiently by scraping, but when the common synovial membrane 
 on the inner side is involved, amputation will probably be required, 
 failing success by conservative measures. 
 
 (c) If the tuberculous disease affects the ends of long bones, it most 
 commonly starts in the epiphysis, or under the articular cartilage, 
 though sometimes on the shaft side of the epiphyseal cartilage. 
 The changes already described take place, and lead to early 
 destruction of the latter cartilage, so that the adjacent parts 
 of both epiphysis and diaphysis become involved (tuberculous 
 
DISEASES OF BONE 
 
 5'9 
 
 epiphysitis). The general signs are similar to those present 
 when the smaller bones are affected, but the results produced 
 may vary considerably, (i.) In the slighter forms, where efficient 
 treatment is adopted, the tuberculous tissue may be totally ab- 
 sorbed, and the process thus comes to an end, though the affec- 
 tion of the epiphyseal cartilage may lead to subsequent impair- 
 ment of growth, (ii.) In others it may be circumscribeel by the 
 bone becoming sclerosed around a caseating focus, and then, if 
 suppuration ensues, a deep abscess in the cud of the bone may be 
 produced (Fig. 177). Such is rarely of large size, containing 
 at most 1 or 2 drachms of curdy pus, and is lined by a definite 
 pyogenic membrane of 
 
 the usual tuberculous type. - - ~^' . % 
 
 The effects produced by 
 this condition are similar 
 
 to those of chronic osteo- * '& 
 
 periostitis, viz., a deep 
 aching or boring pain in 
 the bone, worse at night, 
 together with enlargement 
 of the affected part, whilst 
 one spot is often very 
 tender on palpation. If it 
 has existed for any length, 
 of time, the whole shaft 
 may become enlarged as a 
 result of chronic osteo-peri- 
 ostitis (p. 511). (iii.) The 
 disease may burrow along 
 the epiphyseal line, and 
 find its way into the neigh- 
 bouring joint, if the epi- 
 physis is intra -articular, 
 as in the hip ; but if the 
 epiphyseal cartilage is 
 placed beyond the limits of 
 the capsule, a subperiosteal 
 extra-articular abscess will 
 result (Fig. 178). Should the disease spread equally in all 
 directions, the epiphysis may actually be separated, (iv.) A 
 more common result is for the whole or part of the cancellous 
 tissue of the epiphysis to become involved, and the joint to be 
 secondarily affected with tuberculous arthritis, either by perfora- 
 tion, 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-periostitis with or without a medullary 
 abscess (Fig. 179). 
 
 Fig. 179. — Localized Abscess in the Lower 
 End of the Femur, extending from 
 the Epiphyseal Line upwards into the 
 Medulla. (From Specimen in the 
 College of Surgeons' Museum.) 
 
520 A MANUAL OF SURGERY 
 
 The Treatment of tuberculous epiphysitis is conducted in the 
 first place by absolute immobilization 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. As soon as 
 possible, an opening should be made into the interior of the 
 epiphysis, and all the pulpy granulation tissue, caseous debris, or 
 diseased bone removed with a sharp spoon, the cavity being sub- 
 sequently disinfected, and stuffed with gauze infiltrated with 
 iodoform. Of course, the utmost care must be taken not to open 
 the joint by scraping through the articular cartilage. Where a 
 chronic abscess 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 with- 
 out the formation 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. 511). 
 
 Syphilitic Diseases of Bone. 
 
 The osseous tissues may be involved in acquired syphilis in 
 either the secondary or the tertiary periods. 
 
 In the Secondary Stage flying pains about the bones (sometimes 
 termed osteocopic) are often complained of ; they are, however, 
 of but little importance, and disappear 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 periosteum, 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 ; the Haversian canals are always placed at right angles 
 to the subjacent osseous tissues. 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 
 increased warmth of the limbs when in bed ; indeed, patients with 
 syphilitic tibia? frequently sleep with their legs exposed. Night- 
 
DISEASES OF BONE 
 
 521 
 
 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. These consist 
 in an infiltration and overgrowth of the connective tissues, which 
 if diffused through an organ produce sclerosis, if localized to one 
 spot lead to the formation of a gumma. Hence the following 
 lesions are met with : 
 
 (a) The formation of subperiosteal gummata, either localized or 
 diffuse, probably resulting in caries of the subjacent bone ; if the 
 affection is limited, only a small portion may be thus involved; but 
 
 HG. iSo. 
 
 -Diffuse Gummatous Disease and Caries of the Skull. 
 (From King's College Museum.) 
 
 where it is widely diffused, an extensive surface of the bone may 
 become eroded and irregular. This process is sometimes accom- 
 panied by a development of new bone under the adjacent peri- 
 osteum, and is very often complicated by sclerosis and necrosis. 
 The calvarium is the part most frequently involved in this change, 
 but, owing to the osteogenetic powers of the pericranium being 
 small, there is rarely any new formation of bone in the neigh- 
 bourhood, and thus the skull may present a curious worm-eaten 
 appearance (Fig. 180). Frequently the gummata break down and 
 destroy the superficial scalp tissues, leaving deep and extensive 
 wounds, discharging an abundance of foul pus, at the bottom of 
 which bare and even dead bone may be felt. 
 
522 
 
 A MANUAL OF SURGERY 
 
 (b) At the same time a condition of sclerosis may be produced 
 in the underlying or surrounding parts, and this may progress to 
 such a degree as to seriously compress and constrict the vessels 
 in the Haversian canals. Moreover, an obliterative endarteritis 
 is almost always present, and these factors, combined with the 
 separation of the periosteum by the above-mentioned gummatous 
 changes, so interfere with the vitality of the bone, that should 
 sepsis occur in the broken-down gummata, necrosis is almost 
 certain to ensue, especially in the skull. 
 
 The effects produced vary considerably in different cases, and 
 especially with the situation. When the calvarimn is attacked, 
 
 septic phenomena are com- 
 monly present, and necrosis 
 is a usual accompaniment 
 of the gummatous changes. 
 The process in such a case, 
 as is represented in Fig. 181, 
 would probably be as 
 follows : The pericranium 
 corresponding to the necrotic 
 area became gummatous, 
 and at the same time the 
 subjacent bone underwent 
 sclerosis. Sooner or later 
 the gummata burst or were 
 opened; septic changes 
 supervened, and the scalp 
 tissues were stripped off the 
 calvarium to the limits of 
 the disease, necrosis result- 
 ing in the sclerosed area of 
 bone. A line of rarefaction 
 subsequently formed around 
 the sequestrum in conse- 
 quence of Nature's attempts to separate it. The disease is marked 
 by its extreme chronicity, the sequestrum lying bare in the wound 
 perhaps for years without being separated, owing to the slight 
 degree of vascularity and the extreme condensation of the sur- 
 rounding 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 underlying 
 parts ; but if this compact layer is thin, and especially when the 
 cancellous ends are involved, a considerable amount of destruction 
 from caries may result, though if sepsis is not admitted there will 
 be an entire absence of necrosis. 
 
 In the Treatment constitutional remedies, in the form of iodide 
 
 FiG. 181. — Syphilitic Necrosis of the 
 Skull 
 
 The sequestrum is becoming separated, and 
 a ring of caries is forming around it 
 
DISEASES OF BONE 523 
 
 of potassium and mercury, should, if possible, be depended on. 
 Gummata should never be opened without the strictest attention 
 to asepsis. If sepsis has occurred, the wounds may be treated by 
 applying iodoform and dressing with lint steeped in lotio nigra, 
 or covered with mercurial ointment. Counter-openings are often 
 required for purposes of drainage, especially in the scalp. Necrosed 
 portions, when separated, are to be removed, carious tissue may 
 be scraped away with a sharp spoon, and the surface powdered 
 with iodoform and dressed antiseptically. In the calvarium no 
 attempt must be made to chisel away the dead bone. 
 
 (c) Occasionally a gummatous osteomyelitis is met with, in which 
 a gumma forms in the interior of a bone. It results in the 
 so-called expansion of bone and secondary thickening and enlarge- 
 ment of its whole structure, i.e., a diffuse osteo-periostitis. The 
 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 opening the medullary cavity, and removing all 
 diseased tissue. These cases when affecting the long bones have 
 often been mistaken for malignant growths ; necessarily, it is a 
 matter of the most vital importance to come to a right conclusion 
 as to their nature. The greater rapidity of growth in the syphilitic 
 cases, and the evidences of syphilis elsewhere, or of a syphilitic 
 history, will often guide the surgeon to a right conclusion ; but if 
 there is any doubt an exploratory incision should always be under- 
 taken before amputation is resorted to. 
 
 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. 
 
 1. 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 colour. If the process is not checked by suitable anti-syphilitic 
 treatment, the newly-formed osseous tissue becomes dense and 
 sclerosed, and the deformity may then persist through life 
 (Fig. 18, p. 138). Any part of the calvarium may, however, be 
 affected, and the change is not necessarily limited to the first 
 years of life. 
 
 2. A similar condition is met with in the shafts of long bones, 
 due to the deposition of alternating lamellae of soft and hard bone, 
 outside the ordinary compact tissue. 
 
 3. Syphilitic epiphysitis (or, as it is termed, syphilitic osteo- 
 
524 A MANUAL OF SURGERY 
 
 ■ hondntis) is a lesion characterized by enlargement of the ends 
 of the bones, met with in infants, and somewhat resembling 
 rickets, but coming on at an earlier date. The enlargement is 
 mainly situated in the epiphysis, but not uncommonly 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 
 diaphysis, 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. This in turn 
 sometimes results in suppuration and 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. 
 
 4. A symmetrical overgrowth of the tibiae, perhaps combined 
 with an anterior curvature, also occurs in syphilitic children, 
 resulting in permanent elongation of the legs (p. 400). 
 
 5. Craniotabes consists of a localised 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, witli 
 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 earned 
 out in acccordance with general principles, and mainly by the 
 administration 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 sometimes appears later. 
 
 Causes. — Any and every fault in the hygienic and dietetic treat- 
 ment of a child seems capable of inducing rickets ; but the most 
 important factor in its aetiology is insufficient or improper food, 
 especially the too early administration of starchy materials, 
 whilst uncleanliness and want of air and light also predispose to 
 it. Prolonged lactation is not necessarily a cause, if the mother 
 is healthy and capable of feeding the child ; but amongst poor 
 patients this habit is frequently responsible for its appearance, 
 although in Japan, where the children are suckled for two or 
 
 * Carpenter. ' Syphilis of Children in Every-day Practice.' Bailliere, 
 Tindall and Cox. 1901. 
 
DISEASES OF BONE 525 
 
 three years, the disease is unknown. Rickets is common in 
 the poorer classes, who are herded together in small and badiy 
 ventilated rooms, and is so peculiarly frequent in this country 
 as to be known in Germany as the ' English disease ' (Englischt 
 kvankheit). 
 
 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 emaciated ; the mucous 
 membranes are pale, and vomiting and diarrhoea are constantly 
 present, the motions being often green, slimy, and very offensive. 
 The spleen is enlarged, the abdomen tumid, and profuse sweating 
 of the head is very characteristic. 
 
 The commencement of the osseous changes is usually indicated by 
 increasing irritability and restlessness, the child tossing off his 
 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. 386), or less frequently 
 by scoliosis (p. 381) ; the kyphotic curve results when the patient 
 is allowed to lie too much in bed with the head on a high pillow, 
 or if it is carried about with a curved back ; scoliosis more often 
 occurs when the patient is able to walk. Occasionally the two 
 conditions are associated in the same child, a kypho-scoliosis 
 resulting, which is usually due to its being carried about sitting 
 on a nurse's arm with the pelvis tilted. 
 
 Changes in the thorax are produced by enlargement of the 
 costo-chondral junctions (beaded ribs), which, when present on 
 either side of the sternum, produce what is known as the rickety 
 rosary. If there is any obstruction to the entrance of air into the 
 lungs, as from a 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 
 breast), whilst the curvature of the ribs at the angle is increased. 
 A very characteristic feature of the rickety change consists in the 
 
526 
 
 A MANUAL OF SURGERY 
 
 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 ribs by the tumid abdomen. 
 
 The pelvis is flattened antero- 
 posterior^, or more rarely tri- 
 radiate, the former condition 
 being produced when the patient 
 lies habitually on his back, the 
 latter only occurring when he is 
 allowed to walk about, the ace- 
 tabula being thus pressed in- 
 wards and backwards by the 
 heads of the femora. 
 
 The deformity of the long bones 
 (Fig. 182) usually consists in an 
 increase in their natural curves, 
 especially at points where power- 
 ful muscles are attached. The 
 femora are curved antero-pos- 
 teriorly, and the tibiaein a similar 
 direction, although there is often 
 some lateral displacement super 
 added. Genu valgum or varum 
 may also result from the epiphy- 
 seal changes. 
 
 When the acute stage of 
 rickets has passed away, any 
 deformities present become fixed 
 by the complete ossification of 
 the softened bony tissues. As 
 a rule, the density of such de- 
 formed 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. Growth is 
 often checked by this disease, 
 so that the individual becomes 
 stunted and dwarf-like. 
 Pathologically, the chief changes in rickets are found in the 
 neighbourhood of the epiphyses. Ordinarily, the epiphyseal 
 cartilage 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, 
 shelving gradually into normal cancellous bone. In rickets the 
 epiphyseal cartilage is not only circumferentially enlarged, but also 
 
 Fig. i32. — Pelvis and Leg-bones 
 in Rickets. (From College of 
 Surgeons' Museum.) 
 
DISEASES OF BONE 
 
 527 
 
 thickened and irregular (Fig. 183), outgrowths of cartilage project- 
 ing on either side into the calcified tissue, which is more abundant 
 and more open in texture than usual, whilst it passes irregularly 
 into the cancellous bone. Thus, there is an increase in the 
 material which Nature prepares for the formation of bone, but the 
 ossifying process is inefficiently carried out. In addition to this, 
 the Haversian canal systems and the medullary spaces in the 
 
 Fig. 184. — Transverse Section through 
 the Shaft of the Ulna from a 
 Rickety Child of Thirteen Months 
 ( x 10), showing Spongy Tissue beneath 
 the Periosteum instead of the Com- 
 pact Tissue of Normal Bone. 
 
 Fig. 183. — 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' c ' Diseases of Children.') 
 
 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 compact bone becomes 
 similarly rarefied (Fig. 184). 
 
 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 
 
528 A MANUAL OF SURGERY 
 
 administered. The condition of the bowels must be attended to, 
 and the child placed in as good surroundings as possible. Parrish's 
 food (syr. ferri phos. co.) may be given by itself, but if the infant is 
 thin and emaciated, cod-liver oil should be added. Deformities 
 must, if possible, be prevented by keeping the child in the re- 
 cumbent posture, and not allowing it to crawd or run about. The 
 early stages of deformity can often be corrected by daily manipu- 
 lation of the affected bones, and in the later stages they may be 
 improved by suitable apparatus for immobilizing the limb, com- 
 bined with pressure. Osteotomy, or even resection of portions 
 of bone, is required in the severer cases where the deformity 
 persists (see p. 400). 
 
 Scurvy Rickets (Svu. : Acute Rickets, Hemorrhagic Rickets). — Attention has 
 been directed of recent years, notably by Sir Thomas Barlow, to a curious 
 condition met with in children, which seems to combine some of the most 
 marked features of rickets and scurvy, but in which either one or the other set 
 of phenomena may predominate. It is usually seen in the children of well-to- 
 do people, and apparently arises from defective nutrition, especially from the 
 prolonged administration of peptonized or prepared foods, together with an 
 absence of fresh meat and vegetables. In the slighter cases there may be but 
 little evidence of the scorbutic condition, beyond the fact that in a rickety 
 child there is some tendency for the gums 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 hemorrhagic 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 may be kept so quiet as to suggest that they are paralyzed. This is 
 followed by the appearance of swellings of some size, due to subperiosteal 
 extravasations, the skin over the affected parts being at first shiny and 
 o^dematous, 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 even spontaneous fractures occur. Bleeding 
 may also take place beneath the conjunctiva or into the orbit, leading to 
 protrusion of the eyeball, whilst there may be blood-stained diarrhoea, 
 hematuria, 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 are 
 employed for separated epiphyses or fractures. 
 
 Achondroplasia is the name given to a rare and curious congenital condition, 
 somewhat resembling 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 defec- 
 tive, so that the limbs are short and stunted, and the stature correspondingly 
 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 
 
DISEASES OF BONE 
 
 529 
 
 their mental development, and the thyroid body normal. No known treatment 
 is of any value. 
 
 Simple Atrophy of Bone. 
 
 This results from a variety of conditions quite independent of rarefying 
 inflammation, in which it is always a marked feature, (a) It maybe congenital, 
 perhaps involving bones and soft tissues alike, (b) It may result from inter- 
 ference with the epiphyses, as in rickets, or after injuries, or as a sequela to 
 tuberculous or other inflammations involving the junction cartilage, (c) It 
 may be due to injury or disease of the central nervous system or of peripheral 
 nerves, as in tabes dorsalis, syringomyelia, leprosy, etc. (d) It maybe caused 
 by want of use, as in a paralysed or ankylosed limb, (e) Local pressure, as of 
 a tumour growing within or outside the bone, or of an aneurism, may deter- 
 mine its existence, and possibly to such a degree as to result in spontaneous 
 fracture. (/) It may be a senile change, as seen in the lower jaw, cervix 
 femoris, or cranium. 
 
 The type of atrophy varies with the cause. Sometimes it merely consists 
 in an arrest of longitudinal development ; at others the bones are not 
 only short, but smaller in all directions, and in leprosy may undergo almost 
 total absorption. If the cause is localized, and acts from without, the compact 
 bone is more or less cleanly eroded ; whilst if the cause is general, absorption 
 may occur either from within, the medullary canal becoming enlarged and the 
 compact tissue thinned, or from without, the cross-section of the bone gradually 
 dwindling. 
 
 The possible presence of atrophy must always be kept in mind when 
 dealing with ankylosed or paralysed limbs, since very little force may suffice 
 to produce a fracture. 
 
 Mollities Ossium (Syn. : Osteo-malacia). 
 
 This disease is one of somewhat unusual occurrence, characterized by the 
 absorption of the osseous substance of the bones, as a result of which soften- 
 ing and rarefaction are produced, followed by bending or spontaneous fracture. 
 
 The complaint is almost limited to the female sex (only S per cent, of the 
 cases reported are in males), and usually commences during pregnancy ; it is 
 said to be sometimes connected with a rheumatic tendency. Any part of the 
 skeleton may be affected ; in females the change usually attacks the pelvis, 
 spinal column, and ribs first, and the limbs later ; in men the process starts in 
 the long bones. 
 
 Pathologically, the change consists in a replacement of the medullary 
 substance by a soft fibro-cellular tissue, which is exceedingly vascular, and 
 into which haemorrhage often occurs ; the resulting material looks in the fresh 
 state something like splenic pulp. The bony cancelli are absorbed, as also the 
 greater part of the compact tissue, with the exception of a thin layer situated 
 beneath the periosteum ; in a well-marked case the mineral salts may be 
 diminished to about one-sixth of their normal amount, but the relative propor- 
 tion of phosphate of lime to the carbonate is not changed. Part of the bone 
 substance remains for a time in a decalcified state, with the corpuscles evident, 
 but in a condition of fatty degeneration. Probably some acid, e.g., lactic acid, 
 is the active agent in dissolving the earthy salts, which escape partly in the 
 urine, partly in the faeces. It is possible that the process is connected with 
 the absorption of some internal secretion, normal or vitiated, particularly that 
 from the ovary, an idea suggested by the fact that the removal of the uterine 
 appendages has in a few cases stayed the disease. 
 
 Clinically, the onset is usually somewhat indefinite, the only complaint 
 being of pain in various parts of the body, whilst the patient becomes 
 emaciated and exhausted. Sooner or later skeletal changes ensue and 
 demonstrate the character of the disease. The limbs may either bend or 
 break ; in the latter case there is often no attempt at repair. The pelvis 
 becomes tri-radiate in shape owing to the acetabula being pressed inwards 
 and backwards by the weight of the body, and in p.egnant women this may 
 
 34 
 
53Q A MANUAL OF SURGERY 
 
 cause so much deformity as to necessitate Caesarian section or Porro's opera- 
 tion. Death may result from exhaustion, or from obstruction to parturition, 
 or the patient may live more or less bedridden for years, the limbs becoming 
 useless, shortened, and perhaps contorted in a strange and abnormal fashion. 
 Treatment is unsatisfactory. Opiates may be administered to relieve pain, 
 which is often very severe, and various drugs, such as alum, and phosphate 
 or hypophosphite of lime, have been recommended. In cases not associated 
 with parturition or pregnancy, oophorectomy is said to have been employed 
 with benefit. The induction of premature labour is considered by some to be 
 beneficial, not only for the sake of obviating the necessity for such operations 
 as Caesarian section, but also on the chance of checking the disease. 
 
 Hypertrophy of Bone. 
 
 It is always a matter of difficulty to draw a definite line between a true 
 hypertrophy and inflammatory or other overgrowths, and especially is this the 
 case in connection with bones where chronic inflammation is always associated 
 with new bone formation. Two or three conditions to which the term 
 hypertrophy is perhaps more correctly attached may, however, be mentioned, 
 (d) It is sometimes congenital ; if involving a whole limb or any large portion 
 of the body, it is known as Gigantism ; if merely affecting the fingers or toes, 
 it is termed macrodactyly (p. 390). (b) It may follow inflammatory affections 
 of bones, which are thereby left with an increased blood supply, e.g. , after 
 acute osteomyelitis, which has not destroyed the epiphyseal cartilages ; in 
 such cases the overgrowth is mainly longitudinal, (c) Increased growth of 
 bones is associated with several diseases to be described immediately, viz., 
 osteitis deformans, acromegaly, etc., and in these it is possibly due to the 
 effect of some internal secretion. 
 
 Osteitis Deformans. 
 
 Osteitis deformans is an inflammatory disease of the osseous skeleton, first 
 described by Sir James Paget in 1876. The onset is insidious, and the progress 
 very slow. It is characterized by a painful overgrowth of the long bones, 
 spine, cranium, and pelvis, which are also softened, so that those which bear 
 the weight of the body become curved. It may commence in one bone alone, 
 and then usually the tibia or femur, but more often many bones are affected 
 at the same time. Attention may be drawn to the condition, either by the 
 pain, which the patient at first considers to be rheumatic, or by the general 
 enlargement and bending of the bones, or by the increased size of the head, 
 necessitating the use of larger hats. The cranial overgrowth is eccentric in 
 character, and the calvarium may become very thick ; the facial skeleton, 
 however, is not much affected. The spine becomes markedly kyphotic 
 (Fig. 185), the dorsal curve being increased, and the lumbar concavity 
 obliterated ; it is nearly rigid from ankylosis of the vertebrae, and may be 
 very painful. The head is carried forwards by the bend of the spine, the 
 height is diminished, the shoulders are round, and the chest sunken towards 
 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 osseous 
 tissue is suggestive of inflammatory 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 irregularly, whilst the bony substance is chalky- 
 looking. 
 
 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 
 
DISEASES OF BONE 
 
 53» 
 
 cranium. From acromegaly it is distinguished by the absence of enlargement 
 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 
 described by Dr. Pierre Marie in 18S5. It is a general affection involving 
 mainly the osseous system, commencing usually in young adults, and, after 
 
 Fig. 185.— Osteitis Deformans. (Bryant.) 
 
 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 skin are unchanged, whilst the other segments, both of the upper 
 and lower limbs, are usually unaffected, though sometimes considerable over- 
 growth 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 over- 
 hanging. 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 ; 
 amenorrhcea is a marked symptom in women, whilst men suffer from a loss 
 of virile power. The urine is abundant, but cf a low specific gravity. Vision 
 is usually diminished, and optic neuritis has been observed in some cases. 
 
 Morbid Anatomy. — But little is known as to the cause or pathological 
 changes occurring in this disease, beyond the fact that the anterior glandular 
 
532 
 
 A MANUAL OF SURGERY 
 
 half of the pituitary body is hyper trophied, and the sella turcica expanded. 
 The. changes in the bones are merely those of overgrowth. 
 
 Diagnosis. — The disease has been mistaken for myxasdema, 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 deformans, the 
 distinguishing features have already been indicated. 
 
 Treatment is merely symptomatic, antipyrine being useful in relieving the 
 headache, as also valerianate of caffeine. Possibly thyroid extract may be of 
 some use in combating the functional phenomena, though it will not influence 
 the skeletal changes. 
 
 Fig. i85. 
 
 -Head of Woman with Acromegaly, 
 
 AND FROM THE SlDE.* 
 
 Seen from the Front 
 
 Another curious affection which has been recently described is that known 
 by the formidable title of Hypertrophic Pulmonary Osteo-arthropathy. It 
 has been long known that clubbing of the terminal phalanges was a common 
 accompaniment of chronic pulmonary disease ; but this new affection is more 
 extensive. The terminal phalanges of the fingers and toes are enlarged and 
 bulbous, with the nails curved over them towards the palm or sole ; there is 
 also a considerable swelling of the bones just above the wrists and ankles, and 
 possibly a similar condition around other joints. 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 only of the terminal phalanges ; (b) the 
 swellings above the wrists and ankles ; and (c) the absence of the characteristic 
 deformities in the skull and head. These phenomena probably result from 
 a chronic osteitis, due to toxic absorption, since the condition arises in such 
 
 * Reproduced from the Edinburgh Medical Journal, by kind permission of 
 Dr G. A. Gibson. 
 
DISEASES OF BONE 
 
 532 
 
 diseases as chronic bronchitis, bronchiectasis, and chronic empyema, where 
 suppuration has existed for some time. Little can be done in the way of 
 treatment, except to remove the cause. 
 
 Tumours of Bone. 
 
 Many different types of tumours grow from bone. The 
 characters of the osteomata, chondromata, and fibromata have 
 been described in Chapter VII., and various solid and cystic 
 tumours connected with the teeth are dealt with elsewhere. 
 
 Sarcoma is the most important primary tumour of bones, and 
 almost any form may occur. The microscopical characters have 
 been detailed in the chapter on tumours, and we shall here only 
 
 Fig. T.87. — Endosteal Sarcoma. (King's College Hospital Museum.) 
 
 refer to their clinical characteristics. They may be divided into two 
 main groups — the endosteal or central, and the periosteal. 
 
 Endosteal or Central Sarcoma (Fig. 187) of bone commences in 
 the medullary cavity or cancellous tissue, and results in the so- 
 called ' expansion of bone,' which consists in absorption of the 
 bone from within, whilst at the same time new osseous tissue is 
 being deposited from the under side of the periosteum, though in 
 these cases only to a limited degree. The Symptoms at first 
 resemble those of chronic osteo-periostitis, although in most cases 
 of tumour there is rather less pain. The growth usually com- 
 mences near the end of a long bone ; it seldom encroaches on the 
 articular cartilage, so that the joint escapes, although it may 
 contain an excess of serous fluid ; occasionally, however, the 
 growth may extend laterally beyond the level of the cartilage, and 
 thus invade the articular cavity. Spontaneous fracture is not an 
 unfrequent complication, and owing to the expansion of the bony 
 
5 
 
 A MANUAL OF SURGERY 
 
 framework ' eggshell crackling ' is sometimes met with. After a 
 while, the growth may extend beyond the osseous limits into the 
 soft parts, and then the chances of general dissemination are con- 
 siderably increased. The chief varieties of sarcoma growing from 
 the interior of long bones are the round or spindle-celled, and the 
 myeloid. The two former early diffuse themselves throughout 
 the medullary cavity, and infect neighbouring tissues and the 
 system generally. Not unfrequently cartilaginous nodules may 
 be found scattered through the mass. Myeloid tumours are almost 
 benign in character, never giving rise to secondary deposits, either 
 in lymphatic glands or viscera, and their growth within the bone 
 
 Fig. 188. — Periosteal Sarcoma. (Bryant.) 
 
 is limited to the region from which they originated ; sometimes a 
 layer of condensed bone forms a definite barrier to check any 
 advance along the medullary canal. The sites of election for 
 myeloid tumours are the lower ends of the femur and radius, and 
 the upper ends of the tibia and humerus — that is, where the 
 growth of the limbs is greatest ; they also grow within the hori- 
 zontal ramus of the lower jaw and the diploe. Not uncommonly 
 a fibro-sarcomatous epulis is myeloid in nature. 
 
 In considering the nature of an endosteal sarcoma, it should be 
 remembered that myeloid tumours grow more slowly than the 
 round- or spindle-celled, and are more likely to develop cysts 
 owing to haemorrhage into their substance. In all of them a 
 certain amount of bony skeleton may pervade the growth. 
 
DISEASES OF BONE 535 
 
 The Periosteal Sarcomata (Fig. 188) are round- or spindle- 
 celled in nature. They often grow very rapidly, without giving 
 rise to much pain, unless causing erosion of the bone. They 
 usually start on one side of the bone, but later on may surround 
 its whole circumference. They spread rapidly along its exterior, 
 and are highly malignant in nature, giving rise to secondary 
 growths in the neighbouring lymphatic glands or in the viscera. 
 They frequently become ossified, with or without the development 
 of cartilage, and in such cases the subjacent bone becomes sclerosed 
 and thick. The bony skeleton of such a growth is very character- 
 istic, consisting of fine spiculated trabecular, radiating more or 
 less regularly from the surface, and looking in the dried state 
 somewhat like asbestos. When a periosteal sarcoma does not 
 become ossified, the growth usually erodes the underlying bone, 
 and may lead to spontaneous fracture ; the tumour in such cases 
 is softer and more elastic than in the former variety. All osseous 
 sarcomata are exceedingly vascular, and may even pulsate, whilst 
 the superficial veins are obviously dilated 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 
 be mistaken for chronic osteo-periostitis, medullary gumma, or a 
 deep abscess of the bone, and can sometimes only be distinguished 
 from them by an exploratory incision, which should always be 
 undertaken in doubtful cases prior to radical operations, such as 
 amputation. In the later stages, the presence of ' eggshell 
 crackling ' or cystic change will 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 irregular 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. 261. 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 joint. It will, how- 
 ever, 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 without pain, whilst the starting 
 pains at night characteristic of joint mischief are absent. The 
 age of the patient, and the presence or not of cachexy, are also 
 important features which have to be taken into consideration. 
 Skiagraphy serves in some cases as an important diagnostic 
 adjuvant. 
 
 The Treatment of osteo-sarcoma must always be of a radical 
 nature, and, remembering the highly malignant character of many 
 of these growths, we would strongly urge the importance of an 
 early exploratory operation in doubtful cases ; if undertaken. 
 
536 ./ MANUAL OF SURGERY 
 
 with antiseptic precautions no harm can ensue, and a definite 
 diagnosis is thereby possible. If the case is left until increased 
 growth reveals the true state of affairs, it is more than likely that, 
 except in the myeloid variety it will be too late for successful 
 operative interference. In every form of the disease except the 
 myeloid, the affected limb should be removed high above the 
 tumour. Thus, if growing from the lower end of the tibia, dis- 
 articulation at the knee-joint should be performed ; if at the upper 
 end of the tibia, amputation through the middle or lower third of 
 the thigh ; if from the lower end of the femur, amputation through 
 the upper third of the bone, if not at the hip-joint. For sarcoma 
 of the head of the humerus, disarticulation through the shoulder- 
 joint may suffice, but it is often wiser to remove the scapula and 
 greater part of the clavicle as well (interscapulo-thoracic amputa- 
 tion). The results of the latter proceeding, as regards final cure, 
 have been much more satisfactory than those of the former. 
 When muscular bellies have been invaded, it is desirable, though 
 not always practicable, to include the whole of them in the scope 
 of the operation. 
 
 Myeloid sarcomata being practically non-malignant, except 
 locally, are dealt with in a much more conservative manner, 
 amputation through healthy tissue just above the growth being 
 all that is necessary. It is advisable that the medulla at the 
 point of section of the bone should be examined microscopically 
 before the wound is closed, to make certain that it has not been 
 invaded. When affecting the lower end of the radius, an attempt 
 may be made to save the limb by excising the diseased portion of 
 bone ; if a portion of the ulna is also taken away at the same time, 
 there is less chance of the hand being drawn up and abducted, 
 and hence it is more likely to become useful. A leather gauntlet 
 to steady the part subsequently will almost certainly be required. 
 Central sarcoma of the lower jaw, if myeloid in nature, may be 
 treated by making a free opening in the bone, scraping the 
 diseased tissue away, and swabbing out the cavity with pure 
 carbolic acid. The continuity of the jaw may thus be maintained, 
 even if the teeth are lost. Several successful cases treated ac- 
 cording to this plan have been recorded. 
 
 Secondary Sarcoma of bone is by no means uncommon. It is 
 usually endosteal in character, and, except in the most unusual 
 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 difficulty of fixation, 
 it would be justifiable to remove the limb. 
 
 Carcinoma of bone is always secondary in nature, although it 
 may be involved by direct extension in a primary growth. It may 
 occasionally lead to spontaneous fracture, but the bone may 
 consolidate again satisfactorily. 
 
DISEASES OF BONE 557 
 
 A rare form of secondary carcinoma of bone is that known as 
 Thyroid Cancer. The primary growth is in the thyroid body, 
 whilst the secondary deposits in the bone are exactly similar in 
 structure to it, and usually pulsate strongly. 
 
 Pulsating Tumours of Bone, or Osteo-ar.eurism. — Not a few cases 
 of sarcoma of bone, whether central or peripheral in character, 
 have an evident pulsation, owing to their extreme vascularity, 
 the thin-walled vessels in their substance being even dilated and 
 aneurismal. Apart from these, two other conditions are met with, 
 the nature of which cannot be considered as yet settled, in which 
 distinct pulsation is also noticeable. 
 
 In the first of these the medullary cavity is occupied by a 
 non-malignant vascular tissue, practically identical with what we 
 have already described as an aneurism by anastomosis. A large 
 number of small arterioles open into spaces without the interven- 
 tion of capillaries, so that an erectile tissue similar in nature to 
 the corpus cavernosum penis results. 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 ' eggshell 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 formed in the cancellated tissue, and 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 sarcomata 
 of extreme tenuity. 
 
 The Diagnosis of these conditions from an ordinary aneurism is 
 alluded to elsewhere (p. 261) ; but it is often impossible to distin- 
 guish one form of pulsating tumour of bone from another without 
 an exploratory incision. 
 
 The Treatment of these cases necessarily varies with the con- 
 dition found after the preliminary incision into its substance, 
 which should always be made after rendering the limb bloodless. 
 Where it seems probable that the condition is not associated with 
 malignant disease, or is merely due to a myeloid tumour, the 
 cavity should be well scraped, swabbed out with pure carbolic 
 acid, and then firmly stuffed with gauze, so as to obtain healing 
 by granulation from the bottom. In other cases amputation is 
 the only treatment. 
 
 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 
 has become sufficiently absorbed, spontaneous fracture may follow. 
 
538 A MANUAL OF SURGERY 
 
 A peculiar characteristic of this affection is that there is no 
 limiting cyst wall, the small daughter cysts being diffused widely 
 throughout the affected area. A diagnosis is little likely to be 
 made (at any rate, in this country, where hydatid disease is so 
 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, amputation holds out the only prospect of cure. 
 
CHAPTER XIX. 
 
 INJURIES OF JOINTS— DISLOCATIONS. 
 
 Sprains and Strains. — -When some of the ligamentous fibres 
 around a joint are ruptured or stretched, as the result of sudden 
 violence, the joint is said to be sprained or strained. The acci- 
 dent itself is associated with severe pain, and is immediately 
 followed by more or less haemorrhage into the surrounding 
 tissues, or into the articular cavity. An attack of synovitis, 
 varying in severity, generally ensues, and may lead to persistent 
 weakness and pain in the joint, either from the formation of 
 adhesions, or from imperfect repair of the ligaments. If this con- 
 dition is neglected, it may originate tuberculous disease in those 
 who are so predisposed, whilst osteo-arthritis is a by no means 
 uncommon sequela. If the patient is in a bad state of health at 
 the time of the injury, it is possible that an attack of acute 
 infective arthritis may be lighted up. Treatment. — The joint 
 should be firmly supported by a bandage as soon after the 
 accident as possible, and cold or evaporating lotions applied. In 
 the slighter cases, all that is needed is to strap the joint or use 
 elastic pressure, the patient being allowed to use the limb at the 
 end of a day or two ; but in severe sprains it is better to keep the 
 part absolutely at rest for some days, since neglect in the early 
 stages may give rise to as much, if not more, trouble than if the 
 limb had been fractured. Friction with stimulating liniments^ 
 massage, and douching the joint alternately with hot and cold 
 water, are subsequently useful in restoring the limb to full func- 
 tional activity. When synovitis supervenes, the treatment suit- 
 able for that condition must be adopted. 
 
 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 inflammation, the severity and extent of which 
 depend on whether the joint is infected and the character of that 
 infection. If no infection has taken place, and the joint is main- 
 
540 A MANUAL OF SURGERY 
 
 tained in an aseptic condition, a simple synovitis ensues, and soon 
 passes off; if, however, micro-organisms have entered, acute 
 arthritis probably supervenes, leading to destruction and dis- 
 integration of the joint. (For symptoms and treatment, see 
 Chapter XX.) A penetrating wound, even if untreated, does 
 not necessarily become septic ; 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 to all discharges, recovery with- 
 out septic inflammation is possible. 
 
 Considerable difference of opinion has been expressed as to the 
 necessity for accurately determining whether or not the synovial 
 membrane has been involved. Speaking generally, one would 
 recommend that if the wound is small, and the surgeon has 
 reason to believe that the instrument inflicting it has been aseptic, 
 the external skin should be thoroughly purified, and an antiseptic 
 dressing applied. A careful watch must be kept upon the con- 
 dition 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 inflicted by 
 a dirty instrument, and there is but little doubt that the joint 
 has been penetrated, it is most important to make certain of 
 this fact. For this purpose the wound 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 ; if acute arthritis supervenes, it must 
 be treated in the usual way. 
 
 Dislocations. 
 
 Although the term ' dislocation ' is most commonly applied to a 
 forcible displacement of one of the bones entering into an articula- 
 tion, as the result of an injury, it must not be forgotten that con- 
 genital and pathological displacements also exist. 
 
 Congenital Dislocation. — This term is applied generally to any 
 defect of a joint present at birth, but is really a misnomer, since 
 the condition is almost always due to an error of development, as 
 a result of which a normal location of the bony constituents has 
 never been present, and hence a dislocation cannot have taken 
 place. 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. 
 
 Congenital Dislocation of the Hip is by no means rare, although 
 its causation is still quite uncertain ; probably it is due in some 
 cases to malposition of the foetus in the uterus or to some irregu- 
 larity in the shape of the uterine wall, e.g., such as results from 
 
INJURIES OF JOINTS— DISLOCATIONS 
 
 54i 
 
 the presence of fibroids. The malformation is frequently bilateral, 
 more commonly unilateral. It often passes 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, necessitating a consider- 
 able amount of lordosis to maintain the body in a vertical position 
 (Fig. 191), whilst scoliosis is well marked in one-sided cases. 
 Since the head of the femur is displaced from the middle line, a 
 
 Figs. 189, 190. — Congenital Dislocation of Both Hips in a Girl of 
 Fifteen Years, seen from the Front and Back. (From Photographs 
 
 KINDLY LENT BY Mr. J. JACKSON CLARKE.) 
 
 gap is usually noticed between the thighs close to the perineum. 
 Considerable adduction of the lower end of the femur (Figs. 189 
 and 190) may result from muscular contraction (adductors), 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, 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 
 
542 
 
 A MANUAL OF SURGERY 
 
 easy to rtduce the displacement and put the head of the bone in 
 the acetabulum in children that have not walked much. It is 
 sometimes necessary to invert, sometimes to evert, the limb, as 
 well as make traction, in order to accomplish this, the head of the 
 bone not being always in the same place. At a subsequent date 
 
 strains to the limb are almost entirely 
 borne by the ligamentous tissues, and 
 hence attacks of synovitis are common. 
 The Pathological Anatomy varies con- 
 siderably according to whether or not 
 the child has walked. At bivth the head 
 and neck are sometimes nearly normal, 
 although the head is often rather small 
 and perhaps flattened at the spot where 
 it rests against the innominate bone, and 
 the neck is short and stunted. The liga- 
 mentum teres is long, thin and usually 
 somewhat flattened. The acetabulum 
 is smaller and more shallow than usual, 
 but can usually receive the head of the 
 bone, though it cannot retain it : this is 
 stated by Lock wood to be due to the 
 absence of the cartilaginous rim, but 
 this explanation is certainly not true 
 in all cases. The capsule is large and 
 roomy. After the child has walked, sundry 
 modifications make themselves evident. 
 The head of the bone becomes more and 
 more displaced, so that it may finally lie 
 well above the acetabulum on the dorsum 
 ilii (Plate XXVI.). The capsule becomes 
 stretched over the displaced head, and 
 much thicker than usual ; the ligamen- 
 tum teres is flat and band-like. The 
 head of the bone is considerably altered 
 in shape ; the defective development of 
 the acetabulum is more obvious, since it becomes triangular in 
 shape, owing chiefly to want of growth of the iliac portion, whilst 
 the muscles are necessarily modified as to their length. A new, 
 but very imperfect, acetabulum forms on the spot where the head 
 of the bone usually rests. 
 
 Treatment. — Should a diagnosis be made before the child has 
 commenced to walk, there is no reason why treatment should not 
 be instituted at once. The head of the bone can usually be placed 
 in its socket, and is kept there by fixing the limb in a position of 
 abduction, whilst inward pressure is made over the trochanter 
 with a screw apparatus. Schede has by this means converted 
 the unstable articulation into a stable one. Such treatment will 
 
 Fig. 191. — Side View of 
 Same Patient to show 
 the Extreme Lordosis. 
 
PLATE XXVI. 
 
INJURIES OF JOINTS—DISLOCATIONS 545 
 
 last from six to twelve months. Others have effected the same 
 result by prolonged traction. 
 
 At a later age (up to five or six years) Lorenz's bloodless 
 method of treatment may be employed with good hopes of a 
 successful issue in unilateral cases. (1) The head of the bone is 
 first drawn down to the level of the acetabulum. Some surgeons 
 recommend this to be effected by gradual extension ; others do it 
 at one sitting under an anaesthetic. The adductor muscles are 
 the chief hindrance, and will require a good deal of kneading, 
 or even possibly section with a tenotome. (2) The head of the 
 bone is to be replaced in the acetabulum, and as this cavity is 
 small and chink-like, and sometimes covered in by the front of 
 the capsule, a good deal of difficulty may be here experienced. 
 The limb is fully flexed and then forcibly abducted, extended 
 and everted, no undue violence being permissible, or the bone 
 may be fractured. The head of the bone can sometimes be felt 
 to slip into the acetabulum, and the manoeuvre should be repeated 
 several times, as it were, grinding the head of the femur into the 
 acetabulum. (3) The limb is then put up in plaster of Paris from 
 the pelvis to the knee in a position of abduction and slight eversion, 
 and with the leg flexed. It is maintained in this position for 
 ten or twelve weeks, and it is well to ascertain by skiagraphy 
 that the bone has not slipped. At the end of that period it will 
 probably be found that a less degree of abduction will suffice in 
 order to keep the bone in place, and a fresh case of plaster is 
 applied with the limb in this new position, the extension and out- 
 ward rotation being maintained. As soon as possible the child is 
 encouraged to walk on the limb in this position of abduction, so 
 as to force the head of the bone still deeper into the acetabulum ; 
 crutches are required at first, but he will soon do without them. 
 The plaster casing is usually needed for six months. 
 
 In older children (from five to ten years) operative treatment 
 can be undertaken with some prospect of success. Hoffa and 
 Lorenz have been the great exponents of this proceeding, though 
 for children under five years they both admit the value of the 
 bloodless method. Their operations consist in opening the joint 
 from the back and front respectively, shaping up the head of the 
 bone, enlarging the acetabulum so that the head can be replaced 
 in it, and dividing any tense structures which prevent reduction. 
 The limb is subsequently immobilized in a position of eversion 
 and abduction, but for as short a time as possible. Even if anky- 
 losis results, the patient's gait is considerably improved. 
 
 Pathological Dislocations are produced as the result of some 
 intra-articular affection, e.g., tuberculous disease, osteo-arthritis, 
 Charcot's disease, etc. It is unnecessary to describe them here. 
 
544 A MANUAL OF SURGERY 
 
 Traumatic Dislocations. 
 
 Causes. — These are divided into the predisposing and exciting. 
 Under the former head may be included some anatomical pecu- 
 liarity of the joint, such as the shallow socket of the glenoid cavity, 
 or some weakness of the muscles or ligaments which control the 
 movements of the articulation. Dislocations are rare in children, 
 since any violence directed to a joint or its neighbourhood is more 
 likely to lead to an epiphyseal separation. Moreover, in old 
 people the bones become brittle, and thus fractures, rather than 
 dislocations, are produced ; hence the later lesions are almost 
 limited to adults, and, owing to their greater exposure to injury, 
 occur in men rather than in women. 
 
 The Exciting Causes are the application of external violence and 
 muscular force, acting alone or in combination. The former may 
 be direct, but is more commonly indirect, the force being applied 
 at a distance from the joint. Muscular action by itself can only 
 produce dislocation in certain joints, which by their peculiar con- 
 formation are predisposed to it ; the head of the humerus, the 
 patella and condyle of the jaw are the bones most often affected 
 in this way. If, however, the ligaments of a joint have been 
 stretched by previous disease or displacement, recurrent disloca- 
 tions, the result of muscular action, are not unusual. 
 
 The term complete dislocation, or luxation, is applied to that con- 
 dition in which the articular surfaces of the bones are completely 
 separated from one another. An incomplete dislocation, or subluxa- 
 tion, is one in which the surfaces are only partially separated. 
 
 A compound dislocation is one in which the skin has been ruptured 
 and a communication established with the external air. A com- 
 plicated dislocation is one in which there has been some associated 
 injury of vessels, nerves, or viscera. The term fracture-dislocation 
 is one applied to a condition in which a dislocation is complicated 
 by fracture of one or both bones involved. 
 
 The Signs of a dislocation are as follows : (i) The evidences of 
 a local trauma, e.g., pain, bruising, and swelling 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 abnormal position, where it can often be felt and sometimes 
 seen : and (3) restricted mobility of the affected joint, and hence 
 impairment of function of the limb. The degree to which this 
 obtains is necessarily variable, but, as a rule, it is very marked ; 
 if, however, fracture is also present, passive movements may be 
 possible, though associated with pain and crepitus. 
 
 The Effects produced by a dislocation extend to all the struc- 
 tures entering into and surrounding the site of injury. The liga- 
 ments are partially or completely torn ; the bony surfaces are not 
 unfrcquently fractured, especially in closely-fitting hinge joints, 
 
INJURIES OF JOINTS— DISLOCATIONS 
 
 54 5 
 
 such as the elbow and ankle ; the cartilages may be bruised, 
 or portions of them detached, and neighbouring muscles and 
 tendons lacerated and displaced ; adjacent vessels and nerves are 
 often contused or compressed. Considerable effusion of blood is 
 always present, infiltrating the whole area involved. 
 
 The character of the injury explains the difficulties that are 
 met with in its reduction. These arise from two main causes : 
 (a) The anatomical structure of the joint and its ligaments, re- 
 sulting in the hitching of bony prominences against one another, 
 whilst the head of the bone does not always lie opposite the hole 
 in the capsule through which it originally passed. In a few cases 
 
 A B 
 
 Fig. 192. — Old-standing Suecoracoid Dislocation of the Shoulder, show- 
 ing Atrophy of True Glenoid Cavity, together -with Formation of 
 New Joint and Alteration in Shape of Head of Bone. A, View from 
 the Front ; B, from the Outer Side. (From College of Surgeons' 
 Museum.) 
 
 the end of the bone may be grasped by neighbouring ligaments 
 and muscles in such a way as to render its replacement a matter 
 of the greatest difficulty. (b) Muscular contraction also con- 
 stitutes an obstacle, which, though formerly difficult to counter- 
 act, is now readily overcome by the use of anaesthetics. Not 
 only does the patient maintain the limb in a condition of rest 
 by a voluntary tonic contraction, but it becomes fixed by the 
 involuntary passive tension of the displaced muscles. Moreover, 
 clonic spasms may arise from the direct or reflex irritation of 
 nerves, and these the patient is quite incapable of controlling. 
 When once reduced, Nature soon restores tiie part, so that in many 
 
 35 
 
546 A MANUAL OF SURGERY 
 
 cases no permanent lesion remains, although in some the rent in 
 the capsule does not heal firmly, leaving the joint weak and 
 liable to a recurrence of the displacement, while intra-articular 
 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 adherent to the structures amongst which it 
 lies ; as the result of a plastic inflammation, either dense fibrous 
 adhesions are formed, or a new false joint (psetidarthrosis). 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 displaced head rests undergoes changes, partly atrophic (from 
 pressure), partly hypertrophic (as a result of chronic periostitis), 
 whereby a new socket is produced (Fig. 192). Neighbouring 
 muscles are secondarily shortened, and accommodate themselves 
 to the abnormal position of the limb, and tendons which have 
 been torn gain fresh attachments. These changes necessarily 
 interfere more or less seriously with the power of the limb and 
 the movements of the joint. 
 
 Treatment. — The treatment of dislocations consists in the re- 
 duction of the displaced bone with as little delay as possible. 
 There are two chief methods of gaining this end, viz., manipula- 
 tion and extension. 
 
 Manipulation 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 treat- 
 ment than hinge joints. Anaesthesia will be required in difficult 
 cases. The special manipulations needed in any particular 
 instance are detailed under the various joints. 
 
 Extension is employed to overcome muscular and other forms of 
 resistance, so as to draw the bone back into its original position. 
 In order to make this effectual, the parts above the dislocation 
 are steadied by some counter-extending force applied either by the 
 hands of an assistant, or by a belt or towel, or by the knee or foot 
 of the surgeon. Extension may be made by the hands, or a 
 firmer grip may be maintained, and greater force used, by apply- 
 ing a bandage or a jack-towel to the limb by means of a clove- 
 hitch. In a few cases, the force may be exerted through some 
 form of multiplying pulley, fixed at one end to a hook or staple, 
 and at the other end to the loop of a towel or bandage attached 
 to the limb. When any such contrivance is employed, precau- 
 tions must be taken to prevent the soft tissues from being injured. 
 
INJURIES OF JOINTS— DISLOCATIONS 547 
 
 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 continu- 
 ously ; no jolting or jerking action is allowable, or considerable 
 mischief may ensue. Since the introduction of anaesthetics, how- 
 ever, pulleys have been very rarely required, except in dealing 
 with old-standing cases. 
 
 Reduction, however produced, is usually accompanied by a 
 sudden and distinct snap or suction sound, due to the contraction 
 of muscles, unless the patient is deeply under an anaesthetic, and 
 the muscles are absolutely relaxed. The limb is subsequently 
 kept at rest for some days, to allow the rent in the capsule to heal. 
 Cooling lotions are applied to reduce the swelling, and at the end 
 of ten days or a fortnight passive movements commence, together 
 with friction and massage of the soft parts. 
 
 The treatment of unreduced dislocations is often a matter of con- 
 siderable difficulty. Attempts to reduce them may be undertaken 
 up to two or three months, but no undue violence is permissible, 
 owing to the fact that adhesions to neighbouring parts may thereby 
 be ruptured, and the main vessels or nerves endangered. The 
 use of pulleys has been sometimes recommended, but so many 
 accidents have been reported, varying in severity from laceration 
 of the skin to actual avulsion of the limb, that it is better to dis- 
 continue such treatment if it has failed on its first application. 
 
 The amount of mobility possible in 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 painful and limited, operative treatment should 
 be undertaken ; subcutaneous section of muscles and tendons has 
 been practised, but without much success, and the risk, owing to 
 the fact that the peri-articular structures are displaced and dis- 
 torted, is so great as to render such a procedure unadvisable. 
 Two chief methods of operative treatment are applicable : (i.) Re- 
 duction by an open operation. The head of the bone is cut down on, 
 and freed from its adhesions to surrounding structures, the capsule 
 of the joint being also opened, and the cavity cleared; reduction 
 may then be possible by means of manipulation or extension. 
 A few cases of successful treatment of old-standing dislocations 
 of the shoulder by this means have been recorded ; but, as a rule, 
 the gain derived thereby is not commensurate with the risks and 
 difficulties of the operation, especially if a considerable interval 
 has elapsed since the accident, (ii.) Excision of the displaced head 
 of the bone will give the best result in most cases. In the elbow- 
 joint it is often the only practicable treatment, and in the shoulder 
 and hip it is usually better than attempting open reduction. 
 
54 8 
 
 A MANUAL OF SURGERY 
 
 Compound dislocations are almost always serious lesions, for not 
 only is the skin lacerated, and the joint exposed to the risk of 
 septic contamination, but adjacent vessels and nerves are liable 
 to injury. Unless efficient treatment is adopted, suppurative 
 arthritis ensues, leading to disorganization of the articulation with 
 subsequent ankylosis, or, in the case of larger joints, possibly to 
 death from pyaemia and septic poisoning. The treatment consists of 
 the application of the principles of antisepsis already enunciated for 
 the treatment of lacerated wounds, together with reduction of the 
 dislocation. If necessary, the wound in the skin must be enlarged, 
 in order to allow of the replacement of the bone, and, should the 
 latter structure be much bruised or injured, it may be advisable to 
 resect it at once. If, however, vessels and nerves are also injured, 
 or if the patient is old or debilitated, amputation may be required. 
 
 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, 
 laughing, or attempting to take a large bite. It has also been 
 produced in dentistry by a violent strain during tooth-drawing, or 
 
 from digging out roots with 
 an elevator. In some persons 
 the accident happens with the 
 greatest ease, and constantly 
 recurs, owing probably to 
 laxity of the capsule or in- 
 sufficient development of the 
 eminentia articularis. 
 
 The mechanism of the dis- 
 location is as follows : When 
 the mouth is opened, the 
 condyle of the jaw slips for- 
 wards on to the eminentia 
 articularis, and it requires 
 very little force to displace it 
 still further into the zygo- 
 matic fossa (Fig. 193). The inter-articular cartilage sometimes 
 follows the condyle, and the attachment of the external pterygoid 
 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 interval 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 
 
 Fig 193— Dislocation of Jaw. 
 
INJURIES OF JOINTS— DISLOCATIONS 549 
 
 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 inserted into the mouth may be able to 
 make out the coronoid process in an abnormal position beneath 
 the zygoma. 
 
 When the dislocation is unilateral, the symptoms are much less 
 marked. Some amount of movement of the jaw still remains, 
 whilst the chin is displaced towards the sound side. 
 
 Treatment. — The reduction of the bone is in most cases easily 
 effected. 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 guards his thumbs with thick napkins to prevent 
 being bitten, 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 
 few days by means of a four-tailed bandage. 
 
 A few cases are on record of displacement of the condyle of 
 the jaw backwards, associated with fracture of the tympanic plate 
 and tearing or separation of the cartilage of the auricle, leading 
 to bleeding from the ear. Displacement upwards into the cranial 
 cavity through the roof of the glenoid fossa has also been described, 
 the patient in one case dying of meningitis. 
 
 Dislocation of the Sternal End of the Clavicle. — It might be 
 supposed that displacement at this joint would not be uncommon, 
 when the shape and relative sizes of its articular surfaces are con- 
 sidered, together with the great strains to which it is subjected. 
 Owing, however, to the strength of the ligaments surrounding it, 
 particularly of the rhomboid, this is not the case, the clavicle being 
 broken rather than displaced. The cause of such displacements is 
 violence directed to the acromial end of the clavicle. If the force 
 acts from in front, the bone may be thrown forwards ; if from 
 above, downwards and inwards, the upward dislocation may 
 occur ; if the shoulder is driven forwards and inwards, the head 
 of the bone may pass backwards. Three varieties are described 
 according to whether the head of the bone travels fonvards, back- 
 wards, or upwards. 
 
 In the forward dislocation the end of the bone lies on the 
 anterior surface of the manubrium, where it can be easily de- 
 tected ; all the ligaments of the joint are torn, except, perhaps, 
 the interclavicular. The point of the shoulder is approximated 
 to the middle line. Treatment. — Reduction is 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 
 
5 So A MANUAL OF SURGERY 
 
 front of the mid-axillary line. The displacement is very likely to 
 recur, and to prevent this a pad is kept over the end of the bone 
 by a figure-of-8 bandage, whilst the point of the shoulder is 
 pushed outwards by placing a pad in the axilla, and binding the 
 arm to the side. It is advisable to keep the patient in bed for a 
 few days, so as to give the ligaments a better chance of reuniting, 
 but some amount of forward displacement is very likely to 
 persist. No bad result follows, even should the dislocation 
 remain unreduced. 
 
 The backward dislocation is not often met with. The head of 
 the bone lies behind the upper part of the sternum, close to the 
 origin of the sterno-hyoid and sterno-thyroid muscles. All the 
 ligaments are ruptured, including the rhomboid. A depression is 
 felt in the usual position of the head of the bone, which may be 
 sometimes detected lying deeply in the superior mediastinum. 
 The shoulder is thrown forwards, and situated nearer the middle 
 line of the body than usual, whilst the movements of the head 
 and neck are painful and limited. Pressure of the bone upon the 
 trachea, oesophagus, and vessels of the neck gives rise to diffi- 
 culty in breathing and swallowing, whilst the consequent conges- 
 tion of the head may even cause semi-coma. Reduction by exten- 
 sion of the shoulders backwards is usually accomplished without 
 much trouble. In cases of difficulty, a firm pad can be placed in 
 the axilla, and the shoulder levered outwards by using it as a ful- 
 crum, the elbow being pressed to the side. It is retained in position 
 by keeping the shoulders well extended by the use of two hand- 
 kerchiefs, as suggested in the treatment of fractured clavicle. If 
 the condition cannot be reduced, and serious symptoms of pressure 
 result, the head of the bone should be 
 excised. 
 
 The upward dislocation is one of ex- 
 treme rarity. The head of the bone is 
 felt in front of the trachea, in which 
 situation it may compress both windpipe 
 and oesophagus, especially when the 
 patient sits up or leans forwards. To 
 effect reduction, a pad is placed in the 
 axilla, and the arm pressed inwards over 
 it ; the elbow is subsequently bandaged 
 to the side and well elevated. A pad is 
 
 nov3^i ) c I ^ L A . CATI0N at the same time kept over the end of 
 Downwards of Acromiom . • . . . . r . . , , 
 
 from the End of the tne bone, but it is very probable that 
 Clavicle. (Tillmanns.) some amount of displacement will 
 persist. 
 
 Dislocation at the Acromio-clavicular Joint consists in the 
 acromion being forced either above or below the outer end of the 
 clavicle, more commonly the latter. The displacement is easily 
 
INJURIES OF JOINTS— DISLOCATIONS 551 
 
 recognised by the abnormal prominence of one or other of the 
 bones (Fig. 194). It usually results from violence directed to the 
 scapula. No difficulty is experienced in reduction, but the dis- 
 placement is very liable to recur, especially in the more common 
 form. The 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 is then applied over the shoulder and under 
 the elbow, and suffices to maintain the bone in position. It is kept 
 from slipping by passing a bandage under the strap round the 
 opposite side of the chest. Should the displacement persist, and 
 give rise to pain or impair the movements of the arm, the bones 
 may be wired together after removing the cartilaginous surfaces. 
 
 A condition is sometimes met with, described as a Dislocation of 
 the Lower Angle of the Scapula, or, better, Winged Scapula. It is 
 characterized by projection backwards of that part of the bone 
 when the arms are thrust forwards ; and is due rather to paralysis 
 of the serratus magnus and rhomboids than to slipping of the 
 fibres of the latissimus dorsi from the lower angle, as was formerly 
 supposed. In several cases we have noticed pain and tenderness 
 over the roots of the 5th and 6th nerves in the neck, suggesting 
 its dependence on a chronic neuritis of these trunks. A similar 
 condition is sometimes noted in progressive muscular atrophy. 
 The Treatment consists in the administration of strychnine, and 
 the use of massage and of the faradic current, whilst, if per- 
 sistent, a properly applied apparatus may correct the deformity. 
 
 Dislocation of the Shoulder occurs almost as frequently as all 
 the other dislocations 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 of the accident 
 being widely outstretched, to enable the individual if possible to 
 save himself. The weak lower and inner part of the capsule 
 receives the chief portion of the shock, and yields, the head of the 
 bone being primarily displaced downwards into the axilla (sub- 
 glenoid variety), and then, according to the direction of the force, 
 or the character of the subsequent manipulations, the head travels 
 either forwards (subcoracoid or subclavicular dislocation) or back- 
 wards (subspinous). Falls on the elbow or shoulder may, how- 
 ever, cause a direct forward or backward displacement. 
 
 The Signs of a dislocation of the shoulder are sufficiently 
 obvious, and certain characteristic features are met with in almost 
 all varieties. (1) The shoulder looks flattened, owing to displace- 
 ment of the head inwards (Figs. 138, B and 197), and as a result 
 of this the acromion process is unduly prominent, and a hollow felt 
 below it, occupied by the tense deltoid. (2) The head of the bone 
 
552 
 
 A MANUAL OF SURGERY 
 
 lies in some abnormal position, and the glenoid cavity is empty. 
 (3) The elbow is displaced away from the side, and it is im- 
 possible 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 type. (4) The vertical 
 measurement round the axilla is increased in all the varieties (Call- 
 away'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 acromion process and the outer 
 condyle of the elbow in most cases of dislocation (Hamilton'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. 
 
 Fig. 195.— Subglenoid Dislocation Fig. 196.— Subcoracoid Dislocation 
 of Shoulder. (Tillmanns.) of Shoulder. (Tillmanns.) 
 
 Subglenoid Dislocation (Fig. 195) is the primary condition met 
 with in all cases where the accident is due to a fall upon the out- 
 stretched arm, but is not commonly seen, since the head of the 
 bone usually slips up under the coracoid, as before stated. The 
 head of the bone passes downwards into the axilla, resting 
 against the outer border of the scapula below the glenoid cavity, 
 between the subscapularis above and the teres minor below, 
 whilst the long head of the triceps is placed behind. The capsular 
 ligament and muscles passing to the tuberosities are lacerated, 
 whilst the axillary vessels and nerves may be seriously com- 
 pressed. The head of the bone is detected 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 1 inch, whilst the forearm 
 is usually flexed, and the fingers may be numbed from pressure 
 on the nerves. 
 
INJURIES OF JOINTS— DISLOCATIONS 
 
 553 
 
 A few cases have been recorded in which the arm was abducted 
 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. 196 and 197) is, without doubt, 
 the most common form. In it 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 anato- 
 mical neck impinging en its anterior border. In this position it 
 
 Fig. 197. — Subcoracoid Dislocation of the Right Shoulder. 
 
 is above the tendon of the subscapularis, which is either torn or 
 stretched over the neck as a tense band, and may considerably 
 impede reduction. Two forms of this displacement are described 
 by Malgaigne, according to whether the muscles attached to the 
 great tuberosity are intact, resulting in marked external rotation 
 of the limb (subcoracoid variety), or whether they are lacerated, 
 or even the great tuberosity itself pulled off, the humerus being 
 then rotated inwards (intracoracoid variety). In both types the 
 elbow is displaced backwards and outwards, and the head of the 
 bone can be usually felt with ease, especially on rotation of the 
 arm, under the outer third of the clavicle, except in stout people 
 
554 
 
 A MANUAL OF SURGERY 
 
 or where the muscles are greatly developed. Comparatively little 
 alteration in the length of the arm is produced. 
 
 The Subclavicular variety is very uncommon, and merely an 
 exaggeration of the subcoracoid. The head of the humerus 
 passes further inwards, and lies deeply under the pectoralis major, 
 on the second and third ribs. The capsule and surrounding 
 muscles are much lacerated, or perhaps the great tuberosity torn 
 off; the elbow is markedly separated from the side and directed 
 a little backwards, whilst distinct shortening is present. 
 
 The Subspinous Dislocation (Fig. 198) is not frequently met 
 with. The head of the bone lies in the infraspinous fossa, im- 
 mediately behind the glenoid cavity, between the infraspinatus 
 and teres minor muscles, the subscapularis being usually torn. 
 Malgaigne states the head of the humerus is most commonly 
 found resting on the posterior edge of the glenoid cavity im- 
 mediately below the acromion process 
 (subacromial variety). The elbow is dis- 
 placed considerably forwards, but can 
 be made to touch the chest wall ; the 
 arm is rotated inwards, so that the hand 
 is thrown across the front of the body. 
 There is usually a marked hollow be- 
 neath the coracoid process, whilst a 
 distinct prominence is caused by the 
 head of the bone in its false position. 
 The length of the limb is frequently 
 unaffected, or if any change is present, 
 the arm is slightly lengthened. 
 
 Three or four cases have been de- 
 scribed of what is known as a Supra- 
 coracoid Dislocation. The head of the 
 bone is here displaced upwards, and 
 either the coracoid or acromion process is broken, more commonly 
 the former. Replacement with crepitus is easily obtained, but 
 the dislocation is liable to recur. 
 
 The Treatment of Dislocation of the Shoulder consists in reduc- 
 tion by manipulation or extension. 
 
 1. For reduction by manipulation an anaesthetic is advisable, though 
 not absolutely essential, and preferably chloroform, although 
 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 pre- 
 paration of the patient. The greatest care must therefore be 
 exercised in giving the anaesthetic. 
 
 Many different methods of manipulation have been suggested, 
 
 Fig. iq». — Subspinous Dis- 
 location of Shoulder. 
 (Tillmanns.) 
 
INJURIES OF JOINTS—DISLOCATIONS 555 
 
 of which the following are the more important. Not unfrequently, 
 when the muscles are relaxed, any slight rotary movement suffices 
 to ' put the bone in.' 
 
 Kocher's Method. — The surgeon standing in front of his patient, 
 who is seated or reclining, and supported by an assistant, grasps 
 the elbow r after flexion of the forearm, and presses it to the side. 
 The arm is now rotated firmly and steadily outwards until the 
 forearm is at right angles to the body, when distinct resistance 
 will be felt. This causes the head of the humerus to roll out 
 beneath the acromion, and is often sufficient to effect reduction ; 
 but if the limb is still displaced, the arm should be drawn forwards 
 to the median line and elevated almost to a right angle with the 
 trunk, with the hand still abducted and everted, whilst finally the 
 arm is rotated inwards so as to carry the hand towards the 
 opposite shoulder, and the elbow lowered. This plan is most 
 useful in subcoracoid dislocations, and its value, 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 outw r ards 
 relaxes this structure and removes it from the fossa, whilst the 
 rent in the capsule gapes, but owing to the fact that the upper 
 and lower margins of the opening are still tight, the head of the 
 humerus remains fixed against the neck of the scapula until the 
 elbow is carried forwards and raised. The upper part of the 
 capsule then relaxes, and the lower part which remains tense 
 guides the head of the bone into the joint. 
 
 Smith's Method varies somewhat in its application, according to 
 whether the head of the bone is displaced anteriorly or 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 circumducted inwards, the thumb following the head 
 of the bone and assisting it to reach the lower and under side of 
 the capsule, and thus enter the socket through the rent. For the 
 subspinous dislocation, the surgeon stands behind the patient and 
 grasps the shoulder with one hand, raising the arm with the 
 other, and making extension backwards combined with external 
 rotation ; i.e., the limb is circumducted outwards, and finally 
 brought to the side. 
 
 2. Extension may be made in different ways, the object of all, 
 however, being to overcome the tension of surrounding ligaments 
 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 
 
550 
 
 A MANUAL OF SURGERY 
 
 lying flat on a mattress placed on the ground, and the surgeon 
 sitting by the side. Another plan consists in using the knee as a 
 fulcrum instead of the heel, the patient sitting in a chair. Occa- 
 sionally the foot has been placed against the thoracic wall, and 
 extension made directly outwards at right angles to the body, as 
 recommended by Sir Astley Cooper. White, of Manchester, 
 suggested vertical traction, the arm being pulled directly upwards, 
 the surgeon's foot having been placed over the acromion, the 
 patient being in the recumbent posture. The only objection to 
 this last method, which may succeed when other plans fail, is 
 that the axillary vessels are somewhat exposed to injury. 
 
 Dislocations of the Elbow- Joint are not very uncommon, occur- 
 ring particularly in young people, and are due to either 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. 456), 
 and of the degree of mobility of the 
 different parts on each other, is essen- 
 tial in order to arrive at a definite 
 conclusion as to the exact nature of 
 the lesion. In cases of doubt, a skia- 
 gram should be taken. 
 
 1. Dislocation of Both Bones may 
 occur either backwards, forwards, or 
 laterally. 
 
 The backward variety (Fig. 142 A) 
 is that most often met with ; it usually 
 occurs without either the coronoid 
 process or the olecranon being frac- 
 £H \ tured, although occasionally the former. 
 
 Il\ I is detached. If the coronoid remains 
 
 intact, it sometimes becomes locked 
 in the olecranon fossa, and renders 
 the arm immobile ; if, however, it is 
 broken, considerable mobility of both 
 Fig. 199.— Reduction of Back- bones occurs, with crepitus. The fore- 
 ward Dislocations at the arm ; s sem i.flexed, the hand held mid- 
 way between pronation and supination, 
 and the displaced bones form a con- 
 siderable swelling at the back of 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, 
 
 Elbow. 
 
INJURIES OF JOINTS— DISLOCATIONS 557 
 
 and the distance between the condyles and the olecranon process 
 is increased. 
 
 Dislocation forwards of both bones rarely occurs without fracture 
 of the olecranon process, although a few cases of this unusual 
 accident are on record. The displacement is readily detected, the 
 forearm being 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 considerably 
 lacerated. 
 
 Lateral dislocations of the forearm are almost always incom- 
 plete and are not very frequent ; the bones may be displaced either 
 inwards or outwards, the latter being the more common. They 
 are recognised by a careful examination of the relative position 
 of the bony prominences. 
 
 2. Dislocation of the Ulna alone occurs only in a backward 
 direction. It is an occurrence of the greatest rarity, owing to 
 the position and strength of the orbicular and oblique ligaments 
 and of the interosseous membrane. If, however, the bones of 
 the forearm are rotated backwards upon the head of the radius as 
 a fulcrum, and then the forearm 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 neces- 
 sary 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 ac- 
 complished by the method de- 
 scribed by Sir Astley Cooper. 
 The patient being in a sitting 
 position, the surgeon presses back- 
 wards, with his knee in the bend 
 of the elbow, against the lower 
 end of the humerus; at the same 
 time he grasps the patient's wrist, 
 and slowly and forcibly bends the 
 forearm (Fig. 199). 
 
 3. Dislocations of the Radius 
 alone may occur either forwards, Fig. 200.— Dislocation of the 
 backwards, or outwards. Radius Forwards. (Pick.) 
 
 The forward dislocation 
 (Fig. 200) is that usually seen, and results from falls on the hand 
 when the forearm is in a state of extreme pronation. The head 
 of the radius rests against the lower end of the humerus in the 
 hollow above the capitellum, and the most characteristic feature 
 consists in the inability of the patient to flex his forearm, owing 
 to the bone impinging against the lower end of the humerus. It 
 can be readily detected in this situation, rotating with the move- 
 
558 
 
 A MANUAL OF SURGERY 
 
 ments of the forearm, whilst a deep hollow is felt behind, imme- 
 diately below the external condyle. The forearm is somewhat 
 flexed, and midway between pronation and supination ; the former 
 act can be satisfactorily accomplished, but supination 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 produced by direct violence (Plate XXVII.). If 
 this luxation is not reduced, very great impairment of the mobility 
 of the limb results, flexion beyond an obtuse angle becoming 
 impossible. Treatment. — Reduction is accomplished by traction 
 from the wrist, with the forearm flexed to a right angle, combined 
 with pressure over the head of the bone. Owing to the fact that 
 the orbicular ligament is ruptured, the deformity is very likely 
 to recur, and hence active movements of the limb must be inter- 
 dicted for three or four weeks ; a pad is placed anteriorly over the 
 head of the bone, and the limb flexed on a splint. 
 
 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 (Fig. 201). The forearm is 
 flexed, and the limb pronated. 
 Even if left unreduced, it leads to 
 but little inconvenience. 
 
 Dislocation outwards is also 
 rare, the head of the bone being- 
 displaced to the outer side of 
 the external condyle, where it 
 can easily be felt, causing con- 
 siderable impairment of the 
 natural movements. Reduction 
 is accomplished without diffi- 
 culty. 
 
 Occasionally a rare form of 
 dislocation is met with in which the ulna passes backwards and 
 the radius forwards, resulting in great deformity. 
 
 A very common accident in children consists of a subluxa- 
 tion of the head of the radius downwards within the orbicular 
 ligament, so that a portion of it slips up and becomes nipped 
 between the head and capitellum. It results from forcible traction 
 of the hand, and is a common nursery accident, popularly known 
 as pulled elbow. The limb becomes fixed in a position of semi- 
 flexion, and the child cries out with the pain; it is readily treated 
 by completely flexing the iimb, and subsequently extending it, 
 and leaves no bad results. 
 
 lit must not be forgotten that we have here merely described 
 the pure dislocations. In actual practice complications of a serious 
 
 Fig. 201. — Dislocation of the 
 Radius Backwards. (Diagram- 
 matic.) 
 
PLATE XXtfll. 
 
 Dislocation of Radius forwards, and Fracture of Upper Third of Ulna. 
 
 To face /. 558.] 
 
INJURIES OF JOINTS— DISLOCATIONS 559 
 
 nature are frequently present in the shape of fracture of one or 
 both condyles, which lead to much difficulty in diagnosis. These 
 fracture-dislocations give rise to so much haemorrhage that it 
 is frequently impossible to come to a correct conclusion as to 
 the nature of the case without the assistance of the Rontgen rays. 
 It is doubtful, however, whether even an accurate knowlege of 
 the nature and extent of the lesion will enable us to improve on 
 the results hitherto gained, apart from operation. So much callus 
 is formed, and fibrous adhesions of such strength are developed, 
 that considerable impairment of function is almost certain to 
 ensue. Probably the best line of practice is to keep the elbow at 
 rest on a rectangular splint for a few days, so as to allow the 
 immediate effects of the accident to pass off, and then to make an 
 aseptic incision, dealing with the condition of affairs in the way 
 best suited to the requirements of the particular case. 
 
 Dislocation of the Wrist is a very uncommon accident, and may 
 occur forivards or backwards. The lower ends of the radius and 
 ulna become prominent under the skin, and especially the styloid 
 processes. By this means it is easily distinguished from a fracture 
 of the lower ends of the bones. 
 
 Occasionally the radius, carrying with it the hand, is dislocated 
 from the lower end of the ulna, as a result of forcible pronation. 
 This is usually described as a backivavd dislocation of the ulna, and 
 is easily reduced by manipulation. 
 
 Dislocations of various Carpal Bones have been described, but 
 the only one which is at all common is a displacement of the os 
 magnum backwards. It forms a rounded prominence under the 
 skin in the usual situation of the bone, which becomes more 
 prominent on flexion, and may disappear on extension. As a rule, 
 it is readily reduced, but is very likely to recur. 
 
 Dislocations of the Metacarpal Bones and Phalanges are not 
 
 unfrequent, but need no special mention, except in the case of 
 Dislocation Backwards of the First Phalanx of the Thumb. The 
 chief interest in this case lies in the difficulty experienced in re- 
 duction, which was erroneously attributed to the head slipping 
 between the two portions of the flexor brevis pollicis and being 
 grasped by them, as a button in a buttonhole. It has now been 
 shown that there are two much more important factors, viz., the 
 tension of the long flexor tendon, which hitches round the neck 
 (Fig. 202), and the arrangement of the glenoid ligament. This 
 structure passes between the two heads of insertion of the 
 short flexor, and is thus incorporated between the two sesa- 
 moid bones ; it consists of fibro-cartilage, and, whilst firmly 
 attached to the base of the phalanx, is but loosely connected with 
 the head of the metacarpal bone, so that it accompanies the 
 phalanx in its dislocation. It thus comes to be situated imme- 
 
560 
 
 A MANUAL OF SURGERY 
 
 diately behind the head of the metacarpal, and opposes any 
 attempts at reduction. Treatment. — -Traction and manipulation 
 are always attempted in the first instance. The thumb is grasped 
 by a suitable apparatus and hyper-extended to a right angle, thus 
 making the head of the metacarpal project still further through 
 the muscular interspace, and, as it were, 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 will, a purified tenotome should be 
 
 inserted in the middle line 
 of the thumb behind, im- 
 mediately above the base of 
 the phalanx, and should be 
 pushed on till it reaches and 
 divides the glenoid fibro- 
 cartilage between the sesa- 
 moid bones ; this little 
 manoeuvre will at once 
 render replacement simple. 
 
 Dislocation of the Hip, 
 
 though not very common, 
 is a condition of extreme 
 gravity. The depth of the 
 socket in which the femur 
 rests, and the strength of 
 the muscles and ligaments 
 surrounding the articulation, 
 explain the comparative in- 
 Fig. 202. -Dislocation of Thumb, f req uency of the accident. 
 showing Head of the Metacarpal t h . j , , , 
 
 Bone protruding Forwards between ^ 1S never produced by 
 the Heads of the Short Flexor direct violence, but always 
 Muscle. (Pick.) results from a force applied 
 
 to the feet or knees, or, if 
 the legs be fixed, to the back. It is rarely met with except in 
 young people or adults, since after the age of forty-five fractures 
 of the neck of the bone are much more likely to occur. 
 
 In considering these dislocations, the relative strength or weak- 
 ness of the different parts of the capsule and its surrounding 
 structures must be remembered. Thus, the weakest part of the 
 capsule is placed below and behind, and the fibres here are easily 
 lacerated : indeed, it is through a rent in this part of the capsule 
 that the b^ad of the bone most frequently escapes. In front, the 
 ilio-femoral or Y-shaped ligament of Bigelow, extending from the 
 anterior inferior iliac spine to the anterior intertrochanteric line, 
 is a structure of much strength, on the integrity of which depends 
 the fact whether the displaced head of the bone shall occupy some 
 definite position or be freely moveable. Bigelow, to whom we 
 
INJURIES OF JOINTS— DISLOCATIONS 561 
 
 owe so much in the elucidation of the mechanism of these dis- 
 locations, has divided them into two classes — the regular and the 
 irregular — according to whether this ligament is intact or com- 
 pletely 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 depends in some measure on 
 whether it remains intact or is ruptured. It must also be remem- 
 bered that the ligamentum teres is relaxed when the thigh is 
 forcibly abducted, and is made tense by adduction. 
 
 Four chief varieties of dislocation are described, in two of 
 which the head of the bone is displaced posteriorly, and in two 
 anteriorly. The two former are known as the Dorsal and the 
 Sciatic varieties, although Dorsal below the tendon, as originally 
 suggested by Sir Astley Cooper, is the better appellation for the 
 latter variety. The two anterior dislocations are known as the 
 Obturator or Thyroid, and the Pubic; in the former the head 
 of the bone is located in the obturator notch, and in the latter 
 upon the pubic ramus. The relative frequency of these disloca- 
 tions is as follows : About 50 to 55 per cent, of the cases are 
 of the dorsal type, 20 to 25 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 have been described, 
 which it will be unnecessary to further particularize. 
 
 Mechanism. — Some surgeons strongly maintain the opinion 
 that the limb is always in a position of abduction at the moment 
 of dislocation, the head of the bone escaping from the capsule 
 through a rent in the lower and back part of the ligament, and 
 thus being primarily displaced downwards. The type of accident 
 responsible for this is 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 is to be subsequently produced. If the 
 limb is externally rotated and extended, 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 back- 
 wards, 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 ; but if the tendon is ruptured, 
 or if the head of the bone slips in front of it, there is no obstacle 
 to its upward displacement on the dorsum ilii. 
 
 Bigelow, however, and with him many other surgeons, main- 
 tain that dislocation of the hip does not only occur with the limb 
 in a position of abduction. Under certain circumstances, it may 
 
 36 
 
562 
 
 A MANUAL OF SURGERY 
 
 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 obturator internus ; such 
 an accident is sometimes, but not always, associated with fracture 
 of the posterior lip of the acetabulum. The type of violence 
 leading to this occurrence is when a heavy weight falls on the 
 back of a person whilst kneeling, or when, his knee being fixed, 
 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 displaced below 
 the tendon of the obturator internus, 
 and the sciatic variety will then result. 
 
 i. Dorsal Dislocation (Fig. 203). — 
 The head of the bone in this form is 
 found lying on the dorsum ilii, a variable 
 distance above and behind the aceta- 
 bulum, and always above the obturator 
 internus tendon. It may be detected on 
 manipulation of the limb, although in 
 muscular subjects 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 abduc- 
 tion or adduction. The small external 
 rotator muscles are usually lacerated, 
 and perhaps even the glutei and the 
 pectineus. The ilio-femoral ligament 
 usually remains intact. The great 
 sciatic nerve is sometimes compressed 
 or contused. The trochanter is raised 
 above Nelaton's line (p. 473), and ap- 
 proximated to the anterior superior 
 spine ; the ilio-tibial band of fascia is 
 therefore relaxed, and there is consider- 
 able shortening of the limb, amounting 
 often to 2 or 3 inches. The leg is in a 
 position of flexion, adduction, and in- 
 version, so that the axis of the femur crosses the lower third of 
 the sound thigh. The knee is semi-flexed, and the ball of the 
 great toe rests against the opposite instep ; the heel is somewhat 
 raised. A marked hollow is felt in the upper part of Scarpa's 
 triangle, and the main vessels of the limb appear to be unsup- 
 ported. 
 
 The Diagnosis should be easy, the only difficulty being experi- 
 enced in distinguishing it from an impacted extra-capsular 
 
 Fig. 203. — Dorsal Dislo 
 
 CATION OF THE HlP 
 fTlLLMANNS.) 
 
INJURIES OF JOINTS— DISLOCATIONS 
 
 563 
 
 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 flexion in the adducted position. The lesions of muscles 
 and ligaments are practically 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 1 inch ; 
 the limb is flexed, adducted, 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 thick- 
 ness of the glutei muscles at that 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 mani- 
 pulation and rotation, so accurately worked 
 out by Bigelow. The patient is anaesthe- 
 tized, preferably on a mattress placed on 
 the floor. The leg is first flexed on the 
 thigh, and the thigh on the abdomen, the 
 position of adduction being still maintained, 
 so that the knee extends beyond the middle 
 line of the body (Fig. 204). 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 other. By 
 this manoeuvre the tense structures in front 
 of the joint are relaxed, and then the head 
 of the bone is made to retrace its course 
 towards the rent in the capsule, and finally 
 directed upwards into the acetabular cavity. 
 These movements are tersely summarized in Bigelow's words — 
 1 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 
 
 36—2 
 
 Fig. 204. — Reduction of 
 Dorsal Dislocation 
 of Hip. (Bryant.) 
 
564 
 
 A MANUAL OF SURGERY 
 
 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 acetabulum. If this is unsuccessful, the move- 
 ments described above can be energetically repeated in this posi- 
 tion. 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 jack-towel passed between the injured thigh and 
 
 Fig. 205.— Dislocation of the Hip: 
 Obturator Variety. (Tillmanns.) 
 
 Fig. 206. — Dislocation of the 
 Hip Forwards: Pubic Variety. 
 (Tillmanns ) 
 
 the perineum, and fixed to a staple in the floor, close to the head 
 of the patient, and on the side of the dislocation. When sufficient 
 force has been applied, the surgeon rotates the limb outwards so 
 as to allow the head of the bone to once more slip into its socket. 
 3. Thyroid or Obturator Dislocation (Fig. 205). — 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 
 
INJURIES OF JOINTS— DISLOCATIONS 
 
 565 
 
 ligamentum teres is, of course, ruptured. The head lies 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 by a depression. The limb 
 is slightly abducted and everted, as well as lengthened, perhaps 
 to the extent of 2 inches, though this is more apparent than real. 
 It is also flexed, owing to the tension of the ilio-psoas muscle, and 
 advanced before the other, with the toes pointing outwards. The 
 adductor longus tendon stands out prominently, and much pain 
 may be experienced from pressure on the obturator nerve. If the 
 patient stands, the body is bent forwards, whilst it is interesting 
 to note that if the dislocation remains unreduced the patient may 
 be able to walk without much pain or inconvenience, though in a 
 more or less stooping position. 
 
 4. Pubic Dislocation (Fig. 206). — In this variety the head of 
 the bone lies on the horizontal ramus of the pubes, just internal 
 to the anterior inferior spinous process 
 of the ilium, where it can be felt roll- 
 ing 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-femoral 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. The iimb is shortened to 
 the extent of 1 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 anaesthetized ; the knee is flexed, as also the thigh upon the 
 abdomen, but in a position of abduction ; circumduction inwards 
 follows (Fig. 207), and on extension 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 abducted position, the unbooted foot 
 being placed against the pelvis to steady it. 
 
 If extension by pulleys is required in the thyroid dislocation, 
 it is made transversely outwards across the upper part of the thigh, 
 counter-extension being obtained by means of a band passed round 
 
 Fig. 207. — -Reduction of An- 
 terior Dislocations of 
 the hip. (Bryant.) 
 
5 66 A MANUAL OF SURGERY 
 
 the abdomen. The limb, at first in a position of abduction, is 
 subsequently adducted forcibly by drawing the ankle inwards, the 
 band by means of which extension is being made acting as a 
 fulcrum to lever the head of the bone into the acetabulum. In 
 the pubic variety traction is made downwards, outwards, and 
 backwards, and the head of the bone drawn into its socket by a 
 towel passed transversely across the limb. 
 
 After reduction of any form of dislocation of the hip, the patient 
 should be kept in bed with the legs tied together for about a 
 fortnight, and then passive movement may be commenced, but 
 with considerable caution ; voluntary movements should not be 
 undertaken for another week or two. 
 
 Should the dislocation recur, it may be due to fracture of the 
 posterior lip of the acetabulum, or to some involuntary move- 
 ments of the patient, or perhaps to the fact that the displacement 
 has not been fully reduced. Under such circumstances further 
 attempts at replacement should be undertaken, and the limb sub- 
 sequently kept immobilized for a longer period than usual. 
 
 Irregular dislocations of the hip occur when the Y-shaped 
 ligament is completely torn through, so that the head of the bone 
 is not restricted, but can be moved round the acetabular cavity. 
 Reduction is usually easy. 
 
 Dislocation of the Patella may occur outwards, inwards, 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 
 complete 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 intercondyloid 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 distinguishable in the posi- 
 tion usually occupied by the patella. It is not unfrequently, 
 however, incomplete, and then the inner half of the articular 
 surface of the patella lies in contact with the cartilaginous surface 
 of the outer condyle, with its outer border projecting forwards. 
 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 
 
INJURIES OF JOINTS— DISLOCATIONS 567 
 
 bone is lodged 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 Kotation of the patella, is 
 an interesting condition in which the bone is said to be twisted 
 vertically upon its own axis, and even to have been turned com- 
 pletely round. Incomplete rotation is practically identical with 
 that just described as an incomplete lateral dislocation, whilst the 
 complete rotation of the patella must indeed be a rare accident. 
 
 Dislocations of the Knee may occur laterally, as also forwards or 
 backwards. When due to disease of the joint, the backward dis- 
 location is commonest ; but when arising from traumatic causes, 
 the lateral is the most frequent. 
 
 The lateral displacements are rarely complete, and are usually 
 associated with a certain amount of rotation ; the leg is partially 
 flexed. Reduction is effected without difficulty. 
 
 Dislocation of the tibia forwards is more common than dis- 
 placement backwards. It is frequently complete, the lower end 
 of the femur projecting into the popliteal space, and compressing 
 the vessels. 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 considerable shortening of the 
 limb if the articular surfaces overlap. 
 
 Dislocation of the tibia backwards is a much rarer accident, and 
 is more often incomplete than the former. The signs are exceed- 
 ingly characteristic, the pressure effects upon the popliteal vessels 
 and nerves being less pronounced. 
 
 Reduction of either of these conditions is easily accomplished 
 by traction on the limb, whilst the thigh is flexed, combined with 
 manipulation in order to guide the head of the tibia into its 
 normal position. The limb must subsequently be kept at rest 
 in splints for two or three weeks. 
 
 Displacement of a Semilunar Cartilage (Syn. : Subluxation of the 
 Knee, Internal Derangement of the Knee-joint) is a condition fre- 
 quently met with, resulting from sprains and strains of the joint. 
 In any rotary movement of the knee, which, however, can only be 
 undertaken when the limb is flexed, the pressure of the condyles 
 always tends to modify the position of the cartilages ; moreover, 
 with the limb in a state of flexion, they are relaxed and more 
 freely moveable on the upper surface of the tibia than in exten- 
 sion. Any sudden strain or wrench, e.g., turning quickly round in 
 such games as tennis, or slipping off the kerbstone with the knee 
 bent, may lead to this accident. The internal cartilage is much 
 more frequently affected than the external, and the character and 
 
5 6S A MANUAL OF SURGERY 
 
 extent of the lesion varies much in different cases. Not unfre- 
 quently its anterior tibial attachment is torn through, thereby per- 
 mitting considerable lateral mobility. Its peripheral connections 
 with the capsule and internal lateral ligament may also be ruptured, 
 whilst sometimes a portion is more or less detached from its free 
 border, and in other cases the cartilage has been broken across a 
 little behind its centre. It is obvious that when once its connec- 
 tions have been loosened it can be displaced readily, and may pass 
 into the intercondyloid notch, or may slip out from between the 
 tibia and femur, or may even be doubled over. After displacement 
 it becomes inflamed and swollen, and unless properly treated 
 this will be likely to predispose to a renewal of the displace- 
 ment. 
 
 The Symptoms produced by this accident are a sudden sicken- 
 ing pain of much severity, located in the knee, which becomes 
 partially locked in a position of flexion, with inability to extend. 
 The patient may be able to ' wriggle ' his joint free, or the limb 
 may remain stiff for some hours, or even a day or two, when 
 movement suddenly returns more or less spontaneously, a snap 
 being at the same time felt within the joint. An attack of sub- 
 acute synovitis usually follows. In other cases the cartilage 
 remains out of place, until reduced by the surgeon, with or with- 
 out an anaesthetic. If the case is not carefully treated, the dis- 
 placement is liable to recur, the cartilage constantly slipping in 
 and out, and getting nipped between the bones ; as time goes on, 
 this becomes more and more easy, owing to the ligaments of the 
 joint being relaxed from the recurrent attacks of synovitis. In 
 fact, the limb may pass into such a state of chronic weakness as 
 to seriously interfere with the patient's comfort. No physical 
 changes can as a rule be detected between the attacks, but there 
 is usually a spot of localized pain in the front of the joint, cor- 
 responding to the upper surface of the tibia ; possibly there may 
 be some amount of lateral mobility of the leg, and movement of 
 the cartilage may ba detected on flexing and extending the knee. 
 
 The Treatment in the early stages consists in replacement of 
 the cartilage by manipulation. The limb is fully flexed and then 
 suddenly extended, pressure being applied at the same time in the 
 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 in- 
 flammation has subsided ; it is then further immobilized for some 
 weeks in plaster of Paris or water-glass, so as to allow the 
 lacerated ligaments to reunite and consolidate. At the expiration 
 of six or eight weeks after the accident an elastic knee-cap is 
 applied, and the patient again allowed to move the joint. 
 
 When the cartilage has become loose and is constantly slipping 
 out of place, immobilization of the limb, with pressure over the 
 painful spot by an elastic knee-clip, as recommended by Mr. 
 
INJURIES OF JOINTS— DISLOCATIONS 569 
 
 Howard Marsh, may be useful. Should this not prove satis- 
 factory, operative proceedings must be undertaken. 
 
 The knee-joint is opened by an incision on the appropriate side 
 of the patella, more or less transverse in direction, and the con- 
 dition of the cartilage ascertained. If of normal shape and merely 
 loose and moveable, it may be readily stitched to the periosteum 
 over the head of the tibia, so as to keep it from again slipping 
 between the bones ; this is perhaps best accomplished by splitting 
 the cartilage diagonally into two portions, and securing each of 
 these by two or three catgut stitches. If, however, it is doubled 
 on itself, or deformed, or if fixation seems impracticable, it may 
 be removed ; it is astonishing how well patients get on after such 
 an operation. The greatest care must be taken to maintain 
 asepsis, and no strong or irritating antiseptic should be allowed 
 access to the joint cavity, which is closed by a series of buried 
 sutures, dealing in order with the synovial membrane, the capsule, 
 the superjacent tendinous tissues, and, finally, the skin. It is 
 advisable to drain the joint for twenty-four hours, and, as an 
 additional precaution against infection, it may be well to immunize 
 the patient by preparatory injections of antistreptococcic serum. 
 
 Dislocations of the Ankle-joint may occur in the following 
 directions : outwards, inwards, backwards, forivards, and upwards, this 
 being the order of their frequency. Owing to the fact that the 
 astragalus is wedged like a block 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. 489). 
 
 Although the upper articular surface of the astragalus is broader 
 in front than behind, dislocation of the foot backwards is a more 
 common 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 lower end of the tibia usually rests upon the 
 neck of the astragalus, the scaphoid, or even the cuneiform bones. 
 
 Dislocation forwards is very uncommon, and may occur with- 
 out any associated fracture of the bones of the leg. The foot is 
 apparently 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 is lost, and the 
 normal depression in front of the latter structure is occupied by 
 the lower ends of the bones of the leg. 
 
 The treatment of antero-posterior dislocations consists in reduc- 
 tion by traction. The leg is flexed upon the thigh, so as to relax 
 the tendo Achdlis, or, if necessary, this structure is divided. The 
 
57c 
 
 A MANUAL OF SURGERY 
 
 ankle is commanded by a pair of Cline's side-splints, care being 
 taken to ascertain that the foot is at right angles to the leg, and 
 that the articular surfaces of the astragalus and tibia are exactly 
 in apposition, thus preventing any displacement of the heel back- 
 wards or forwards. A Roughton's splint — i.e., an external splint 
 with a sole-piece — is sometimes useful. 
 
 A dislocation upwards has been described in which the astra- 
 galus, together with the foot, is carried up between the tibia and 
 fibula. To allow of such, the inferior tibio-fibular ligament and 
 the lower end of the interosseous ligament must have been 
 ruptured. Impracticable as such an accident appears, competent 
 
 Fig 20S. — Dislocation of the Astragalus Forwards. 
 
 observers maintain that they have met with it. The displacement 
 js very marked, and the character of the lesion very evident. 
 
 Dislocations of the Astragalus alone are by no means common, 
 although their distinguishing features are well recognised. They 
 consist in a partial or complete detachment of the bone from all 
 its normal connections, both to the bones of the leg and of the 
 foot, and its displacement from under the tibio-fibular arch. It 
 may travel backwards or forwards with or without lateral rotation. 
 
 Dislocation forwards (Fig. 208) is much the more common 
 variety, although it is usually associated with partial rotation, the 
 displacement occurring more frequently outwards than inwards. 
 When complete, the bone is entirely detached from its connec- 
 tions with the os calcis, scaphoid, and bones of the leg, and lies 
 upon the upper surface of the scaphoid and cuneiform bones, the 
 
INJURIES OF JOINTS—DISLOCATIONS 571 
 
 skin of the dorsum of the foot being tightly stretched over it, or 
 even torn. The limb is shortened, and the malleoli are approxi- 
 mated to the sole, the lower end of the tibia resting on the upper 
 surface of the os calcis. 
 
 In the incomplete variety, the head of the astragalus 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 malleoli. 
 
 Treatment. — Reduction is only possible in the incomplete forms 
 of dislocation. The patient is anaesthetized, the knee flexed to 
 relax the muscles or the tendo Achillis divided, and traction upon 
 the foot established, so as to enable the surgeon to apply direct 
 pressure upon the displaced bone in a suitable direction. In the 
 complete variety reduction is impracticable, owing to the fact that 
 the os calcis is drawn up into contact with the malleolar arch. 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 displace- 
 ment of all the bones of the foot from below the astragalus, which 
 retains its normal position between the malleoli. The interosseous 
 and other ligaments passing from the malleoli and astragalus to 
 the other tarsal bones are necessarily ruptured. The cause of 
 this, as of other dislocations in the neighbourhood, is some violent 
 strain or wrench of the foot. 
 
 Displacement of the foot may occur either forwards or back- 
 wards, 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 downwards. The head 
 of the astragalus is very evident, forming a rounded globular 
 swelling under the tense skin. In a compound dislocation of this 
 nature which we recently 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 had become 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 
 
572 A MANUAL OF SURGERY 
 
 malleolus is lost in a deep depression caused by the lateral dis- 
 placement 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 the outer 
 buried, a position of talipes equino-valgus being thus assumed. 
 In both forms the tendo Achillis is curved, with its concavity 
 towards the displacement. Treatment consists in reduction by 
 manipulation, which is sometimes readily accomplished, but may 
 be a matter of the greatest difficulty, probably from the tibial 
 tendons becoming bitched around the neck of the astragalus. 
 Section of the tendo Achillis is occasionally needed. 
 
CHAPTER XX. 
 
 DISEASES OF JOINTS. 
 
 Acute Synovitis. 
 
 By Synovitis is meant an inflammation limited almost entirely to 
 the synovial membrane, the ligaments and other structures of the 
 joint being usually but little affected. 
 
 The Causes are local and general. Local conditions include 
 cold and injury ; general or constitutional comprise rheumatism, 
 gout, syphilis, pyaemia, and gonorrhoea. 
 
 Pathological Anatomy. — Acute synovitis results in hyperaemiaof 
 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 spontaneously coagulable ; after a time the plasma 
 may coagulate, depositing lymph upon the articular surface whilst 
 serum remains. The lymph thus deposited may either be removed 
 by a natural process of absorption when the inflammation comes 
 to an end, or it may organize, so as to form adhesions. In the 
 later stages the synovial membrane becomes somewhat thickened, 
 and the ligaments possibly a little infiltrated and relaxed. 
 
 The Clinical Signs of acute synovitis consist in the joint be- 
 coming painful and distended, whilst if the articulation is super- 
 ficial, as in the knee, a sense of heat may be imparted to the hand, 
 and the surface may even be red and hyperaemic. The limb is 
 maintained by muscular spasm in that position which gives the 
 most ease, viz., that in which its capacity is the greatest, and this 
 is usually one of slight flexion, but if the condition is neglected, 
 the flexion may increase considerably, the muscles undergoing 
 tonic contraction, and the limb remaining more or less fixed in an 
 undesirable position. The muscles governing the movements of 
 the joint occasionally undergo rapid atrophy, probably resulting 
 from a reflex disturbance of their trophic centres in the cord. 
 
574 A MANUAL OF SURGERY 
 
 Evidence of Effusion into Various Joints. — Shoulder : The curva- 
 ture of the shoulder is increased, and the deltoid expanded by a 
 fluid swelling beneath it, which is especially noticeable at its 
 anterior border along the bicipital groove, and sometimes pos- 
 teriorly ; in the axilla a painful intumescence may also be felt. 
 These symptoms may be somewhat simulated by inflammation 
 of the 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 by the fact that, although when the patient voluntarily moves 
 his arm pain is produced, yet when the surgeon gently manipu- 
 lates it, so as to press the head of the bone against the glenoid 
 cavity, there may be none. Elbow : The hollows on either side 
 of the olecranon and tendon of the triceps are replaced by soft 
 fluid swellings, the outer of which also extends down to, and 
 masks, the head of the radius ; there is usually a little general 
 puffiness 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. Wrist : There is a general fulness both on 
 the anterior and posterior aspects of the joint, whilst fluctuation 
 may be detected beneath the dorsal tendons, which are slightly 
 separated and displaced. It is distinguished from synovitis of the 
 superjacent tendon sheaths by the fact of its strict limitation to the 
 neighbourhood of the joint, and the absence of the superficial 
 crepitus, so characteristic of the latter condition. Effusion into 
 the Hip-joint cannot be easily detected by digital examination. 
 There may be a little fulness and tenderness in the gluteal region, 
 or in the upper and outer part of Scarpa's triangle. The most 
 characteristic feature, however, is the position of flexion, abduc- 
 tion, and eversion taken by the limb, whilst limitation of move- 
 ment is equally marked. The Knee, when distended with fluid, 
 presents a rounded outline, in which all the normal hollows, 
 especially those on either side of the patella and ligamentum 
 patellae, have disappeared. There is also a swelling correspond- 
 ing to the subcrureal pouch, more marked on the inner than the 
 outer side, and extending for 3 or 4 inches above the patella. 
 Fluctuation can 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 effusion is large in amount, the patella is felt to float, and 
 on pressing it sharply backwards can be made to tap against the 
 intercondyloid notch of the femur (patella tap). Enlargement of 
 the bursa patellae is easily distinguished from it by the swelling 
 in the former case being central and in front of the patella, so that 
 its outline is obscured. Ankle : The hollows between the tendo 
 
DISEASES OF JOINTS 575 
 
 Achillis and the malleoli are replaced by fluctuating swellings 
 whilst the dorsal tendons are displaced forwards, and a fluid 
 swelling appears in front of each malleolus. Enlargement of the 
 bursa beneath the tendo Achillis is so obviously confined to the 
 back of the joint that it should never be mistaken for true synovitis 
 of the ankle. 
 
 When the acute stage has 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 synovitis 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 fibro-cicatricial tissue, containing a 
 few delicate bloodvessels, and covered by endothelium extending 
 over them from the adjacent serous membrane. The charac- 
 teristic signs of such a condition are painful limitation of move- 
 ment in some particular direction, and possibly a little soft 
 crepitus. 
 
 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 utility. Thus, the shoulder 
 should be bandaged to the side and the hand kept in a sling ; the 
 elbow is placed on an internal angular splint, and flexed to a little 
 more than a right angle, whilst the hand is midway between 
 pronation and supination ; for the wrist all that is needed is to 
 apply a palmar splint to the forearm ; 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 sandbags and adjusting an 
 extension apparatus to the foot ; the knee is put on a back-splint, 
 perhaps slightly flexed ; whilst the ankle is best kept at rest by 
 applying what is known as a Roughton's splint, i.e., an external 
 splint with a foot-piece. Necessarily, in all severe cases of acute 
 synovitis the patient should be confined to bed and the limb 
 elevated. If the case has been neglected and the limb has 
 assumed a vicious position, the patient should be anaesthetized 
 and the malposition corrected ; or gradual extension made by 
 means of a weight and pulley, until the correct position is 
 attained. In the early stages cold should be applied to the joint 
 by means of evaporating lotion, an icebag or Leiter's tubes, but 
 this is not advisable in old people. In the later stages fomenta- 
 tions give greater relief, whilst the application of a few leeches 
 may also be beneficial. When the distension is considerable, 
 removal of some of the fluid by a carefully purified aspirator, or 
 trocar and cannula, may diminish pain and hasten recovery. 
 
 In the subacute stage, when the joint is weak and relaxed, 
 massage or friction with stimulating liniments should be em- 
 ployed, whilst in the more chronic forms firm pressure, and pre- 
 
576 
 
 A MANUAL OF SURGERY 
 
 ferably by means of a Martin's bandage, is most useful as an 
 additional measure. 
 
 If adhesions are present, they should be carefully broken down 
 under chloroform ; the limb is subsequently kept at rest for a 
 few days upon a splint, whilst passive movements and massage 
 are afterwards adopted. 
 
 Chronic Synovitis. 
 
 This affection follows an acute attack, or may be lighted up by 
 some injury or condition insufficient 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, then con- 
 stituting the condition de- 
 scribed as chronic serous synovitis 
 (Fig. 209), a phenomenon often 
 seen affecting the knees after 
 rising from a prolonged stay 
 in bed. The pain is usually 
 not severe, being replaced by a 
 sense of uselessness and weak- 
 ness. It is interesting to note 
 that, in cases where the effu- 
 sion is well marked, the bursae 
 communicating with the joint 
 frequently become distended ; 
 they are prevented from par- 
 ticipating in the acute forms 
 of inflammation by the fact 
 that the apertures of com- 
 munication with the interior 
 of the joint are narrow and slit 
 like, and thus readily become 
 occluded by the swelling of 
 the membrane. Crepitus is 
 sometimes met with in chronic 
 synovitis, possibly from a roughening of the articular surfaces on 
 which lymph has been deposited, or between which fibrous 
 adhesions have formed. 
 
 Occasionally the synovial fringes become hypertrophied, giving 
 rise to a condition similar to that described under osteo-arthritis 
 (p. 598). The overgrown villi usually spring from the reflections 
 of the synovial membrane close to the bone, and may be loaded 
 with fat, constituting the condition known as ' Lipoma arbo- 
 
 Fig. 209. — Chronic Serous Synovitis 
 of Knee, with Distension of the 
 subcrureal pouch. (from col- 
 LEGE of Surgeons' Museum.) 
 
DISEASES OF JOINTS 
 
 577 
 
 rescens.' In the knee-joint the fringes may be felt rolling under 
 the fingers, and painful symptoms may be caused by the loose 
 ends being caught and nipped between the bones. 
 
 Treatment consists in fixing the joint in a suitable position, and 
 applying counter-irritation and pressure ; blisters are especially 
 useful in this affection. At a somewhat later stage elastic 
 pressure by a Martin's bandage may be employed, together with 
 friction with stimulating liniments, or even hot-air baths. Re- 
 moval of some of the fluid by aspiration and subsequent com- 
 pression may also do good ; but if the affection resists such treat- 
 ment, the best procedure consists in opening the joint, washing it 
 
 Fig 210. — Baker's Cysts from Back of Knee. (Howard Marsh ) 
 
 out with normal saline solution or with a solution of corrosive 
 sublimate (i in 4,000), and draining it for a few days. 
 
 Should enlarged villi be present and give rise to trouble, the 
 joint should be opened, and if they are limited in their distribution 
 they may be clipped away, or the synovial membrane from which 
 they grow dissected out. When very extensive, so that removal 
 would involve total excision of the synovial membrane and con- 
 sequent stiffness, it may be wise to wash out and drain, in the 
 hope that they may become fixed, before undertaking complete 
 extirpation of the membrane. 
 
 Hydrarthrosis (Hydrops Articuli) is the term applied to any 
 condition of a chronic nature in which the joint is much distended 
 with fluid. It may arise from at least five different affections : 
 (a) Chronic serous synovitis; (b) in osteo-arthritis, a very common 
 cause; (c) in Charcot's disease; (d) in secondary syphilitic 
 synovitis ; and (e) very rarely in tuberculous synovitis. It must 
 
 37 
 
578 A MANUAL OF SURGERY 
 
 be remembered that it is but a symptom, and not a disease sui 
 generis, and treatment necessarily varies with the cause. 
 
 Baker's Cysts. — This condition, first described by the late 
 Mr. Morrant Baker, consists in a hernial protrusion of the 
 synovial membrane of a joint through an aperture in its fibrous 
 capsule (Fig. 210). It is usually due to some chronic affection 
 of the articulation, especially osteo-arthritis, or tuberculous 
 disease, whereby the intra-articular pressure is increased, and 
 not uncommonly several such sacs are connected with the same 
 joint. They vary much in size, contain synovial fluid, and, 
 though at first communicating with the joint cavity, have a 
 tendency to travel away from it, burrowing along muscular 
 and fascial planes, and coming, perhaps, to the surface some 
 distance from their origin, the aperture of communication with 
 the joint having in some instances been shut off. If causing 
 no troublesome symptoms, there is no necessity to interfere ; but 
 if they become inconvenient or painful, it is easy to dissect them 
 out, closing where necessary by ligature or suture the narrow neck 
 which leads into the joint. Of course, the strictest asepsis must 
 be maintained in all such proceedings, and the causative affection 
 must not be forgotten. 
 
 Acute Arthritis. 
 
 By the term Arthritis is meant any inflammation of a joint 
 which involves all the structures of which it is composed, viz., 
 bones, ligaments, cartilages, and synovial membrane. 
 
 Causation. — Acute arthritis is practically always due to infection 
 of the joint cavity with bacteria, which reach it either from within 
 or without the body, (i.) It may be due to the entrance of cocci 
 through a punctured or valvular wound of the joint, or during 
 operations. It is interesting to note how extremely prone to in- 
 flammation is the synovial membrane when opened, even after the 
 most careful antiseptic precautions. The micro-organism most 
 commonly present is a modification of the Streptococcus pyogenes, 
 known as the Strep, articulorum ; it is pathogenic to mice and 
 rabbits, but not to guinea-pigs, and when injected into a rabbit 
 seems to especially select the joints. Various non-pathogenic 
 organisms have also been found in special cases, (ii.) It may arise 
 in a manner exactly analogous to that in which acute infective 
 osteomyelitis is produced — i.e., the patient is in a low state of 
 health, his natural germicidal powers are diminished, pyogenic 
 organisms are present in the blood-stream, gaining access through 
 some breach of surface, and, finally attacking any weak or 
 damaged tissue, produce therein suppurative inflammation. A 
 slight injury, e.g., a sprain or strain occurring in a weakly child, 
 convalescent from measles or scarlet fever, may result in this 
 affection, (iii.) It may be produced by the lodgment of a pyaemic 
 embolus, and in a similar way it not unfrequently follows as a 
 
DISEASES OF JOINTS 579 
 
 sequela of fevers, such as enteric or pneumonia, by direct trans- 
 mission 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 lighted up as 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 commonly due to the 
 former of these conditions, being consecutive to an acute infective 
 osteomyelitis of the upper end of the femur, (vi.) It is occasion- 
 ally observed as a result of rheumatism , the inflammation 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 becomes purulent, and the tissues around 
 are hyperaemic and cedematous. 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, 
 bursting through it, and either travelling directly to the surface, 
 or burrowing deeply into the substance of the limb ; 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 conscious- 
 ness, the muscles which fix the joint are relaxed, and allow the 
 inflamed surfaces to slightly shift their position, exciting severe 
 pain and a sudden spasmodic contraction of the muscles. Gradu- 
 ally the deformity becomes more and more obvious, whilst the 
 infiltration and relaxation of the ligaments sometimes allow of 
 abnormal movements, e.g., o f lateral mobility in the knee-joint ; 
 the ends of the bones become carious, and absolute displacement 
 or dislocation may follow. Sinuses may open in all directions, 
 and the patient suffer from recurrent rigors, caused by toxaemia 
 or the onset of pyaemia. The constitutional effects are always 
 severe, consisting of high fever, and rapid exhaustion from the 
 pain, sleeplessness, and absorption of toxins. 
 
 The terminations of this affection are as follow : {a) Recovery, 
 rarely with a moveable joint, and then only after active inter- 
 
 37~ 2 
 
5 8o 
 
 A MANUAL OF SURGERY 
 
 i 
 
 ference ; in most cases ankylosis in a good or bad position, accord- 
 ing to the treatment, is the best result that can be expected. 
 (b) During the acute stage the patient may die of pyaemia, or acute 
 toxaemia and exhaustion, (c) If he survive the acute stage, chronic 
 suppuration may ensue, and symptoms of hectic and amyloid de- 
 generation in 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 by amputation, the patient is likely 
 to die from exhaustion or chronic sapraemia. 
 
 Pathological Anatomy. — The synovial mem- 
 brane, at first merely infiltrated and hyper- 
 aemic, soon becomes converted into granula- 
 tion tissue from within outwards, exuding 
 abundant pus. The ligaments in turn are 
 sodden and relaxed by the presence of a 
 plastic exudation between the fibres, render- 
 ing them soft and cedematous, 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 inflammation and the amount 
 of pressure to which they are exposed. In 
 acute cases they early lose their normal bluish- 
 white appearance, and become opaque and 
 slightly yellow. The central parts, which are 
 exposed to pressure between the ends of the 
 bones, soon disappear, whilst the peripheral 
 portions are eroded by the growth of the 
 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. In the more chronic forms of the 
 disease, proliferation of the cartilage cells 
 occurs, whereby the capsules become dis- 
 tended, and the matrix encroached upon ; some of these cavities 
 burst into the joint, and leave more or less flask -shaped 
 openings into which pyogenic organisms find their way, thus 
 aggravating the mischief; others nearer the deep aspect of the 
 cartilage become transformed into granulation tissue by vascu- 
 larization from the vessels in the bone. In these ways the carti- 
 lage is destroyed or replaced by granulation tissue, a proceeding 
 
 Fig. 2ii. — Ends of 
 the Bones after 
 Acute Arthritis 
 of Elbow, show- 
 ing the Carious 
 Surfaces devoid 
 of Cartilage, 
 and the De- 
 velopment of 
 Stalactitiform 
 Osteophytes. 
 (From King's Col- 
 lege Museum.) 
 
DISEASES OF JOINTS 581 
 
 analogous to ulceration of the softer parts. The intcvavticular 
 cartilages are affected in a very similar manner, and quickly dis- 
 appear. 
 
 The ends of the bone pass into a condition of acute osteitis 
 resulting in the transformation of the medulla into granulation 
 tissue, absorption of the bony cancelli with or without suppura- 
 tion, and sometimes necrosis of small portions of the cancellous 
 tissue {caries necrotica). The veins within the cancelli become 
 thrombosed, and hence pyaemia may result. The periosteum 
 covering the ends of the bones is also inflamed and hyperaemic, in 
 consequence of which spiculated or stalactitiform osteophytes 
 are produced (Fig. 211). The muscles in the neighbourhood of the 
 joint undergo rapid atrophy and fatty degeneration, probably as 
 a result of some reflex disturbance of the trophic centres. 
 
 Treatment. — In the early stages the limb must be elevated, abso- 
 lutely immobilized, and put into such a position that, if ankylosis 
 subsequently obtains, it may be of some use to the patient. 
 Fomentations or an icebag may be temporarily applied, but as 
 soon as the symptoms point to suppuration, the joint should be 
 freely opened in one or two places, washed out with some sterile 
 or antiseptic solution, and drainage-tubes inserted, whilst neces- 
 sarily any peri-articular abscesses are dealt with in the same way. 
 Openings should preferably be made on opposite sides of the 
 joint, so as to allow the cavity to be frequently flushed out, or, if 
 considered desirable, for continuous irrigation of the joint with 
 some mild antiseptic (e.g., weak boracic lotion, or sublimate solu- 
 tion, 1 in 8,000), or some bland unirritating fluid, such as sterilized 
 normal saline solution. The fixation of the limb is maintained, 
 and the general health attended to. Irrigation should be continued 
 until all signs of inflammation, pain, heat, and startings of the 
 limb have passed away. Under such a regime it is sometimes 
 possible to obtain a moveable joint, but more frequently ankylosis 
 must be expected. Excision may be required in order 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 and displacement, but, as a rule, 
 not until all acute symptoms have passed away. If the patient 
 is suffering from severe toxaemic or pyaemic symptoms threatening 
 life, amputation may be required, as also for exhaustion from 
 long-standing 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 pene- 
 trating injury. Severe pain is caused by any movement of the 
 arm affecting the joint, and the pus in the distended synovial 
 
S 8 2 A MANUAL OF SURGERY 
 
 membrane comes to the surface in front of or behind the deltoid, 
 or in the axilla. It may suffice to open the articulation anteriorly 
 and flush it out, but, if possible, a counter-opening should be made 
 behind by cutting down on a pair of dressing forceps pushed back- 
 wards through the capsule. In many instances the patient's 
 condition will not improve until the head of the bone has been 
 excised. The subsequent results as regards movement and power 
 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 rectangular splint, and with the hand midway 
 between pronation and supination ; of course, the patient is kept in 
 bed, with the arm raised on a pillow. In an adult excision may 
 be undertaken as soon as the acute stage has passed, in order to 
 obtain a moveable elbow ; but in children, where the growth is 
 incomplete, it is better to allow ankylosis to occur, and excise", if 
 need be, at a later date. 
 
 The Wrist may be infected secondarily to septic conditions 
 following operations on ganglia in the neighbourhood, or through 
 direct injury. The essential treatment consists in free incisions 
 parallel 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 
 infective osteomyelitis attacking the upper end of the shaft of 
 the femur, and involving the joint, owing to the epiphyseal car- 
 tilage being intracapsular ; it also results from pyaemia, and 
 rarely from penetrating injuries. The symptoms are similar to 
 those of the first stage of ordinary tuberculous disease (p. 613), 
 but much more acute. There is high fever, together with intense 
 pain, marked flexion and eversion 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 disintegrated articular cavity. As soon 
 as the capsule gives way, the pus may come to the surface in 
 any of the usual localities for hip-joint abscesses. In treating 
 these cases, the joint should be freely laid open in the situation 
 which appears most favourable. The anterior incision is more 
 suitable for the early, and the posterior for the later stages, when 
 the head of the bone is either dislocated, or remains in situ and 
 separated from the shaft. A double opening may sometimes be 
 utilized with advantage. 
 
DISEASES OF JOINTS 5S3 
 
 The Knee-joint is more frequently involved by this disease than 
 any other, and is usually infected from without. The symptoms 
 are exceedingly typical : the pain is very acute and the joint hot 
 and distended to its utmost capacity, the limb lying semiflexed 
 and on its outer side. Left to itself, the capsule gives way, and 
 suppuration rapidly extends upwards beneath the vasti or down- 
 wards into the leg, the pus ultimately finding its way to the 
 surface. The deformity gradually increases, until in the worst 
 forms the tibia slips behind the condyles 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 subcrureal pouch, 
 and the whole articular cavity well washed out. In some cases a 
 counter-opening may be made with advantage and a drain-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 ex- 
 ternal popliteal nerve. By this means more efficient drainage of 
 the articular cavity is obtained. 
 
 When the Ankle-joint is involved, amputation has often to be 
 resorted to, in consequence of the difficulty of securing good 
 drainage, although excision of the astragalus will sometimes cut 
 short the disease and lead to a good result. 
 
 Special Forms of Synovitis and Arthritis. 
 
 Rheumatic Synovitis is met with in the course of acute rheu- 
 matism, or as a chronic affection from the commencement. The 
 former is recognised by the presence of fever, acid sweats, high- 
 coloured urine loaded with lithates, and a tendency to metastasis, 
 one joint after another being involved ; complete resolution 
 usually follows, but there may be some thickening of ligaments 
 and consequent impairment of mobility. If the disease is limited 
 to one joint, absolute disorganization, though without suppura- 
 tion, may ensue (acute rheumatic arthritis). 
 
 The chronic variety is characterized by swelling of the joints, 
 due partly to effusion, partly to thickening of the synovial mem- 
 brane and of the capsular and other ligaments. If neglected, it 
 may produce fixity of the joint, due mainly to ligamentous 
 changes, but also resulting from the 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 rheumatism may be present, such as chorea, ery- 
 thema, etc., whilst rheumatic nodules {i.e., new growths of fibrous 
 tissue in the subcutaneous tissues, perhaps reaching the size of a 
 walnut, but more often much smaller) may also develop. 
 
584 A MANUAL OF SURGERY 
 
 The Treatment of the acute form is rather constitutional than 
 local, and consists in the administration of large doses of salicy- 
 late of soda ; at first, when the temperature is considerably raised, 
 20-grain doses are given every three or four hours, but as the 
 pyrexial phenomena disappear, these are gradually diminished in 
 frequency and amount, until merely io-grain doses are given 
 thrice daily. Some patients cannot take salicylates, as they 
 induce maniacal attacks of alarming severity ; under these circum- 
 stances the practitioner must depend on quinine and bicarbonate 
 of potash. Locally, the joints should be 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 salicine and iodide of potash are 
 perhaps more effectual, together with alkaline mineral waters, 
 whilst stimulating friction and massage may also be adopted. 
 Counter-irritation in the form of frequently repeated blisters, or 
 even of the actual cautery, may prove beneficial ; localized hot- 
 air baths may also be used with advantage in the earlier stages. 
 Failing such treatment, a visit to some of the home or Continental 
 spas may be recommended. 
 
 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 
 (cheiragra). Its onset is usually sudden, and it frequently com- 
 mences in the middle of the night. The tissues around the joint 
 become swollen, red, shiny, and cedematous, whilst the super- 
 ficial veins are prominent. The attack is exceedingly painful, 
 and the skin exquisitely 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 biurate 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 deposit, whilst the ligaments 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 these, and a chalky discharge 
 results. In some cases the cartilages are eroded, and eburnation 
 of the exposed bone may follow, as in osteo-arthritis. The treat- 
 ment of acute gout consists in well fomenting the parts or applying 
 glycerine of belladonna, whilst colchicum, citrate of lithia, and 
 alkaline purgatives are administered. In the more chronic forms 
 iodide of potassium, and possibly piperazine, may be given, and 
 the diet and drink are carefully regulated. 
 
DISEASES OF JOINTS 585 
 
 Pyasmic Synovitis is due to embolic infection from some sup- 
 purating 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 pre- 
 vented (vide Pyaemia, p. 106) ; otherwise destructive changes will 
 quickly follow. 
 
 Typhoid Disease of Joints. — Several well-defined varieties of 
 joint trouble arise in connection with typhoid fever. 1. A simple 
 chronic synovitis occurs in one or more joints with but slight effusion 
 and little inflammatory disturbance. 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 tvue typhoid arthritis, due to the Bac. typhosus, is character- 
 ized by a marked inflammatory effusion into one or more joints, 
 and is liable to end in spontaneous dislocation. The hip-joint is 
 specially liable to this trouble. Suppuration, however, is rare, and 
 the prognosis good, 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 suppuration within 
 the joints, the Bac. typhosus playing quite a subsidiary part. 
 4. A pure pyogenic infection. In these latter two varieties the 
 ordinary symptoms of acute suppurative arthritis occur, and the 
 treatment for that affection must be instituted. 
 
 Pneumococcal Arthritis. — In the course of an acute pneumonia 
 the pneumococcus is occasionally disseminated through the body, 
 and is then very likely to attack a joint which has been already 
 damaged, giving rise to a suppurative arthritis, with an effusion 
 of thick creamy pus, or sometimes to a milder form of synovitis. 
 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. There are no special 
 peculiarities in the course of the disease, but it must be recognised 
 as merely part of a general infection, and hence a high mortality 
 is associated with it. Suppuration usually occurs, and its onset 
 is always an indication for incising, washing out, and draining 
 the joint. 
 
 Gonorrhceal Disease of Joints is always due to infection with the 
 gonococcus, transmitted by the blood from the primary focus of 
 mischief. Naturally, it is usually seen in connection with 
 gonorrhceal urethritis, but it has been known to follow ophthalmia 
 neonatorum, and has been lighted up by passing a full-sized 
 bougie on a patient with gleet. Under ordinary circumstances 
 it generally commences after the third week of the gonor- 
 rheal attack, when the discharge is becoming subacute. It 
 may attack one or many joints, the knee, ankle, and wrist being 
 
586 A MANUAL OF SURGERY 
 
 most frequently involved, and perhaps on both sides of the body. 
 Two distinct types of trouble may manifest themselves, but they 
 are not unfrequently combined. In one, the synovial membrane is 
 mainly affected, and the effusion is chiefly intra-articular, so that the 
 condition closely resembles an ordinary attack of acute traumatic 
 synovitis. In the other, 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 cedematous ; 
 the ligaments are infiltrated and softened, so that displacement 
 readily occurs ; surrounding muscles atrophy rapidly ; the patient 
 suffers from severe pain and a good deal of fever, so that he 
 becomes thin and worn. In the worst cases the intra-articular 
 effusion increases and is sero-purulent, yellowish-green in colour, 
 and contains flakes of lymph, but it is never truly purulent. 
 Both 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 discharges 
 must be arrested as soon as possible, whilst the affected joints are 
 kept at rest ; moderate pressure and counter-irritation, as by 
 Scott's dressing, are perhaps the best means of dealing with the 
 later stages in simple cases. Iodide of potassium, mercury, and 
 quinine may be administered internally. Should the local 
 phenomena be at all severe, the joint must be opened, irrigated, 
 and drained, but even then ankylosis is likely to follow. 
 
 Tuberculous Disease of Joints. 
 
 Tuberculous Arthritis {Syn. : Pulpy Degeneration of the Synovial 
 Membrane, White Swelling, etc.) may commence either in the 
 synovial membrane or in the articular end of the adjacent bone 
 (tuberculous epiphysitis, p. 518) ; or it may spread from the 
 periosteum to the synovial membrane, as a result of a tuber- 
 culous periostitis, or from a neighbouring bursa. There is some 
 slight difference of opinion as to the relative frequency of the 
 synovial and osseous varieties, but the latest investigations cer- 
 tainly seem to indicate that 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. 
 
 The Causes may be summed up as follows : The individual is 
 predisposed to the development of tuberculous disease, usually as 
 the result of an inherited tendency, a family history of tubercle 
 being often obtainable ; the general health of the patient may be 
 at fault, owing to insufficient or inappropriate food, bad hygienic 
 surroundings, or exposure to cold. Some slight injury of which 
 but little notice is taken may lead to the actual deposit of the 
 Bac. tuberculosis, which gains access to the body through some 
 breach of surface, or even perhaps through a healthy mucous 
 membrane. Severe articular lesions, such as dislocations, are 
 
DISEASES OF JOINTS 587 
 
 much 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 thick- 
 ened, pulpy, and cedematous, and in the early stages, on naked-eye 
 examination, may be 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 discharge into the joint, leaving 
 ulcerated surfaces. 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 cedematous fibro-cicatricial tissue, whilst 
 the superficial parts undergo fatty or necrotic changes. Micro- 
 scopically, one finds all the ordinary appearances of tuberculous 
 disease, the vessels being in a state of endarteritis for some distance 
 from the serous surface. Fringes of the synovial membrane, 
 swollen and succulent, spread over the margins of the articular 
 cartilage, and as they increase in size become adherent to it, just 
 as, according to Billroth's classical description, ivy creeps along a 
 wall. On lifting the edges of these fringes, the underlying cartilage 
 is found hollowed out and eroded. As soon as the whole thick- 
 ness is destroyed at any one spot, the cancellous tissue at the end 
 of the bone becomes similarly affected, and the granulations spread 
 along under the cartilage, cutting it off from its nutritive supply, 
 and thus necrosis, as well as superficial ulceration, may assist in 
 its destruction. As a result of the hyperaemic condition of the end 
 of the bone, especially when sepsis is super-added, a new formation 
 of subperiosteal osteophytes, stalactitiform in character, sometimes 
 takes place, but not to such an extent as in acute arthritis. Occa- 
 sionally the periosteum itself is involved in the tuberculous process, 
 and the disease may then extend some distance from the joint. 
 
 When the bone becomes involved, either primarily or secondarily, 
 any of the manifestations of tuberculous disease described in 
 Chapter XVIII. may be met with, and thus it is not uncommon 
 to find sequestra in connection with tuberculous arthritis. When 
 it 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, the latter structure 
 may escape. Sometimes a pre-tuberculous synovial effusion of a 
 simple nature occurs, but gives place to the more typical mani- 
 festations when infection has followed. Should the perforation be 
 a large one, e.g., when a tuberculous abscess bursts into a joint, 
 
5»» 
 
 A MANUAL OF SURGERY 
 
 f- 
 
 S 
 
 '•''■ 
 
 ? 
 
 I 
 
 acute symptoms supervene, but gradually quiet down, and the 
 usual chronic phenomena subsequently develop. More com- 
 monly the infection is slow 
 and gradual, and the onset of 
 the articular symptoms is of a 
 similar character. The extent 
 of the mischief in the bones 
 may sometimes be ascertained 
 by the X rays (see Plates 
 XXVIII. and XXIX.). 
 
 Clinical History. — The 
 disease usually commences in 
 a most insidious 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 becomes more and more 
 marked, and the joint is fixed, 
 usually in a semiflexed posi- 
 tion, whilst it looks slightly 
 swollen. On inspection it is 
 white, smooth, and rounded, 
 the swelling being more 
 apparent on account of the 
 wasting of adjacent muscles. 
 On palpation, the part is found 
 to be hotter than that on the 
 opposite side of the body, 
 whilst fluctuation is not readily 
 detected, there being but little 
 fluid in the joint, though the 
 affected tissues are elastic and 
 puffy. In a few rare cases, 
 where the synovial membrane 
 is widely involved, the affec- 
 tion commences with consider- 
 able serous exudation, giving 
 rise to the condition known 
 as tuberculous hydrops ; after 
 persisting for a while, the usual manifestations of the disease show 
 themselves. According to Konig a number of joints may be 
 
 Vc^ 
 
 Fig. 212. — Bones entering into For- 
 mation of Knee-joint, which has 
 been disorganized by tuberculous 
 Disease. (From College of Sur- 
 geons' Museum.) 
 
 The cartilage is almost entirely de- 
 stroyed, and the exposed bone is 
 carious and eroded. 
 
PLATE XXVIII. 
 
 Tuberculous Disease of Knee-Joint, showing Invasion of Patella. 
 To /ace p. 588.] 
 
DISEASES OF JOINTS 589 
 
 affected with hydrops in the first place, but all clear up except 
 one, and that becomes tuberculous. In this type fibrinous 
 melon-seed bodies are occasionally found. 
 
 From time to time exacerbations of pain and increase of swelling 
 occur, which subside after a few days, but leave the joint more 
 and more crippled. Sooner or later abscesses are likely to 
 develop, with increased local disturbance, and often starting pains 
 at night, due to the erosion of cartilages, together with slight 
 general fever and malaise. If they burst, temporary relief follows ; 
 but if the discharge continues, and fresh abscesses form, septic 
 phenomena are usually added to those already present. The 
 patient develops a hectic temperature ; amyloid degeneration of 
 the viscera may supervene, the joint becomes more and more 
 deformed, abnormal movements from relaxation of ligaments may 
 exist, and finally the patient, exhausted partly by the discharge, 
 partly by the pain, and partly by the want of sleep, becomes 
 emaciated, and may even die, unless prompt measures are taken 
 for his relief. 
 
 Results. — (a) If seen in the early stages, and suitably treated, 
 the disease may be entirely cured, and a moveable joint result. 
 
 (b) More frequently the articular structures are so severely 
 damaged, that a cure can only be established by means of anky- 
 losis. Unless measures have been adopted to maintain the 
 limb in a satisfactory position, permanent deformity may ensue. 
 
 (c) If sepsis has been admitted, the patient will probably develop 
 hectic or amyloid disease from chronic toxaemia, and from this 
 he may succumb. On the other hand, in a few instances he 
 may survive such dangers, the sinuses alternately drying up and 
 discharging, although he remains a permanent invalid, and the 
 joint is crippled, (d) Acute miliary tuberculosis is occasionally 
 met with as a complication of this affection, whilst similar 
 associated disease of the lungs, brain, kidneys, or other viscera, 
 may be lighted up. 
 
 The Prognosis is mainly influenced by the condition of the 
 individual and his surroundings. In children of the better classes, 
 where every hygienic and medical assistance can be given, re- 
 covery generally follows, unless there is a strong counterbalancing 
 hereditary tendency. Amongst the poorer classes, and especially 
 in ' slum children,' the outlook is correspondingly serious. More- 
 over, the extremes of life are unfavourable : babies resist tuber- 
 culous invasion badly, and patients over fifty have comparatively 
 little recuperative power ; hence radical rather than conservative 
 measures have often to be resorted to in these two classes. 
 
 The Treatment of tuberculous joints varies not only with the 
 articulation affected, but also with the type of patient, and the 
 extent to which the disease has advanced. 
 
 1. Hygienic Treatment. — Local tuberculosis is a manifestation of 
 a general condition of weakness which can often be eradicated 
 
59Q A MANUAL OF SURGERY 
 
 from the system by suitable constitutional treatment. Conse- 
 quently, in the early stages, many cases of tuberculous synovitis 
 can be cured by keeping the limb absolutely at rest, by means of 
 splints, plaster of Paris, etc., and elevating it if there is much pain. 
 The general health should be improved by sending the child to 
 the seaside, giving it plenty of good food, and administering cpd- 
 liver-oil and syrup of the iodide of iron. An endeavour must be 
 made at the same time to correct any faulty position of the limb 
 by a process of gradual extension, made at first in the direction 
 of the displacement, and with only just sufficient energy to keep 
 the joint surfaces at rest and counteract the tonic muscular con- 
 traction which is tending to produce a fixed deformity ; it may be 
 necessary to employ tenotomy for this purpose. Any form of 
 apparatus which depends upon a screw mechanism to straighten 
 out a limb is certain to increase intra-articular tension, and there- 
 fore is not to be used. The sudden application of force under an 
 anaesthetic is also unadvisable, since tuberculous material may 
 thereby be disseminated through the system. Counter-irritation 
 by blistering or iodine paint, or combined with pressure in the 
 form of Scott's dressing, is often useful in promoting repair. 
 Possibly the severe pain experienced when the contiguous osseous 
 tissues are involved may be relieved by an application of the 
 actual cautery, but it is doubtful whether the progress of the 
 disease can be checked by such means. 
 
 2. Parenchymatous injections of iodoform suspended in glycerine 
 into the articular cavity, or into the substance of the synovial 
 membrane, have been much recommended of late, and have 
 apparently done good ; 10 parts of iodoform are mixed with 20 of 
 sterilized water, and made up to 100 with pure glycerine, and 
 about an ounce of this fluid is injected. The limb is at the same 
 time immobilized. The injection usually needs to be repeated 
 more than once. /3-naphthol and some other antiseptics have 
 also been employed in a similar fashion. 
 
 3. A new plan of treatment was suggested by Bier of Kiel 
 a few years back ; it consists in inducing venous engorgement of the 
 diseased tissues by applying an elastic bandage above and below 
 the joint, but only loosely over it ; the pressure is kept on for 
 two or three hours daily, if the patient can bear it, and during 
 the intervals a splint is applied. The general health must also be 
 attended to during the treatment. The process is based on the 
 observation that phthisis rarely develops in association with 
 mitral regurgitation, whereby pulmonary engorgement is induced ; 
 whilst if the cardiac lesion supervenes in a phthisical subject, the 
 lung symptoms improve. It is too early yet to say what the final 
 verdict as to this method will be, but the results hitherto gained 
 are encouraging.* It must never be employed when septic 
 
 * Archiv. j. klin. Chirwgie, vol. xlviii., bd. ii., p. 306. 
 
DISEASES OF JOINTS 591 
 
 sinuses are present, as it considerably aggravates the trouble by 
 providing increased pabulum for the micro-organisms. 
 
 4. Abscesses are, if possible, dealt with sufficiently early and in 
 such a manner as to obviate the need for prolonged drainage. To 
 this end they must never be left long enough to allow the skin 
 and subcutaneous tissues to become involved, but as soon as a 
 collection can be detected it should be tapped by a large trocar 
 and cannula, the cavity well irrigated, and injected with iodoform 
 emulsion. It is wise to incise the skin with a knife, and not to 
 puncture it with the trocar ; the irregular wound made by the 
 latter might not heal quickly ; a stitch closes the incision and 
 assists satisfactory healing. 
 
 Of course, when the skin is reddened, and the pus subcutaneous, 
 the abscess must be incised and drained in the usual manner, any 
 thin and undermined skin being snipped away. 
 
 5. In other cases where expectant treatment cannot satis- 
 factorily be carried out, or where the disease is progressing, 
 arthrectomy, or total removal of the diseased tissues with the least 
 possible disturbance of the parts, should be undertaken. This 
 treatment is only feasible in certain joints, viz., the elbow, knee, 
 and ankle, which can be readily reached, and more or less 
 efficiently dealt with. It consists in freely opening the articular 
 cavity, and cutting or scraping away the diseased membrane, 
 whilst carious foci in the bone are scraped and purified. The 
 advantages claimed for it are, that it interferes neither with the 
 immediate length nor with the subsequent growth of the limb, 
 and that no bone is cut through, and hence risk of tuberculous 
 infection of this structure is avoided. As to its practical value — 
 if the proceeding is limited to the synovial membrane, we have 
 little confidence in it, recurrences being frequently met with ; but 
 if it is modified in the knee and ankle by the additional removal 
 of a thin slice of articular cartilage, so that it is converted into a 
 limited excision, and osseous ankylosis between the two epiphyses 
 is obtained, good results may be anticipated. At the knee, 
 however, there is some tendency to subsequent flexion and dis- 
 placement. 
 
 6. Excision is at the present time being utilized much less 
 frequently in the treatment of tuberculous joints than a short time 
 back, owing to increased confidence in conservative measures ; it 
 is quite possible that this neglect of operation is being carried too 
 far. We advise its employment under the following circum- 
 stances : {a) To cut short the course of the disease where con- 
 stitutional and expectant treatment cannot be efficiently carried 
 out, or where owing to constitutional weakness or defective 
 hygiene it has failed ; (b) where extensive superficial abscesses 
 have formed, requiring prolonged drainage, and the disease has 
 seriously involved the bones ; (c) for total disorganization of the 
 joint ; (d) to prevent ankylosis in certain joints, viz., the elbow 
 
592 A MANUAL OF SURGERY 
 
 and temporo-maxillary ; and (e) to remedy ankylosis in a faulty 
 position. In determining whether or not excision is advisable, the 
 following considerations must be passed under review : (i.) The 
 operation makes a considerable call upon the recuperative powers 
 of the individual, and hence is not to be recommended in infants 
 or in patients of advanced age. Various age-limits are given by 
 different authorities, but, speaking generally, we would say that 
 the operation should only be undertaken upon those between five 
 and forty-five years of age. In infants arthrotomy, or at most 
 arthrectomy, is all that is practicable ; the ends of the bones are 
 so largely cartilaginous that extensive osseous trouble is not 
 likely to be present. In the hip-joint, however, removal of the 
 head of the femur often gives excellent results even in the young. 
 The latter limit depends more on the vitality than on the actual 
 age of the individual, whilst some joints are more amenable to 
 excision in elderly patients than others ; thus, one would excise 
 the knee or shoulder in cases where one would not think of 
 dealing with the wrist, ankle, or elbow in this manner, (ii.) More- 
 over, the general health of the individual must be sufficiently 
 good, otherwise repair will not be satisfactorily accomplished. 
 Hectic and amyloid disease, unless very advanced, do not contra- 
 indicate this proceeding, but in weakly children living in the slums 
 it is often better practice to amputate, (iii.) The extent of the 
 disease in the bones is also a matter of importance, since, if a 
 large amount of bone has to be removed, a shortened or flail-like, 
 useless limb is almost certain to follow. More bone can, however, 
 be removed without detriment in the upper than in the lower 
 extremity, (iv.) Again, the disease must not have invaded the 
 soft parts too extensively ; if the skin is unhealthy and riddled 
 with sinuses, removal of the limb is often preferable, (v.) Finally, 
 no acute or subacute septic trouble should be present, for fear of 
 lighting up similar disease in the bones. Under such circum- 
 stances the limb may sometimes be saved by making free incisions 
 to relieve tension, and deferring excision until the more active 
 symptoms have subsided. 
 
 7. If, after carefully weighing the preceding considerations, 
 excision is not thought desirable, and the case is steadily pro- 
 gressing from bad to worse, amputation would appear to be the 
 only treatment available. In addition, it is indicated in patients 
 where excision has been undertaken and failed, either from the 
 limb becoming subsequently flail-like or useless, or from recurrence 
 owing to incomplete eradication, or from the advent of sepsis. 
 Lastly, if the disease is present in two joints at one time, or in a 
 joint and some other organ, neither of which is improving, total 
 removal of one focus of mischief will often induce a rapidly favour- 
 able change in the other. 
 
DISEASES OF JOINTS 593 
 
 Tuberculous Disease of Special Joints. 
 
 The Shoulder -joint is but rarely affected in children, and not 
 very commonly in adults. The disease usually starts in the head 
 of the humerus, affecting subsequently the synovial membrane, 
 and perhaps also the glenoid cavity. If abscesses form, they are 
 likely to point either in front of or behind the deltoid, in the former 
 case extending along the synovial membrane lining the bicipital 
 groove. Excision of the head of the bone is almost always 
 required in order to effect a cure. 
 
 In the Elbow the disease is most common in young adults, and 
 is often primarily osseous, commencing in the olecranon or outer 
 condyle of the humerus. If the synovial membrane is first 
 affected, it frequently starts in the superior radio-ulnar articula- 
 tion. The swollen synovial membrane bulges on either side of 
 the olecranon and tendon of the biceps. Sinuses form by the side 
 of the olecranon, or an abscess may burrow upwards along the 
 ulnar nerve and open on the inner aspect of the arm. Prolonged 
 immobilization, followed, if need be, by incision and partial 
 removal of the synovial membrane, often suffices in children, 
 leaving, however, a stiff elbow ; in adults excision is the correct 
 practice, and the results are very satisfactory, provided that a 
 sufficient amount of bone is removed, and the muscular attach- 
 ments interfered with as little as possible. If expectant treatment 
 is adopted, the arm should be flexed to a right angle, and with 
 the hand midway between pronation and supination, so that, if 
 ankylosis follows, the limb may be in the most useful position. 
 Arthrectomy is occasionally adopted, and is best accomplished 
 by means of an H-shaped incision over the olecranon, which 
 process of bone is divided at its base and turned upwards, so as 
 to thoroughly expose the interior of the articulation. After 
 removing all diseased tissue, the olecranon is replaced and wired 
 to the shaft of the ulna. 
 
 In the Wrist diffuse disease of the synovial membrane and 
 bones is met with, starting most frequently from the former 
 structure ; if primarily osseous, it usually commences in the lower 
 end of the radius. It may also extend from a tuberculous affec- 
 tion of the adjacent tendon sheaths. A characteristic doughy 
 swelling forms over the dorsum, displacing the extensor tendons, 
 and sinuses often develop on the dorsal aspect or by the side of 
 the flexor carpi radialis tendon. Conservative measures may 
 bring about a cure, and every effort should be made to avoid 
 excision, since the result of this proceeding is almost always the 
 production of a weak and flail-like hand, so that the constant use 
 of a leather support is essential after healing has occurred. In 
 elderly people amputation is often the only resource. 
 
 Diseases of the Hip-joint and of the Sacroiliac Articulation 
 are separately considered (pp. 611 and 619). 
 
 38 
 
594 
 
 A MANUAL OF SURGERY 
 
 The Knee-joint is, perhaps, more often affected with tuber- 
 culous disease than any other articulation. It appears to start 
 in the synovial membrane or bone with almost equal frequency ; 
 if the bones are first affected, the primary focus is usually situated 
 on the inner aspect of either the femur or tibia. Sequestra are 
 found in nearly one half of the cases in which the bone is affected, 
 becoming more frequent as the age advances. The disease runs 
 a typical course, and needs no special comment. When the joint 
 has become disorganized, the tibia is liable to be displaced 
 horizontally backwards, flexed and externally rotated, and anky- 
 losis in this position is difficult to remedy, even by operation. 
 Prolonged immobilization on a back-splint, or, preferably, 
 the application of a Thomas's knee-splint 
 (Fig. 213), together with iodoform injections 
 and constitutional treatment, will be effectual 
 in many cases. Failing this, a modified 
 arthrectomy may be undertaken, and to carry 
 it out an incision should be made across the 
 front of the joint from condyle to condyle, 
 as for an excision, dividing either the liga- 
 mentum patellae, or perhaps the patella, 
 which is subsequently wired together. The 
 whole of the synovial membrane is then dis- 
 sected away, special attention being directed 
 to the subcrureal pouch and the back of the 
 joint. A thin slice should be removed from 
 the surfaces of both tibia and femur, and if 
 the epiphyseal cartilages are not encroached 
 upon, the growth of the limb is not impaired 
 to any great extent, although it may become 
 irregular and lead to some deformity, e.g., 
 well-marked flexion, or genu-recurvatum 
 (p. 398). In suitable cases, where the bones 
 are not too extensively involved, so that 
 on section broad healthy surfaces can be 
 apposed, excision is a most satisfactory 
 operation, provided that the bulk of the 
 synovial disease can be removed. In adults, 
 where it is desirable to cut short the disease, 
 one may always undertake this proceeding 
 when the patella has become fixed to the 
 femur, thereby determining ankylosis. Re- 
 currence usually results from a focal point 
 of disease being left in the synovial mem- 
 plied. brane or in the bone. If amputation is 
 
 necessary, the supra-condyloid operation can 
 generally be adopted ; when the joint has been already resected, 
 or sinuses still persist in front, a long posterior flap is often the 
 only healthy tissue available for covering the bone. 
 
 Fig. 213. — Thomas's 
 Knee-splint ap- 
 
DISEASES OF JOINTS 595 
 
 The Ankle-joint. — Tuberculous disease of this joint usually com- 
 mences in the synovial membrane rather than in the bone. If 
 primarily osseous, the astragalus is more frequently affected than 
 the lower end of the tibia. The whole region becomes occupied by 
 a pulpy swelling, which first pushes forwards the extensor tendons 
 and bulges in front of the malleoli, and subsequently appears on 
 either side of the tendo Achillis. The foot is maintained in a position 
 of plantar-flexion so as to bring the narrower portion erf the upper 
 surface of the astragalus into the tibio-fibular mortice. Flexion and 
 extension of the foot are of course lost, but with care the lateral 
 movements (inversion and eversion) which occur at the mid-tarsal 
 and sub-astragaloid joints can be undertaken without pain. In the 
 early stages prolonged rest and immobilization in plaster of Paris 
 are all that is required. Excision of the joint gives fairly satis- 
 factory results in adults, but not unfrequently fails to eradicate the 
 disease, owing to the fact that, when once the astragalus is involved, 
 the tuberculous process is likely to spread to the articulations 
 placed beneath it, and so to the other bones of the foot. When 
 there is any doubt as to the condition of the astragalus, that bone 
 should be removed at the same time as the lower ends of the tibia 
 and fibula. Where the disease is more extensive, a supramalleolar 
 amputation of the foot will be necessary. 
 
 For diseases of the Bones and Joints of the Foot, see p. 515. 
 
 Syphilitic Diseases of Joints. 
 
 Although syphilitic disease of joints is rare in proportion to the 
 prevalence of syphilis, yet several varieties have been differentiated 
 and recognised. (1) In the later stage of the secondary period a 
 chronic form of synovitis occurs, evidenced by passive effusion into 
 the joint, with or without pain, and usually persisting for some 
 time. Any joint may be attacked in this way, perhaps the knee 
 most commonly, and the affection is often symmetrical in its dis- 
 tribution. The effusion may be only slight, but is frequently very 
 considerable (hydrarthrosis), and a marked feature in the condition 
 consists in the rapid variations in the amount of swelling, even 
 from day to day. In some few cases this affection resists all 
 treatment, and leads to ultimate disorganization. (2) Gummatous 
 inflammation of the perisynovial fibrous tissue, which may or 
 may not extend to the adjacent bone, is met with in the tertiary 
 period. It either appears as a localized hard nodule, resembling 
 in measure a fibrous tumour, and then causing but little trouble 
 beyond a sense of painful weakness in the articulation ; or it is more 
 diffuse in its distribution, leading to a moderate effusion, and later 
 on to much thickening and infiltration of the capsular and other 
 ligaments, and resulting in considerable impairment of its move- 
 ments from cicatricial contraction. Some of these gummatous 
 nodules may break down and ulcerate. (3) A diffuse gummatous 
 infiltration of the synovial membrane itself is also seen. It closely 
 
 38—2 
 
596 A MANUAL OF SURGERY 
 
 simulates a tuberculous synovitis, from which it is often impossible 
 to distinguish it, except by the rapid onset and the presence of 
 other syphilitic phenomena. (4) A chondro -arthritis, described 
 originally by Virchow, is the syphilitic analogue of osteo-arthritis. 
 It commences by fibrillation of the matrix of the cartilage, and 
 proliferation of the cells. The cartilage softens, and becomes 
 eroded by friction of the articular surfaces. The bone thus 
 exposed is worn away, and curiously ' pitted ' and excavated. It 
 is recognised from osteo-arthritis by the facts that there is usually 
 but little or no pain ; that the eburnation of the exposed bone is 
 less extensive, and therefore crepitus is but little marked ; whilst 
 the typical osteophytic growths, causing ' lipping ' of the joint 
 margins, are absent. The eroded areas, moreover, do not corre- 
 spond with the sites of intra-articular pressure, and are more 
 rounded and punched out, and not arranged in linear grooves, as 
 in the latter disease. It is not uncommonly associated with a 
 gummatous thickening of the synovial membrane, and, indeed, 
 the hollows or pits above mentioned may be filled with caseous 
 material, derived from degeneration of this tissue. 
 
 The Treatment in the early manifestation consists in the 
 administration of mercury, and the judicious application of pres- 
 sure with or without immobilization, according to the require- 
 ments of the case and the joint affected. In the tertiary forms 
 iodide of potassium in gradually increasing doses has a rapidly 
 beneficial action, which confirms the diagnosis ; it may be 
 occasionally combined with a small amount of mercury, either 
 given internally, or applied locally if any ulcerative lesion exists. 
 In the most pronounced cases, where the pain is severe and 
 disorganization of the joint has occurred, excision may be neces- 
 sary, and the results are often very satisfactory. 
 
 Osteo-arthritis. 
 
 Although this disease is extremely common in this country and 
 has well-marked characteristics, its nature is still extremely 
 obscure, as is evident from the large number of names that have 
 been applied to it, such as chronic rheumatoid arthritis, rheumatic 
 gout, arthritis deformans, arthritis senilis, arthritis sicca, etc. There is 
 not the slightest doubt that several distinct types of disease have 
 been confounded together under this title, and although at the 
 present time it is admitted that rheumatic and gouty conditions 
 are to be excluded, yet it is probable that we are still including 
 more than one type of chronic articular trouble. 
 
 etiology. — Exposure to damp and cold is doubtless an im- 
 portant factor in the production of osteo-arthritis, especially in 
 elderly people, or when some depressed condition of the nervous 
 system is superadded, whether such be due to worry, anxiety, or 
 to defective nutrition. In other cases where there is no question 
 of exposure, the affection is by some attributed to nervous 
 influences (Senator, Ord), and particularly to affection of the 
 
DISEASES OF JOINTS 
 
 597 
 
 uterus and ovaries, which it is supposed are capable of inducing 
 reflex changes in the joints. Such an idea may explain some of 
 the trophic and nervous phenomena associated with this trouble, 
 but it is a little difficult to accept the theory in its entirety. 
 Others again attribute it to auto-intoxication due to indigestion 
 of duodenal origin. Recently a theory of bacterial causation 
 has been propounded, and although it cannot be considered as 
 proven, yet evidence in favour of its probability is steadily 
 accumulating. It is supposed that the organisms find their 
 way into the joints from some other focus of infection, and in 
 this connection it is interesting to note the statement that in a 
 large series of cases 55 per cent, were preceded by some other 
 infective fever or disease (Bannatyne). They develop in the joints 
 and produce toxic bodies which act locally by inducing destructive 
 phenomena of a special type, whilst by their general absorption 
 various trophic and nervous symptoms are caused, whose existence 
 has been constantly noted, but for which hitherto there has been 
 no adequate explanation. Such an origin will also explain the 
 presence of enlarged glands in the 
 neighbourhood of some of the 
 affected joints. Several observers 
 have found bacteria within the 
 joints, and Bannatyne and others 
 have described a short bacillus, 
 the ends of which stain deeply 
 whilst the intervening portion 
 remains unstained, causing it to 
 look like a diplococcus. This was 
 found in several cases, but though 
 injected into the joints of animals, 
 no results followed. 
 
 Traumatism plays an important 
 part in the production of certain 
 types of osteo-arthritis, and Lane 
 is emphatic in maintaining that 
 these cases should be relegated to 
 a different category, and be known 
 as chronic traumatic arthritis; the 
 changes, however, are so similar 
 to those of osteo-arthritis that we prefer to consider it a sub- 
 division or variety. The injury may be slight in nature, such as 
 a sprain or strain, or more severe, such as a fracture or disloca- 
 tion involving the articular surface ; thus, it is not uncommon 
 to see it following Colles's fracture or one of the cervix femoris. 
 Abnormal pressure maintained for a long time also causes 
 changes of a similar type, and thus many of the joints of labouring 
 men are deformed in a peculiar fashion, according to the special 
 type of work and the particular joints that are exposed to strain. 
 
 Pathological Anatomy. — The disease commences in the articular 
 
 Fig. 214. — Patella from Early 
 Case of Osteo-arthritis, show- 
 ing Fibrillation of Cartilage. 
 (Howard Marsh.) 
 
598 
 
 A MANUAL OF SURGERY 
 
 cartilage, the matrix of which cracks and undergoes fibrillar 
 changes, and presents a villous appearance, resembling the pile of 
 velvet (Fig. 214). The cartilage cells proliferate, so that the 
 capsules contain many instead of one, and these, giving way, dis- 
 charge their contents into the joint. The cartilage thus softened 
 is readily worn away by the movements of the articulation, and 
 the exposed surface of bone becomes hard, sclerosed, and polished 
 like ivory (eburnated). This usually occurs in certain definite 
 directions. In hinge joints the surfaces become grooved longi- 
 tudinally, whereas in ball-and-socket joints, like the hip, the head 
 is eroded in a circular manner. This condensed tissue does not 
 extend very deeply, and immediately beneath it the cancellous 
 
 bone is of a more open 
 texture than usual, and 
 filled with fatty me- 
 dulla. In spite of the 
 sclerosis, the articular 
 end of the bone is con- 
 tinually being worn 
 away, and this may 
 go on to such an ex- 
 tent as to lead to actual 
 shortening of the limb. 
 Concurrently with this 
 destruction, new bone 
 formation is taking 
 place at the margins 
 of the articular carti- 
 lage, producing irre- 
 gular osteophytes, 
 which have been 
 likened to the gutterings 
 of a candle. They are 
 \ ■ [\ preceded by an over- 
 
 k_ _^ -—- . : , ; growth of cartilage, in 
 
 which ossification 
 Fig. 215.— Late Stage of Osteoarthritis of takes place secondarily. 
 Knee, showing Destruction of the Articu- when qnrh nnrrrrnwrrU 
 lar Cartilage, and Eburnation of the ^ vnen sucfl outgrowths 
 Exposed Bone in Longitudinal Grooves. n& ve been produced 
 (From College of Surgeons' Museum.) more or less evenly 
 The margins of the surfaces are distinctly lipped, around the joint mar- 
 gin, a characteristic 
 'lipping' of the edge of the cartilage results (Fig. 215). % Some- 
 times these osteophytes attain to a large size, and by interlocking 
 may lead to ankylosis of the joint- The synovial membrane is 
 usually thickened, and the villi occasionally proliferate, and may 
 reach such dimensions as to be felt through the skin, rolling 
 under the finger. They are red, vascular, and succulent during 
 life, but after removal and preservation in spirit, they look 
 
DISEASES OF JOINTS 599 
 
 shrunken and insignificant. This overgrowth is often associated 
 with excessive effusion, though usually the affection is of a dry 
 type. Occasionally cartilaginous nodules develop in the villi of 
 the synovial fringes, later on becoming ossified, and if detached 
 constitute one form of loose cartilage. 
 
 Clinical History. — Several distinct types of. this disease may be 
 observed, but practically they may be subdivided into three chief 
 groups : A chronic type involving one joint only ; a chronic form 
 affecting many joints ; and an acute variety which is also poly- 
 articular. 
 
 i. The chronic monarticular variety is that most frequently seen 
 by surgeons, and is constantly brought about by injury. Pain 
 and creaking of the joint on movement are the early symptoms 
 of this affection. There may be very little swelling, unless 
 effusion is present, but pain, especially at night, is most trouble- 
 some, being usually increased on changes of weather, particularly 
 if rain is threatening. The pain and stiffness are most marked 
 after keeping the parts at rest, and diminish when the limb is used. 
 As the disease progresses, the movements become more and more 
 impaired, and the crepitus more of an osseous type ; the ends of 
 the bones are felt enlarged and lipped, and deformity soon becomes 
 obvious. Exacerbations in the symptoms occur from time to time, 
 resulting in increased crippling of the articulation. Finally, the 
 limb may become absolutely useless, partly from the pain and partly 
 from the limitation of movement produced by the osteophytes. 
 Wasting of the adjacent muscles is also a marked feature. 
 
 It is usually seen in elderly people, and may supervene very 
 quickly after an accident, such as fracture or bruising of the 
 cervix femoris, and then the destructive phenomena may progress 
 at a rapid rate. When it appears in younger people, the osseous 
 lesions are much less evident. 
 
 2. The chronic polyarticular variety arises independently of trau- 
 matism, and is most commonly seen in females of middle life. 
 It may commence in one joint and spread to others, or it may 
 appear in many joints simultaneously. Most frequently one or 
 more of the phalangeal articulations is the starting point, par- 
 ticularly the terminal ones. The joints become stiff and swollen, 
 are tender, and small nodular bony outgrowths develop at the 
 bases of the phalanges, which are known as Heberden's nodosi- 
 ties. The trouble gradually spreads to other joints, and although 
 there are often remissions, yet the condition progresses steaddy 
 until the patient may be entirely crippled thereby. Well marked 
 overgrowth of bone and eburnation of the articular ends are 
 characteristic features of this type. Sometimes there is consider- 
 able effusion, accompanied by overgrowth of the synovial villi, 
 but this is unusual. 
 
 3. The acute polyarticular variety does not often come to the 
 surgeon for treatment, at any rate in the early stages. It usually 
 
6oo 
 
 A MANUAL OF SURGERY 
 
 attacks young or comparatively young people, and females rather 
 than males, frequently following some infective trouble, such as 
 influenza, scarlatina, tonsillitis, etc. It is often ushered in by a 
 distinct febrile attack with persistent increase in the rate of the 
 heart-beat ; trophic and vasomotor phenomena are often co- 
 existent, such as patches of pigmentation, clammy cold hands, 
 and rapid muscular atrophy. The smaller joints of the hands 
 and feet are mainly affected, and that more or less symmetrically, 
 although the terminal interphalangeal articulations often escape. 
 The capsules are distended with a certain amount of effusion, 
 and at first there is but little osseous mischief. In not a few 
 cases a very characteristic deformity in the shape of ulnar 
 adduction of all the fingers occurs. Gradually the trouble 
 spreads to other and larger joints, and osseous manifestations 
 appear ; but the progress is slow, and may be to a large extent 
 arrested by treatment. Neighbouring lymphatic glands may be 
 enlarged in the early stages. 
 
 It is important to note that gouty and rheumatic troubles may 
 be associated with osteo-arthritis ; the rheumatic affections may 
 precede, the gouty usually follow. 
 
 The Diagnosis of osteo-arthritis per se is not often difficult in 
 a well-marked case, the crepitus, pain, and enlargement of the 
 ends of the bones, together with the slight amount of effusion, 
 constituting a tolerably characteristic picture. From simple 
 chronic synovitis it may be known by the history and smaller 
 amount of effusion, and by the pain and rigidity being frequently 
 more marked after rest, and diminishing after the joint has been 
 actively used. There is more difficulty in distinguishing the form 
 associated with increased effusion and enlargement of the synovial 
 villi ; careful examination may, however, enable the surgeon to make 
 out these villi moving to and fro in the joint under his hand, whilst 
 possibly the ends of the bone may be lipped. For diagnosis from 
 chronic rheumatism and Charcot's disease, see pp. 583 and 604. 
 
 The diagnostic points between polyarticular osteo-arthritis and 
 gout are suggested in the following table : 
 
 
 Osteo-arthritis. 
 
 Gout. 
 
 Sex : 
 
 Females : 
 
 Males : 
 
 Type of patient. 
 
 Poor, ill - nourished, de- 
 
 Well - to - do and well- 
 
 
 pressed, anxious; often ex- 
 
 nourished people. 
 
 
 posed to damp and cold. 
 
 
 Onset. 
 
 Insidious. 
 
 Sudden and obvious. 
 
 Locality of onset. 
 
 Usually in hands, espe- 
 
 Feet, especially metatarso- 
 
 
 cially in the thumb. 
 
 phalangeal joint of great 
 toe. 
 
 Type of attack. 
 
 No obvious swelling or 
 
 Red and painful at first, 
 
 
 redness. 
 
 with skin shiny over the 
 joint. 
 
 Pain. 
 
 Slight and aching. 
 
 Severe and acute. 
 
 Symmetry. 
 
 Well marked. 
 
 Not usually present. 
 
 Deposit of urate of 
 
 Absent. 
 
 Present. 
 
 soda. 
 
 
 
DISEASES OF JOINTS 60 1 
 
 The Prognosis is usually unfavourable. The fact that many 
 joints are affected is an indication that there is a considerable 
 constitutional tendency to the development of the disease, and 
 although it may be temporarily combated with success, still, 
 sooner or later, the patient is almost certain to be crippled by it. 
 The affection of only one joint often points to a traumatic origin, 
 and the outlook is correspondingly brighter ; but where the 
 disease attacks several parts of the body, there is but little hope 
 of checking it, and indeed cases are known in which every joint 
 has successively become implicated, the patient dragging on a 
 weary existence, never free from pain, and usually in a cramped 
 or sitting posture, until death from exhaustion supervenes. 
 
 Treatment. — For this troublesome complaint there is, unfor- 
 tunately, little that can be effected in the way of cure, although 
 much can be done to alleviate. Locally, the articulations should 
 be protected from cold and injury by being swathed in flannel, 
 whilst stimulating embrocations and sedative applications may be 
 beneficially employed. It is not advisable to maintain the joints 
 absolutely and always at rest, otherwise they tend to become 
 fixed, and their mobility is seriously limited at an unnecessarily 
 early date. Moreover, it is often found that the more a joint is 
 moved, the easier and less painful do those movements become, 
 and hence regular massage is desirable. As to general treat- 
 ment, the individual is warned against exposing himself to cold 
 and damp, and, since the disease is often considered to be due to 
 perverted or diminished nervous activity, all possible sources of 
 irritation and w T orry should be removed. At the same time the 
 nutrition must be improved, and plenty of good food, cod-liver 
 oil, etc., administered. A large number of different drugs have 
 been tried for this complaint, but none of them are very satis- 
 factory. Perhaps the best is iodide of sodium combined with 
 some alkaline purgative and hepatic stimulant, such as sulphate 
 of soda. Natural mineral waters and baths are often beneficial, 
 those of Bath and Buxton in this country being most frequently 
 recommended. Arsenic is sometimes useful in cases where the 
 disease is probably of nervous origin. 
 
 Occasionally operative treatment in the shape of excision may 
 be useful in this complaint, but only when the disease is limited 
 to one joint, and when it has progressed to such a stage as to 
 seriously cripple the patient's usefulness, as in the knee-joint, 
 elbow or the shoulder, or when the act of mastication is impaired, 
 owing to an affection of the temporo-maxillary articulation. In 
 suitable cases excellent results are obtained. 
 
 The hip-joint is not uncommonly the seat of osteo-arthritis in 
 old people, and it always causes a considerable amount of pain, 
 especially on flexion of the limb, rendering sitting difficult and 
 walking uncomfortable, whilst the movements are steadily more 
 
602 A MANUAL OF SURGERY 
 
 and more curtailed. The limb appears at first to be slightly- 
 increased in length, but later on becomes shortened from erosion 
 of the head and atrophy of the neck of the bone ; the trochanter is 
 also much thickened and more prominent than usual, on account 
 of the associated atrophy of neighbouring muscles. Well-marked 
 crepitus is obtained on moving the thigh. The acetabular cavity 
 is increased in size owing to the formation of a projecting rim or 
 lip. If a patient falls on the affected hip, some difficulty may be 
 experienced in making a diagnosis from fracture of the neck of the 
 thigh-bone. The previous history and the facts that the trochanter 
 rotates around its normal centre, and is unduly prominent rather 
 than approximated to the median line, and that the ilio-tibial band 
 is not relaxed, as in fractures, should suffice to prevent mistakes. 
 
 When the temporo -maxillary joint is affected, the condyle of the 
 jaw becomes larger than usual and somewhat flattened, whilst 
 the eminentia articularis is partially absorbed and the glenoid 
 cavity increased in size, so that there is a tendency for the 
 condyle to slip forwards owing to the action of the external 
 pterygoid muscles. If only one joint is affected, the bone is 
 carried towards the sound side, but when both are involved the 
 chin becomes prominent owing to a forward displacement of the 
 whole bone. Pain and crepitus are experienced on opening the 
 mouth, rendering mastication difficult, and even impracticable. 
 If ordinary treatment fails to give relief, the affected condyle of 
 the jaw should be excised. 
 
 For osteo-arthritis of the Spine, see Chapter XXII. 
 
 Neuropathic Arthritis (Syn. : Charcot's Disease). 
 
 This disease, bearing the name of the late Professor Charcot, is 
 a peculiar affection of joints met with in the course of locomotor 
 ataxy. It is slightly more common in women than men, and is 
 almost always an early manifestation, occurring usually between 
 the lightning-like pains and the onset of the ataxic symptoms. 
 The most typical form is lighted up by some slight injury — e.g., a 
 strain or sprain — and is characterized by a rapid painless dis- 
 tension of the joint with a light-coloured serum, which may also 
 extend into the communicating bursa? ; there is some amount of 
 effusion into the surrounding cellular tissue, although without 
 oedema. This distension may be so rapid that abnormal mobility 
 or even dislocation may occur at the end of a few hours. The 
 joints most frequently affected are the knee, hip, and shoulder ; 
 occasionally more than one articulation is involved. The course 
 of the case varies ; in some few instances the fluid is gradually 
 absorbed and the joint returns to its normal size and shape, 
 although somewhat weakened. Sometimes the attacks of dis- 
 tension recur, and after each the joint becomes more and more 
 crippled. In others, however, and perhaps most frequently, the 
 
DISEASES OF JOINTS 
 
 b03 
 
 bones become eroded to a considerable extent, the ligaments 
 stretched, and a weak, flail-like articulation remains, in which 
 the ends of the bones are atrophied and displaced (Figs. 217 
 and 218). In other instances new osseous formations occur here 
 and there under the synovial membrane, especially in cases where 
 there is much distension, so that on compressing the swelling 
 between the hands a sensation is produced similar to that im- 
 parted by grasping a bag of bo.ies. Occasionally, under these 
 
 Fig. 216. — Hypertrophic Variety of 
 Charcot's Disease of Knee Joint. 
 (From College of Surgeons' Mu- 
 seum.) 
 
 The patella (pat.) can be seen poised on 
 the top of a mass of new bone formed 
 by the welding together of a number of 
 smaller portions formed in the peri- 
 synovial tissues. 
 
 Fig. 217. — Atrophic Variety of 
 Charcot's Disease of Knee 
 Joint. (From College of 
 Surgeons' Museum.) 
 
 The bones are cleanly eroded, and 
 no new formation is present. 
 The patella is reduced to a mere 
 shell, one eighth of an inch 
 thick. 
 
 circumstances, the osseous masses become welded together, giving 
 rise to large overgrowths, which lead subsequently to fixation of 
 the joint (Fig. 216). The disease sometimes runs a more chronic 
 course, and then closely resembles osteo-arthritis, since there is 
 but little effusion, whilst the ends of the bones become eroded, 
 and osteophytes, perhaps of great size, form around the edges of 
 the cartilages, leading to defective mobility and crepitus. 
 
 The Diagnosis of Charcot's disease from osteo-arthritis is, as a 
 rule, readily made if one remembers the following points : Charcot's 
 
604 
 
 A MANUAL OF SURGERY 
 
 disease is usually characterized by a rapid onset, limitation to one 
 joint, considerable effusion, absence of pain, atrophy of the ends 
 of the bones, and a tendency to the production of a weak, flail-like 
 joint, whilst the general signs of tabes are also observed. Osteo- 
 arthritis, on the other hand, comes on slowly, often affects many 
 joints, has but little effusion, is very painful, and is attended with 
 overgrowth tending to produce ankylosis. In the more chronic 
 cases the distinguishing features are much less evident. 
 
 As to pathological anatomy, the changes observed are prac- 
 tically identical with those seen in osteo-arthritis, except that the 
 erosion is more rapid, the effusion greater, and the formation of 
 osteophytes less constant. 
 
 The Treatment of Charcot's disease consists in keeping the 
 
 Fig. 218. — Charcot's Disease of Left Knee and Shoulder 
 
 The great atrophy of the ends of the bones, and the resulting dislocations, are 
 
 clearly evident. 
 
 limb at rest on a splint and applying elastic pressure. The 
 effusion, when considerable, may be removed by an aspirator, but 
 is very likely to re-collect. In the later stages, where the joint 
 is entirely disorganized, some form of fixed apparatus may be 
 applied to render the limb more useful, or, failing that, amputation 
 may be required. 
 
 The same type of articular lesion occurs in Syringomyelia, a disease which 
 consists in a gliomatous development in the spinal cord, and usually in 
 the cervico-dorsal region. It is characterized by loss of the senses of pain, 
 and of heat or cold, but tactile and muscular sensibility persists. Atrophy 
 of various muscles of the hand or forearm also occurs, whilst trophic lesions, 
 e.g., whitlow, perforating ulcer, etc., are common. Joint troubles are observed 
 in at least one-third of the cases, mainly in the upper extremity, tabes 
 generally affecting the lower. Either atrophic or hypertrophic phenomena 
 are developed, and the course is identical with that of Charcot's disease, 
 except that suppuration is a little more likely to follow, owing to the frequent 
 presence of septic sores. 
 
 i Somewhat similar in nature to Charcot's disease is the chronic arthritis met 
 with in many conditions where the nervous supply to a limb is impaired as a 
 result of central or peripheral disease of the nervous system. Thus, it may 
 follow spina bifida, hemi- or para-plegia of cerebral or spinal origin, or may 
 
DISEASES OF JOINTS 605 
 
 be secondary to a peripheral neuritis, due to either injury, syphilis, gout, 
 diabetes, leprosy, etc The terminal articulations of fingers or toes are those 
 most often affected (acro-arthritis), although larger joints may be involved. 
 They become swollen and painful, and after a time ankylosis ensues. 
 
 Haemophilic Diseases of Joints. 
 
 In haemophilia (p. 245) any injury to a joint, such as a sprain 
 or wrench, may lead to a copious effusion of blood into the 
 articular cavity, which becomes suddenly swollen, distended, and 
 evidently full of fluid. There is some pain on movement, the part 
 becoming hot and tender, whilst when coagulation has taken place 
 it is hard and firm. Total recovery may ensue, or the joint be left 
 weak and liable to recurrence of haemorrhage and inflammation. 
 The effects on the articular surfaces are curious : the cartilages 
 usually retain their normal colour, but become thin, worn, and 
 rough, especially at the points of greatest pressure ; fibrillar 
 degeneration of the matrix may occur, and in some cases the 
 cartilage has been found totally absent, being replaced by fibrous 
 tissue. Ecchondroses subsequently developing into bone are 
 formed at the margins of the joint surfaces, the changes thus 
 produced being somewhat akin to those of osteo-arthritis. The 
 ligaments and synovial membranes may remain of a normal 
 texture, or are slightly thickened, and usually of a russet-brown 
 colour. Adhesions are often present, causing considerable impair- 
 ment of mobility. The treatment consists in keeping the part at 
 rest, and applying ice in the early stages ; whilst, later on, 
 friction, massage, and pressure may be employed. The surgeon 
 must never attempt to aspirate the joint, even with a fine needle. 
 
 Loose Bodies in Joints. 
 
 Several varieties of loose bodies are met with in joints, which 
 may be described as follows : (1) The so-called 'melon-seed bodies' 
 consist of dense fibroid tissue derived from altered blood-clot, or 
 more frequently from a fibrinous exudation in cases of very chronic 
 tuberculous disease. At first irregular in shape and laminated in 
 texture, they are generally transformed into round pellets or 
 elongated masses by the movements of the articulation. Bursas 
 and tendon sheaths are much more frequently affected than joints. 
 The number present is usually considerable, whilst there is also 
 some glairy effusion, causing distension and a certain amount of 
 creaking. A few years ago we operated on a case in which the 
 knee-joint was occupied by a number of rounded yellowish-white 
 foreign bodies, several of which were nearly as large as walnuts ; 
 they were probably of haemorrhagic origin. (2) Portions of 
 articular or interarticular cartilage may be broken off as a result of 
 mechanical violence. They usually consist of a smooth rounded 
 mass of articular cartilage enclosing a central bony nucleus 
 (Fig. 219). (3) They are sometimes derived from the develop- 
 
606 A MANUAL OF SURGERY 
 
 ment of cartilaginous nodules in the synovial fringes or villi, 
 which may either remain adherent and become pedunculated, then 
 occasionally wearing a bed for themselves in the articular surface, 
 or may be totally detached. Such structures are usually lobu- 
 lated and irregular in shape, and consist of calcified cartilage or 
 bone, whilst a certain amount of normal cartilage is also present 
 (Fig. 220). It is not at all uncommon for this condition to be met 
 with in osteo-arthritis, but sometimes the cartilaginous cells from 
 which they are derived have persisted as a ' fcetal residue' owing 
 to some modification in development. (4) Finally, portions of bone 
 may become separated from their surroundings, and remain loose 
 in the cavity. Thus, ecchondroses may be broken off in cases of 
 osteo-arthritis, or portions of the articular surface detached by 
 mechanical means, or even sclerosed areas isolated by a process 
 
 Fig. 219. — Foreign Body in Joint, probably derived from a Portion of 
 Articular Cartilage. (From College of Surgeons' Museum.) 
 
 A, cartilage ; B, bone. 
 
 of rarefying osteitis without suppuration, constituting what Paget 
 originally described as ' quiet necrosis.' 
 
 Although cut off from all vascular supply, the growth of some 
 of these loose bodies is said to continue, owing to the highly 
 nutritious fluid which bathes their surfaces. 
 
 The Symptoms caused by this condition are produced by the 
 loose body being occasionally caught between the articular 
 surfaces, leading to a temporary locking of the joint and severe 
 pain, owing to the stretching of the ligaments. The fixation is 
 but momentary, since the foreign body is readily displaced, but 
 an attack of subacute synovitis follows. When this has happened 
 several times, the ligaments are likely to become relaxed, and 
 the joint somewhat loose and distended. Under such circum- 
 stances it may be possible to feel the foreign body and to shift 
 its position, but frequently the surgeon, owing to its ready 
 mobility, is unable to detect the intruder as it slips away into the 
 interior of the joint. From this point of view, the German term 
 'Gelenkmaus' (joint mouse), as applied to this affection, is most 
 
DISEASES OF JOINTS 
 
 607 
 
 happy. The knee-joint is that most frequently affected, but the 
 same condition occurs in the elbow and temporo - maxillary 
 articulation. 
 
 The Diagnosis between a loose body and a displaced semilunar 
 cartilage in the knee-joint is not always easy, since in both con- 
 ditions painful locking of the joint occurs. The fixation, however, 
 is but momentary in the case of a loose body, but may persist 
 until reduced in the latter, whilst a localized spot of tenderness 
 may be detected corresponding to the site of the injury to the 
 interarticular cartilage. Moreover, the history of the case is very 
 different, since the dislocation of a semilunar cartilage is always 
 primarily referred to some twist or sprain of the joint, whereas 
 with a loose body no such traumatic influence need be present. 
 
 Fig. 220. — Loose Cartilage in Joint, probably developed in a Fringe 
 of Synovial Membrane. (From College of Surgeons' Museum.) 
 
 A, cartilage ; B, bone. 
 
 The Treatment consists in the removal of the foreign body. In 
 former days this was done by means of various subcutaneous 
 operations which it is unnecessary to describe here, since at the 
 present time removal by the open method is always practised. In 
 the knee-joint a vertical incision should be made, about 2 inches in 
 length, extending a little above and below the line of the articula- 
 tion. It should be placed about 1 inch from the patella, on which- 
 ever side the loose cartilage presents most frequently, but prefer- 
 ably on the outer. If possible, the foreign body should be fixed by 
 the finger in one of the lateral pouches of the joint before making 
 the incision. •¥ The capsule and synovial membrane are opened, 
 the loose body removed, and the cavity washed out, if thought 
 desirable, with sterilized saline solution. The wounds in the 
 
6o8 A MANUAL OF SURGERY 
 
 synovial membrane, capsule, and skin are then carefully sutured. 
 The joint should be kept at rest subsequently for two or three 
 weeks, and an elastic knee-cap worn for some time. 
 
 Neuralgic Joints. 
 
 In neurotic individuals, especially young women, a neuralgic 
 condition of the joints is commonly met with, simulating disease 
 of the articulation. On careful examination the pain is found to be 
 superficial, not increased by jarring the articular surfaces together, 
 and often not strictly confined to the joint. The movements 
 are apparently limited, but if the attention of the individual is 
 diverted, or anaesthesia induced, they are found to be perfectly 
 free. There are no signs of effusion into the cavity, and no starting 
 pains at night. Occasionally a similar condition is met with in 
 men, where there is no suspicion of hysteria. 
 
 The treatment is constitutional and local. The former is directed 
 towards improving the general health, and correcting any error 
 in the uterine functions. The latter is best accomplished by the 
 use of cold douches and electricity, although counter-irritation in 
 the shape of blisters, or even the actual cautery, has an excellent 
 moral effect. 
 
 Ankylosis. 
 
 By ankylosis is meant a condition of immobility, partial or 
 complete, of a joint, resulting from some preceding inflammation 
 of the articular structures. 
 
 The term false ankylosis is sometimes applied to a condition 
 resulting from extra-articular lesions. Such may be either 
 fibrous or osseous, and is due to cicatricial contraction of the 
 skin, shortening of muscles, or even to the development of bony 
 tissue within them (myositis ossificans). True ankylosis always 
 involves the articular structures, and is either fibrous or bony. 
 
 Fibrous or incomplete ankylosis results (a) from thickening and 
 contraction of the ligaments, such as often occurs after gonorrhceal 
 or rheumatic affections ; (b) from the formation of cord- or band- 
 like adhesions within the joint, after acute synovitis ; (c) from 
 erosion of the cartilage and exposure of the bone ; granulations 
 sprout up on each side, and by their union lead to dense fibroid 
 adhesions between the articular surfaces. Some amount of move- 
 ment is possible in most of these cases. 
 
 Complete or osseous ankylosis (synostosis) arises from the union 
 of either the whole or part of the opposing surfaces left by the 
 destruction of the cartilage, the bond of union, at first fibro- 
 cicatricial, being subsequently ossified (Fig. 221) ; it may also be 
 due to the interlocking and fusion of osteophytes, formed at the 
 margin of the bone in osteo-arthritis or Charcot's disease. 
 
DISEASES OF JOINTS 
 
 609 
 
 The Causes of ankylosis are very variable, but may be arranged 
 as follows : 
 
 1. Injury to the articular surfaces, as from fractures which run 
 into a joint. 
 
 2. Non - suppurative inflamma- 
 tions of joints, involving the for- 
 mation of fibrous adhesions or the 
 contraction of ligaments, as in 
 synovitis, whether traumatic, rheu- 
 matic, gouty, gonorrhceal, etc., and 
 the early stages of acute or tuber- 
 culous arthritis. 
 
 3. Destruction of bones, asso- 
 ciated or not with articular diseases, 
 as in Pott's disease of the spine, 
 and the later suppurating stages of 
 acute or tuberculous arthritis. 
 
 4. Nervous affections are occa- 
 sionally the cause of ankylosis, 
 by leading to a chronic form of 
 arthritis. The lesions may be 
 central, as in spina bifida, tabes 
 and syringomyelia ; or peripheral, 
 as in neuritis, Raynaud's disease, 
 diabetes, leprosy, or division of 
 nerves. 
 
 5. Long - continued abnormal 
 pressure of contiguous bones may 
 result in ankylosis, as in scoliosis or 
 
 osteoarthritis of the spine. In the latter affection the immobility 
 may be due either to ossification of ligaments or to the interlocking 
 of osteophytes. 
 
 The position in which ankylosis occurs and the effects thus pro- 
 duced differ according to the joint affected. 
 
 In the shoulder there is but little displacement, and the existence 
 of immobility is of comparatively little importance, owing to the 
 free movements of the scapula and clavicle. The elbow-joint is 
 very commonly ankylosed on account of its exposed position, and 
 the frequency of fracture-dislocations in its neighbourhood. The 
 formation of callus, and the adhesions likely to form within the 
 joint in these cases, readily explain its frequency. The most 
 favourable position for ankylosis is when the arm is flexed to a 
 little more than a right angle, with the hand midway between 
 pronation and supination. By this means access to the mouth is 
 possible, and the patient can use his hand for feeding purposes. 
 The -wrist is most commonly fixed as a result of gonorrhceal or 
 rheumatic synovitis. In the hip-joint (Fig. 221) much depends 
 upon^the treatment as to whether the ankylosis takes place in a 
 
 39 
 
 Fig. 221. — Ankylosis of Hip- 
 joint in Good Position after 
 Early Hip Disease. (Howard 
 Marsh.) 
 
6io A MANUAL OF SURGERY 
 
 good or bad position. In neglected cases the thigh may be in a 
 position of adduction and internal rotation, crossing in front of the 
 other leg. Occasionally a scissor-like deformity has resulted from 
 inflammation of both hip-joints, one leg lying in front of the 
 other ; progression is accomplished with difficulty, the body 
 twisting at each step, and crutches are often needed. In the knee- 
 joint ankylosis in an absolutely straight position of the limb should 
 not be aimed at, since slight flexion renders the leg more useful 
 both in walking, mounting stairs, and sitting down. In the ankle- 
 ioint considerable trouble may arise from immobility, unless the 
 foot is at right angles to the leg. 
 
 Treatment. — Fibrous ankylosis may be treated by forcible, 
 though judicious, manipulation of the limb under an anaes- 
 thetic, thereby rupturing adhesions ; the limb is kept at rest 
 for a few days, and then massage and passive movements are 
 employed. If massive adhesions are present, but little good 
 as regards mobility results from such treatment, since even 
 if ruptured by the manipulations, they are almost certain 
 to reunite ; in tuberculous cases it is unwise to attempt this 
 for fear of diffusing or again lighting up the disease. It must 
 not be forgotten that marked atrophy of bone is often associated 
 with this condition, and therefore a fracture can easily be produced. 
 
 For osseous ankylosis various operative measures may be 
 employed, with a view either to correct the deformity, or in other 
 cases to restore movement to the part. At the shoulder, wrist and 
 ankle nothing need be undertaken unless obvious and troublesome 
 deformity is present. At the elbow excision may be beneficially 
 employed, and with every prospect of gaining a moveable joint. 
 If, however, ankylosis is present in a child, the operation should 
 be deferred until growth has come to an end. Ankylosis of the 
 knee in a false position needs cuneiform osteotomy, or the resection 
 of a wedge-shaped portion of bone, in order to secure a straight, 
 rigid and useful limb. 
 
 Ankylosis of the hip-joint in a bad position is best treated by 
 dividing the neck or the upper part of the shaft of the femur. 
 Several operations have been devised for this purpose : i. Adams' 
 subcutaneous osteotomy of the neck of the bone consists in passing 
 a sharp-pointed bistoury down to the anterior surface of the cervix 
 femoris, from a point midway between the trochanter and the 
 anterior superior spine of the ilium. A track is thus made, 
 allowing the introduction of an Adams' osteotomy saw, by means 
 of which the neck of the femur is divided subcutaneously. The 
 limb is put up in a straight position, and the bone allowed to 
 reunite. 2. The same result may be obtained by an open method, 
 making the same incision as in the anterior operation for excising 
 the joint (p. 624). Gant suggested division below the lesser 
 trochanter. This may be accomplished by cutting down on the 
 bone from the outer side and chiselling it across. 
 
DISEASES OF JOINTS 
 
 611 
 
 As to the operation to select in any particular case, the surgeon's 
 choice must be guided by the condition of affairs present. A 
 skiagram of the neck of the femur should always be taken so 
 as to ascertain its condition. Sometimes it is stunted, and has 
 practically disappeared ; in other cases it is much thickened, and 
 forms a large bony mass passing from the trochanter to the ilium, 
 and probably containing encapsuled foci of tuberculous material. 
 In both these conditions subtrochanteric osteotomy must be 
 employed, and it is not unusual to find that the adductor muscles 
 are so contracted, that their attachments to the pubes require 
 section before the limb can be satisfactorily straightened. Division 
 of the cervix can only be recommended when that structure is of 
 normal length and size. 
 
 Hip-joint Disease. 
 
 Although the term ' hip-joint disease ' is usually applied to a 
 tuberculous arthritis, it is not the only affection involving this 
 
 Fig. 222. — Tuberculous Disease of the Head and Neck of the Femur, 
 showing Sequestra in an Abscess Cavity, and Communication on 
 the Under Side of the Neck with the Joint. (Tillmanns.) 
 
 The epiphysis of the head has been invaded, and the articular 'cartilage 
 entirely stripped off by the disease; the continuous black line "indicates 
 the amount of bone which it would be necessary to remove. 
 
 articulation. Simple synovitis occurs in the course of rheumatic, 
 gonorrhoeal, or pyaemic affections. Acute arthritis is also met 
 with secondary to an acute infective osteomyelitis of the upper 
 end of the femur, and is evidenced by all the ordinary signs of 
 that affection, separation and necrosis of the upper epiphysis 
 being a frequent result. Osteo-arthritis is not uncommon (p. 601), 
 whilst Charcot's disease may also occur ; but none of these call 
 for special mention here. 
 
 Tuberculous Disease of the Hip (Syn. : Morbus Coxae, Tuberculous 
 Coxitis, Coxalgia) differs in no respect from the same disease as it 
 
 39—2 
 
6l2 
 
 A MANUAL OF SURGERY 
 
 affects other joints, and hence no detailed notice of the pathological 
 anatomy is required. Suffice it to say that it may originate in the 
 synovial membrane or bone, more frequently in the latter, and 
 then commencing either beneath the articular cartilage or in 
 connection with the epiphyseal cartilage of the caput femoris 
 (Fig. 222). Very rarely the disease becomes circumscribed in 
 the neck of the bone, forming a chronic abscess, the diagnosis of 
 which is exceedingly difficult. More usually the disease spreads 
 to the under side of the neck, and thus involves the synovial 
 membrane, which passes into a state of pulpy degeneration. The 
 
 ■ .^ ' : '*''- 
 
 Fig. 223. — Femur and Acetabulum in Hip Disease. (King's College 
 
 Museum.) 
 
 The epiphysis of the caput femoris has been practically destroyed, and the 
 acetabulum is enlarged by absorption of its posterior margin, and dis- 
 placed upwards [travelling acetabulum). The rami of the ischium and 
 pubes have been removed. 
 
 substance of the epiphysis is invaded, and caries of the head is 
 thereby produced, together with necrosis or ulceration of the 
 cartilage. The acetabulum undergoes similar changes ; from 
 the contact and backward pressure of the diseased head the 
 posterior acetabular margin is absorbed and the cavity extended, 
 whilst at the same time a new rim of bone forms beneath the 
 adjacent periosteum at a slightly higher level, thus giving rise to 
 what is known as a ' travelling acetabulum' (Fig/ 223). In this 
 way the socket is increased both in size and depth, travelling 
 
DISEASES OF J 01 NTS 
 
 6i3 
 
 backwards and upwards with the head of the bone towards the 
 dorsum ilii. Other factors assisting in the displacement of the 
 head of the bone are : the tonic action of the muscles, keeping the 
 limb in a position of flexion, adduction, and inversion, thereby 
 causing a considerable portion of the head to project out of the 
 acetabulum ; and the early softening and destruction of the pos- 
 terior ligaments, which are much thinner than those in front of the 
 joint. Occasionally a mass of protuberant granulations sprouts up 
 from the centre of the cavity, and may also assist in this process. 
 Should the acetabulum be perforated, a tuberculous abscess is 
 likely to form within the pelvis. The adjacent pelvic bones may 
 
 A B CD 
 
 Fig. 224. — Diagram to Illustrate the Positions assumed by the Limb 
 
 in the Early and Late Stages of Hip Disease. 
 
 A represents the position of abduction taken by the right limb in the early 
 stage of hip disease, and B, Nature's method of masking this by tilting 
 the pelvis down on the affected side, whilst the other leg is adducted; the 
 effect of this on the spine, in causing a lateral deflection, is also indicated. 
 C shows the same thing in the later stage, when adduction is present, 
 and the pelvis is tilted upwards on the affected side, thus producing 
 apparent shortening (D). 
 
 either become thickened by the deposit of osteophytes, or carious ; 
 if sepsis is present, necrosis may also supervene. 
 
 Clinical History. — The patient, usually a child, is observed to 
 limp, and may complain of pain either in the hip or inner side of 
 the knee, the latter being due to the fact that both joints are 
 supplied by the same nerves, viz., the anterior crural, sciatic, and 
 obturator trunks. There may be some history of injury, but not 
 necessarily. On examining the limb in the early stage, it is 
 usually found to be apparently lengthened, whilst the thigh is 
 slightly wasted. The nates are flattened, and the gluteal fold 
 lost, conditions partly due to atrophy of the muscles, partly to 
 the flexion of the limb. The joint is more or less rigid, and pain 
 is produced on attempting to move it, or on jarring the leg, as by 
 striking the heel or trochanter. The position assumed in this 
 
614 
 
 A MANUAL OF SURGERY 
 
 early stage is one of slight and increasing flexion, abduction, and 
 eversion (Fig. 224, A), the reason for this being that thereby the 
 ligaments, and especially the ilio-femoral, are most relaxed, and 
 the capacity of the joint is at its greatest. The latter fact has 
 been demonstrated in the healthy cadaver by inserting the nozzle 
 of a syringe into the joint through the acetabulum, and forcibly 
 injecting fluid, when this position is at once assumed. The 
 flexion and abduction, however, are not always evident, since the 
 flexion is masked by lordosis of the spine (Figs. 225, 226), and 
 the abduction by the pelvis being tilted down on the affected 
 side, producing thereby apparent lengthening of the diseased 
 limb and lateral curvature of the spine, with its lumbar convexity 
 
 Fig. 225. — Hip Disease, with Well-Marked Compensatory Lordosis, 
 caused by Extending the Legs Flat on the Table. 
 
 Fig. 226. — On Flattening the Spine against the Couch by raising the 
 Unaffected Left Leg and pressing it up against the Abdomen, the 
 Degree of Flexion of the Right Thigh at once becomes Obvious. 
 
 towards the affected side (Fig. 224, B). The sound leg being 
 brought into a position of adduction, the parallelism of the limbs 
 is maintained. The flexion can be demonstrated by any method 
 which obliterates the lumbar curve of the spine, as by fully 
 bending up the sound limb on the abdomen, the affected thigh 
 rising at once from the bed and forming an angle which indicates 
 the amount of flexion (Fig. 226). The abduction is demonstrated 
 by laying a rod across the two anterior superior spines, and 
 placing another at right angles to its centre. This will not 
 correspond with the line of the body or of the limb, but makes 
 an angle with it. The eversion cannot be masked. The rigidity 
 is easily demonstrable in that all movements of the hip-joint are 
 greatly limited ; thus if an attempt is made to bend the affected 
 
DISEASES OF JOINTS 615 
 
 thigh on the abdomen, the corresponding side of the pelvis is 
 raised with it from the bed. 
 
 As the disease progresses, and the bones become more exten- 
 sively affected, the pain increases, with nocturnal startings, whilst 
 abscesses form, and a certain amount of fever and constitutional 
 disturbance is caused thereby. The position of the limb also 
 changes ; for although the flexion is maintained and even in- 
 creased, adduction and inversion are now associated with it. 
 The pelvis is tilted up on the affected side (Fig. 224, C and D), 
 causing appavcnt shortening, lateral curvature with a lumbar con- 
 vexity to the sound side, and abduction of the healthy limb. 
 No satisfactory cause for this position can be given, but it is 
 usually attributed to the yielding of the posterior and outer part 
 of the capsule, together with infiltration and weakening of the 
 small external rotator muscles, allowing the adductors and internal 
 rotators unopposed play. 
 
 When an abscess has formed, the most usual situation for it to 
 point is a little in front of and internal to the great trochanter, 
 close to the insertion of the tensor fasciae femoris. It may reach 
 that spot either from an opening in the anterior part of the 
 capsule, coming thus to the surface along the line of least 
 resistance, or it may burrow from the posterior portion of the 
 capsule along the rotator muscles and superior gluteal nerve. 
 Less frequently abscesses pass directly backwards to open in the 
 gluteal region, or forwards along the pubo-femoral ligament, 
 pointing on the inner side of the femoral vessels below Poupart's 
 ligament. As a rare complication, the tuberculous process may 
 extend to the bursa under the psoas tendon, which usually com- 
 municates with the joint, leading to the formation of an abscess 
 in the lower part of Scarpa's triangle, and occasionally a typical 
 psoas abscess results from an extension upwards within the sheath 
 of the muscle of a tuberculous infection from this bursa. An intra- 
 pelvic abscess following perforation or disease of the acetabulum 
 may either burrow upwards, and come to the surface on the inner 
 side of the vessels above Poupart's ligament ; or it may gravitate 
 downwards, and burst in the ischio-rectal fossa, close to the tuber 
 ischii. 
 
 The final stage of the disease is one of real shortening (Fig 227), 
 due to erosion of the head of the bone and its displacement back- 
 wards upon the dorsum ilii. The position assumed is one of 
 increased flexion, adduction, and inversion ; whilst if septic 
 sinuses persist, hectic fever and amyloid changes in the viscera 
 are likely to follow. 
 
 At any stage cure by ankylosis may be obtained ; but unless 
 the abnormal position has been corrected by extension, deformity 
 is almost certain to be present. 
 
 The Diagnosis of hip disease appears to be a matter of con- 
 siderable difficulty to some, if we may argue from the mistakes 
 
6i6 
 
 A MANUAL OF SURGERY 
 
 which commonly occur. The pain in the knee present in the 
 early stages leads to its frequently being mistaken for disease of 
 that articulation ; a very slight amount of care in the examination 
 should prevent such an error. From disease of the opposite hip, it 
 is recognised by the relative mobility of the thigh on the two 
 sides. The diagnosis from sacw-iliac disease is given at p. 619. 
 Spinal mischief may also be confounded with it, if a psoas abscess 
 points at any of the ordinary situations in which sinuses form in 
 connection with the hip-joint. The presence of spinal deformity 
 and the ability to perform the test movement for hip disease 
 
 A B 
 
 Fig. 227.— Position- of the Limb in the Later Stages of Hip Disease. 
 A shows more especially the adduction and inversion ; B, the flexion and 
 compensatory lordosis. 
 
 should readily enable the surgeon to make a correct diagnosis, 
 but it must not be forgotten that the two conditions may co-exist. 
 If the limb can be put into what is known as the tailor's position 
 — that is, flexion to a right angle with marked abduction and 
 aversion — one may be practically certain that hip disease is not 
 present. 
 
 An encapsuled abscess in the neck of the femur is a condition which 
 it is very difficult to distinguish from true hip disease. A constant 
 deep boring pain is complained of, which is increased by pressure 
 over the neck, or by jarring the trochanter ; but if the limb is 
 manipulated gently, it can be proved that the movements of the 
 joint are not really impaired. 
 
 The Prognosis of hip disease is by no means unfavourable if the 
 
PLATE XXIX. 
 
 5 3 
 
 w c 
 
 - 3 
 
 - » 
 
DISEASES OF JOINTS 
 
 617 
 
 condition is properly treated. Of course, the patient is liable to 
 develop acute tuberculosis or tuberculous disease elsewhere ; or, 
 if abscesses are allowed to become septic, serious complications — 
 such as pyaemia, sapraemia, hectic and amyloid disease — may 
 ensue. Apart from these, however, no serious consequences 
 affecting life need be feared, although the usefulness of the limb 
 may be seriously crippled from shortening or ankylosis, especially 
 if the latter occurs in a faulty position. 
 
 The Treatment ot hip disease must be conducted along the 
 same lines as for tuberculous lesions generally. In the early stages 
 the limb is kept at rest by the application of a Liston's splint, or it 
 may be placed between sandbags, and a weight and pulley attached. 
 By this means not only is rest assured, but deformity is prevented. 
 If the amount of flexion is slight, the limb may be allowed to lie 
 on the bed in the horizontal posture ; this will possibly induce 
 some compensatory lordosis, but as 
 the muscular spasm relaxes, the 
 curvature of the spine disappears. 
 When, however, a considerable de- 
 gree of flexion is present, extension 
 must be made along the axis of the 
 flexed limb, which is supported on 
 pillows. It will be found that after 
 a few days the flexion diminishes, 
 and the limb will then gradually 
 assume the horizontal position. 
 Should this precaution not be 
 adopted, the extension merely pro- 
 duces lordosis, and the pain from 
 intra-articular tension is increased 
 thereby. The general health of the 
 patient must at the same time be 
 attended to, and cod-liver oil and 
 syrup of the iodide of iron may be 
 administered with benefit. When 
 the more urgent symptoms have dis- 
 appeared, a Thomas's hip-splint is 
 applied, so as to enable the patient 
 to get about (Fig. 228). This con- 
 sists of a flat bar of malleable iron, 
 about an inch and a half wide, ex- 
 tending from the axilla to below the knee ; it is shaped so as to 
 fit the varying curves of the body, and cross-pieces embrace the 
 trunk at the level of the nipples, as also the thigh and the calf ; 
 it is firmly bandaged to the body and limb. A patten is placed 
 under the boot of the sound leg, and the patient allowed to get 
 about on crutches. This apparatus should be worn for six 
 months after all signs of active disease have disappeared. It 
 
 Fig. 228. — Thomas's Hip- 
 splint APPLIED. 
 
6i8 A MANUAL OF SURGERY 
 
 may also be employed in the earlier and more painful stages if 
 it is at first bent so as to accommodate itself to the flexed position 
 of the limb ; as the effect of the rest becomes evident in a 
 diminution of muscular spasm, the splint can gradually be 
 straightened out, so that at length the limb is fully extended. 
 
 When abscesses form, they may be opened antiseptically and 
 drained, or preferably tapped and injected with iodoform, the 
 former precautions as to rest and constitutional treatment being 
 still maintained. More extensive operative measures — such as 
 excision of the head by the anterior method (p. 624) — are sometimes 
 undertaken in the early stages to cut short the disease, especially 
 when prolonged treatment is impracticable, as amongst the poor, 
 or when the general health and constitutional powers are defective. 
 The removal of the whole head necessarily involves the upper 
 epiphysis, and hence defective growth of the femur results, as well 
 as immediate shortening. For these reasons, as also because 
 repair is possible in most cases without operation (when there is a 
 certain amount of recuperative power and prolonged treatment is 
 feasible), this proceeding, at one time so common, is being dis- 
 carded more and more in favour of conservative measures. 
 
 It is sometimes possible, however, to save some portion of the 
 head, and if so, this should always be attempted. A very success- 
 ful series of cases has recently been published, in which the joint 
 was opened from the front, the interior freely curetted (in one case 
 after a temporary dislocation of the head), the bone scraped, and 
 in more than one case a channel gouged along its anterior wall to 
 expose and remove a deep focus. Indeed, when one attempts to 
 save the head of the femur in this way, it is always well to remove 
 the compact tissue from the front of the neck so as to expose and 
 explore the epiphyseal line. By this plan, shortening and defective 
 growth can to a large extent be avoided. 
 
 In the later stages, and especially where sinuses have formed in 
 the gluteal region or behind the trochanter, excision by the posterior 
 method (p. 625) is preferable ; this is usually an easy matter 
 since the head is probably eroded and displaced. The sinuses 
 should, if possible, be included in the incision, but under any cir- 
 cumstances must be opened up and scraped. When the aceta- 
 bulum is extensively implicated, the disease can only be satisfac- 
 torily dealt with by removing the head of the bone, and the posterior 
 method affords the best means of subsequent drainage ; of course 
 this presumes that the general condition of the patient has 
 not been seriously undermined, and that there is a good pros- 
 pect of gaining a useful limb. Otherwise amputation through the 
 hip-joint is required, especially when the mischief has extended 
 into the pelvis, or when, after excision, a weak, flail-like limb 
 results or osteomyelitis supervenes. It is also needed when after 
 excision sinuses persist and lead down into the acetabular cavity, 
 from which there is a plentiful secretion of pus, and over the 
 
DISEASES OF JOINTS 619 
 
 entrance to which the upper end of the femur is drawn, thereby 
 obstructing the escape of the discharge, and rendering dressing 
 both difficult and painful. The operation often gives most excellent 
 results, the patient's condition rapidly improving. Removal by 
 the anterior racquet method is perhaps the most convenient. 
 
 Disease of the Sacro-iliac Joint. 
 
 Tuberculous disease of this joint is most commonly met with in 
 adults, but rarely in children. It may commence in the synovial 
 membrane, but is frequently the result of mischief starting in the 
 pelvic bones, especially the ilium. The Pathological Anatomy 
 calls for no description, inasmuch as it follows the ordinary 
 course of tuberculous disease. 
 
 The Clinical Signs consist of pain and a sense of weakness in 
 the lower part of the back, increased by standing, walking, or 
 any movement — such as coughing, sneezing, and the like — which 
 calls the flat abdominal muscles into sudden action and drags on 
 the ilium. It is of a very unpleasant character, a sensation as if 
 the pelvis were coming to pieces being experienced by the un- 
 fortunate individual. Owing to the fact that the lumbo-sacral 
 cord passes in front of the articulation, pain is often referred to the 
 gluteal region or down the leg. Movements of the limb cause 
 pain if the pelvis is not supported, but can be freely performed if 
 the pelvis is steadied. Compression together of the innominate 
 bones, or their forcible separation, is the means of most effectually 
 demonstrating the existence and situation of the pain. The 
 patient is unable to stand or to put any weight on the affected 
 limb, and hence limps during walking, allowing his body to lean 
 forwards, and making use of a stick. There is apparent lengthen- 
 ing on the affected side, but on measurement from the anterior 
 superior spine to the internal malleolus the leg is found to be of 
 the same length as its fellow. This appearance is due to the fact 
 that the whole innominate bone is tilted downwards and forwards, 
 so that the anterior superior spine is at a lower level and more 
 prominent than that on the opposite side. The region of the 
 synchondrosis is often swollen, puffy, and tender ; whilst after a 
 time abscesses form, which may either point immediately over 
 the articulation, or burrow upwards into the lumbar region, or 
 forwards into the groin, or downwards into the pelvis, opening in 
 the ischio-rectal fossa. The last is a most serious complication, 
 since it necessarily introduces the septic element. 
 
 The Diagnosis needs to be made from sciatica, hip disease, and 
 spinal disease. Sciatica is known by the character of the pain, 
 which shoots down the back of the thigh in the course of the great 
 sciatic nerve, which may be distinctly tender on pressure. There 
 is no apparent elongation of the limb, and compression together 
 of the pelvic crests is painless. From affections of the hip-joint, 
 
6ao A MANUAL OF SURGERY 
 
 sacro-iliac disease is recognised by the fact that, if the pelvis is 
 supported, the thigh may be moved in all directions without great 
 discomfort ; whilst compression of the pelvis in hip disease causes 
 no pain. Moreover, in the advanced stages of hip disease, there 
 is apparent or real shortening, a condition never noticed in the 
 sacro-iliac affection. From spinal disease, the diagnosis should not 
 be difficult if a careful examination of the spine and pelvis is 
 made. 
 
 The Prognosis of sacro-iliac disease, though usually stated to 
 be unfavourable, is not necessarily so if asepsis is maintained ; it 
 is the admission of the septic element that constitutes the main 
 danger. When affecting girls, it may lead to subsequent deformity 
 of the pelvis and trouble in parturition. 
 
 Treatment in the early stages consists in absolute rest, with 
 the application of a pelvic support, and attention to the general 
 health, combined possibly with local counter-irritation. When 
 abscesses form, they should be freely opened, and if diseased bone 
 can be felt with a probe, it should be scraped or cut away, and 
 the parts swabbed over with pure carbolic acid. Occasionally it 
 is necessary to remove the posterior part of the iliac crest in the 
 neighbourhood of the posterior superior spine in order to gain 
 access to the diseased area ; this may be accomplished by the 
 chisel or trephine through a vertical incision, and we have had a 
 number of excellent results from this proceeding. 
 
 Excision of Joints. 
 
 Excision of joints is an operation which, though formerly 
 undertaken in a few isolated instances for compound fractures 
 and dislocations, has only during the past fifty years been estab- 
 lished on a scientific basis, or utilized to any great extent. The 
 late Sir William Fergusson was one of the chief pioneers in this 
 branch of operative surgery, and to his skill and insight we owe 
 much of what has thus been gained. Since the introduction of 
 antisepsis, however, the operations have been still further elabo- 
 rated, and excision is now undertaken for many conditions that 
 formerly would not have been so treated. The chief articular 
 lesions for which excision, partial or complete, is now recom- 
 mended are as follow : i, For compound dislocations or fracture- 
 dislocations ; 2, for various forms of simple or comminuted 
 fracture in the neighbourhood of joints where ankylosis is likely 
 to follow, and either interfere seriously with the utility of the 
 joint or fix it in a bad position ; the shoulder and elbow are the 
 joints most frequently dealt with in this way; 3, for some forms 
 of congenital or old-standing dislocation which cannot be other- 
 wise remedied ; 4, in the later stages of acute arthritis, where 
 the ends of the bones are carious, the joint disorganized, and 
 chronic suppuration is present ; 5, in tuberculous arthritis, where 
 
DISEASES OF JOINTS 621 
 
 palliative treatment has failed to cut short the disease, or where 
 disorganization of the joint has occurred with erosion of the ends 
 of the bones ; 6, for ankylosis of certain joints, consecutive to 
 arthritis, either acute, tuberculous, or syphilitic, especially if in a 
 bad position ; 7, for osteo-arthritis in special regions. 
 
 The results to be attained necessarily vary in the different 
 joints, and according to the particular causes. Sometimes anky- 
 losis in a good position is all that can be expected, in others a 
 freely moveable pseudarthrosis ; in some cases the removal of 
 certain diseased tissues is the primary object of the operation, 
 whilst in others no disease is present. All these varying con- 
 ditions must be taken into consideration in determining the nature 
 and extent of any excision. 
 
 The late Professor Oilier of Lyons emphasized and established 
 the benefits to be derived from subperiosteal resections in 
 certain cases. Necessarily, every excision must lead to consider- 
 able interference with the peri-articular structures ; muscles and 
 tendons have to be detached from their insertions, and portions 
 of the bones removed. If, however, the periosteum is raised, 
 together with the attached muscles and tendons, prior to sawing 
 or cutting the bones away, a more satisfactory reproduction of the 
 articular structures follows, and the movements of the joint suffer 
 less interference than if one cuts away the periosteal envelope 
 with the bone. Of course, where the periosteum is invaded with 
 tubercle, this should not be attempted, whilst in some joints — 
 such as the elbow — there is no advantage to be derived from it, 
 since there is always a tendency to too great a formation of bone, 
 and this would possibly be. exaggerated by a subperiosteal resec- 
 tion. It is rather in the operations undertaken for traumatic 
 lesions that this plan is to be recommended. 
 
 In a small text-book like this we must perforce limit ourselves 
 to a description of the methods most commonly adopted, and 
 refer students to special works on Operative Surgery for further 
 details. 
 
 Shoulder-joint. — Excision of the shoulder-joint may be needed for tuber- 
 culous disease, for the later stages of acute arthritis, occasionally for osteo- 
 arthritis if the disease is limited to this articulation, for compound or com- 
 minuted fractures, and possibly for simple fractures of the anatomical neck 
 when associated with dislocation of the small detached head of the bone. In 
 old unreduced dislocations where passive movement is impracticable, and 
 there is little hope of improvement, excision may give excellent results. 
 
 Operation. — The patient lies on the back, the shoulder projecting somewhat 
 over the edge of the table, and with a sandbag beneath the scapula to steady 
 it. The arm being slightly rotated inwards, an incision is made from a point 
 midway between the coracoid process and the acromion, extending downwards 
 and outwards for 3 or 4 inches through the fibres of the deltoid muscle 
 (Fig. 229, D). It is better to incise the deltoid than to pass between it and 
 the pectoralis major, the cephalic vein and accompanying artery being thus 
 uninjured. The wound is thoroughly opened up by means of retractors, and 
 the bicipital groove looked for ; an incision is made along its outer border, 
 
622 
 
 A MANUAL OF SURGERY 
 
 and the long tendon of the biceps, if still present, turned out, and held to the 
 inner side by a blunt hook. A twig of the anterior circumflex artery will here 
 be divided, and need a ligature. The arm is now thoroughly everted, and the 
 tendon of the subscapularis and the anterior part of the capsule, with which 
 it is incorporated, freely divided ; where practicable, the attachments of the 
 muscle to the bone should be separated subperiosteally, a proceeding pre- 
 senting no difficulty where inflammation has previously existed. The arm is 
 now inverted and held downwards by the side of the table, so as to bring the 
 great tuberosity into view ; the muscles attached to this process are dealt with 
 in a similar way, and the upper part of the capsule freely opened. The head 
 of the bone is then protruded into the wound, and removed by the saw. It 
 will often suffice to apply the saw obliquely through the substance of the 
 tuberosity ; this is to be preferred to removal of the whole tuberosity by a 
 horizontal incision at a lower level. The synovial membrane and glenoid 
 cavity are dealt with as circumstances may dictate, and it is often advisable 
 to make a counter-opening through ths posterior axillary fold for the insertion 
 
 Fig. 229. — Incision for Excision of Shoulder. 
 
 A, coracoid process ; B, tip of acromion ; C, intermuscular line between 
 deltoid and pectoralis major; D, incision. 
 
 of a drainage-tube ; the anterior wound can then be entirely closed. In 
 applying the dressing, care must be taken to put a good pad in the axilla, so 
 as to keep the arm from being drawn forcibly inwards by the muscles attached 
 to the bicipital groove. There is no need to commence passive movements 
 before the end of the first week. Fibrous union usually results, and the move- 
 ments of the shoulder are generally very good. 
 
 Excision of the Elbow may be required for simple or compound fracture-dis- 
 location, or for subsequent ankylosis, especially if the limb is in a bad position, 
 for tuberculous arthritis, and possibly in the later stages of acute arthritis. 
 The best plan of operating is as follows : A single longitudinal incision, 
 5 inches in length, is made in the middle line of the posterior aspect of the 
 joint, extending for equal distances above and below the tip of the olecranon, 
 and a little to the inner side The limb is held across the patient's body, the 
 surgeon standing on the affected side. The incision extends through the 
 
DISEASES OF JOINTS 623 
 
 substance of the triceps down to the bone. The origin of the flexor carpi 
 ulnaris and the inner half of the triceps tendon are detached, and the hollow- 
 between the olecranon and the internal condyle cleared, the knife being kept 
 close to the bone, and the soft parts retracted by a vigorous use of the thumb- 
 nail. By this means the ulnar nerve escapes injury, and, indeed, is often not 
 seen at all. The internal lateral ligament should be divided, and the common 
 origin of the flexors from the front of the inner condyle. The outer half of 
 the joint is then dealt with in a similar way, the anconeus being divided close 
 to its insertion to the ulna, the continuity of the triceps with the deep fascia 
 covering it being also maintained. The origin of the extensor muscles is 
 separated from the back of the outer condyle, and the external lateral ligament 
 severed. The joint can now be freely opened by dividing any of the fibres 
 of the posterior ligament which remain intact, and the denuded ends of the 
 bones protruded from the wound. The lower end of the humerus is now 
 thoroughly cleared, and the articular surface removed, the section passing 
 through the centre of the olecranon fossa. The olecranon, together with the 
 upper articular surface of the coronoid process and the head of the radius, 
 are next sawn off, care being taken to draw aside and protect the soft parts by 
 retractors, especially those covering the ulnar nerve. The synovial membrane 
 can be dealt with as may be necessary. Even if the head of the radius is free 
 from disease, nothing is gained by leaving it intact, since ankylosis is very 
 likely to follow unless plenty of bone is removed. For a similar reason sub- 
 periosteal resection is needless, and, indeed, is an undesirable refinement. 
 The wound is carefully sutured, and a drainage-tube inserted for a few hours. 
 The limb is kept on a hinged angular splint for a week, by which time union 
 of the external wound should be complete, but the position is altered each day. 
 After a week, the splint may be dispensed with, and the limb kept at rest on 
 a pillow, free passive movement, both angular and rotatory, being daily 
 practised. Considerable attention is needed in order to obtain a good result, 
 but in a successful case every movement of the joint is perfectly restored. 
 As a rule, the lower end of the humerus develops two lateral bony processes, 
 like malleoli, within the grasp of which the upper rounded ends of the radius 
 and ulna are able to move. 
 
 The Wrist-joint is only excised for extensive tuberculous disease when 
 abscesses and sinuses are present. Ankylosis of the articulation, though a 
 troublesome condition, is not sufficiently so to require such treatment. The 
 best method to employ is that known as Lister's operation, a somewhat com- 
 plicated proceeding, but which in suitable cases gives excellent results. Prior 
 to operating the fingers are well bent, so as to break down any adhesions which 
 are present. Two incisions are made, one on the radial side of the dorsum, 
 and the other on the inner or ulnar aspect of the wrist. The dorsal incision is 
 angular (Fig. 230, L, L), commencing at a point on the back of the radius 
 between the tendons of the extensor secundi internodii pollicis (B) and the ex- 
 tensor communis digitorum (D) ; it is at first parallel to the former tendon, and 
 on its ulnar side, till it reaches the base of the second metacarpal bone, when 
 its direction is changed, and it courses downwards along that bone for an 
 inch or two. It should extend to the bone, and in doing so the tendons of 
 the extensor carpi radialis longior and brevior (H and I) are divided as close 
 to their attachments as possible. The tendinous structures are then stripped 
 off the back of the dorsum on either side of the incision, and on the outer 
 side a pair of cutting pliers is insinuated so as to detach the trapezium 
 from the rest of the carpus. The synovial sheaths of these tendons should, if 
 possible, not be opened. The hand is then rolled over, and the ulnar incision 
 made well on the inner side of the limb, extending for at least 3 inches 
 between the extensor and flexor carpi ulnaris tendons. The separation of the 
 extensor tendons from the back of the carpus is now completed, and the 
 attachment of the extensor carpi ulnaris (K) divided. The tissues on the 
 palmar aspect of the joint are detached, the pisiform being severed from 
 the rest of the carpus, and where possible left, and the hook of the unciform 
 clipped off with cutting pliers. The carpus is now free front and back, and 
 
624 
 
 A MANUAL OF SURGERY 
 
 the bones are either removed piecemeal or taken away en bloc by inserting a 
 pair of cutting pliers above and below, and dividing their upper and lower 
 connections ; more usually the carpal bones are picked out in fragments. 
 Attention is then directed to the lower ends of the radius and ulna, and to the 
 articular ends of the metacarpal bones, all the cartilage and the intervening 
 synovial tissue being cleared away. Finally, the remaining fragments of the 
 carpus are dealt with as the case may require. The radial incision may often 
 be entirely closed, whilst a drainage-tube is inserted through the ulnar wound. 
 The hand is placed on a special splint, with a thick convex cork support for 
 the palm, which keeps the wrist slightly extended, and with a short lateral 
 projection upon which the thumb can rest. The fingers must be thoroughly 
 flexed and extended daily, beginning on the second or third day, but the wrist 
 should be kept at rest until it is quite firm. There is a much greater tendency 
 to a flail-like joint than to undue fixity, owing to the amount of bone removed, 
 
 Fig. 230.— Excision of the Wrist. (Lister.) 
 
 A, Radial artery ; B, extensor secundi internodii pollicis ; C, ext. indicis ; 
 D, ext. communis digitorum ; E, ext. minimi digiti ; F, ext. primi inter- 
 nodii pollicis ; G, ext. ossis metacarpi pollicis ; H, ext. carpi radialis 
 longior ; I, ext. carpi radialis brevior ; K, ext. carpi ulnaris ; L,L, line of 
 radial incision. 
 
 and the necessary divisions cf all the extensors of the carpus ; if such occurs, a 
 leather support must be worn, either as a temporary or permanent appliance. 
 
 The Hip-joint is rarely excised for conditions other than tuberculous disease, 
 and even for this it is performed much less frequently than formerly. There 
 are two chief methods of operating, the anterior and the posterior. 
 
 1. Excision by the anterior method is carried out as follows: The incision 
 (Fig. 75 D ; p. 292) extends from immediately below the anterior superior spine 
 vertically downwards for 3 or 4 inches. It passes between the tensor fasciae 
 femoris and sartorius muscles superficially, and between the glutei and rectus 
 deeply, a small arterial twig from the external circumflex being divided at 
 this stage. The neck of the bone and capsule of the joint are exposed, and 
 the latter is freely incised along its attachment to the anterior intertrochanteric 
 line, so as to allow of the admission of the finger, whereby the joint can be 
 fully explored. The neck of the bone is cut through in situ by means of an 
 Adams' osteotomy saw, the incision through the bone being placed obliquely 
 
DISEASES OF JOINTS 
 
 M 
 
 downwards and inwards. The head of the bone is now either prised out of 
 the acetabulum by an elevator, or grasped by lion forceps and twisted out, a 
 matter easily accomplished where the articular structures are diseased, but 
 a proceeding of some difficulty in the normal joint of a cadaver. As much of 
 the infected synovial membrane as possible is clipped away with scissors, 
 and the acetabulum scraped, if necessary. The external wound is either 
 closed, with the exception of an opening for a drainage-tube, or stuffed with 
 gauze soaked in iodoform emulsion. There may be comparatively little 
 shortening of the limb as the result of this proceeding, but the movements 
 are considerably limited. 
 
 2. Excision by the posterior method, as we have already said, is usually 
 undertaken in the later stages of the disease. Any sinuses which exist pos- 
 teriorly may be utilized, but if the skin is unbroken, an incision known as 
 Langenbeck's may be employed (Fig. 231). The patient lies on the sound 
 limb, whilst the affected thigh is flexed. The incision is made in the line of 
 the femur, extending 2 inches above the top of the great trochanter, and about 
 3 inches below it. It is carried at once down to the bone, and the muscles 
 attached to the summit and posterior border of the great trochanter freely 
 divided, as close to the bone as possible. The capsule is opened to a sufficient 
 extent to allow of the exploration of the joint by the finger. If the disease 
 is very extensive, the femur is now chiselled across, immediately below the 
 great trochanter, but above the lesser. The upper end of the bone is 
 grasped by lion forceps, and twisted out of the acetabulum, after division 
 of the remaining structures, which are attached chiefly along its anterior 
 border. The ligamentum teres has almost always been previously destroyed, 
 and hence this stage of the operation is not especially difficult. The synovial 
 membrane and acetabulum are easily reached, and the diseased portions 
 removed. In favourable cases a drainage-tube may be inserted, and the wound 
 closed, but not uncommonly it is wiser to 
 partially stuff it with gauze infiltrated with 
 iodoform, and allow it to heal by granulation. 
 Slight extension of the limb should be sub- 
 sequently made, so as to prevent undue shorten- 
 ing from the traction of the long thigh muscles. 
 The leg is placed between sandbags, or a Liston's 
 long splint applied. Fibrous ankylosis, with a 
 certain limited amount of movement, is the 
 usual result. 
 
 It is not always necessary to include the 
 trochanter in this operation. If the disease is 
 limited to the head of the bone, it alone should 
 be removed, with as little disturbance as 
 possible to the muscles passing to the trochanter. 
 If such can be effected, the subsequent mobility 
 and usefulness of the limb are considerably in- 
 creased. 
 
 The advantages claimed for the anterior 
 method are : that it is a less severe operation, 
 that fewer muscles and tendons are interfered 
 cision for Excision of the with, that no vessels of importance are divided, 
 Hip from Behind. (Till- and that only the head of the bone is excised. 
 manns.) The objections to it are : that the drainage pro- 
 
 vided is very unsatisfactory, that the trochantei 
 cannot be readily dealt with, whilst it is also difficult to remove all the 
 synovial membrane. 
 
 The great advantages of the posterior operation are that, in spite of a free 
 division of the muscular and tendinous attachments, excellent drainage is 
 provided, and both trochanter and acetabulum are readily accessible. On 
 the whole, the anterior method should be employed in the early stages of the 
 
 40 
 
 Fig. 231. — Langenbeck's In- 
 
626 A MANUAL OF SURGERY 
 
 disease, the posterior in the later. The situation of abscesses or sinuses may, 
 however, determine the choice of the surgeon. 
 
 The Knee-joint is excised for tuberculous disease, osteo-arthritis, or deformity 
 due to osseous or fibrous ankylosis in a bad position. A horseshoe-shaped 
 incision is made, extending from the back of one condyle to the other, reaching 
 downwards nearly as far as the tubercle of the tibia. The limb is well flexed, the 
 ligamentum patella? divided, and the joint opened. The skin and subcutaneous 
 tissues are then separated from the anterior surface of the patella, which may 
 be at once removed by a curved incision above it, communicating on either 
 side with that already made below. The flexion is now increased, and the 
 lateral ligaments divided ; by this means the interior of the joint is freely 
 exposed, so that the attachments of the crucial ligaments to the tibia can also 
 be severed. The lower end of the femur is then cleared of diseased synovial 
 membrane, so as to allow of the application of a broad excision saw. The 
 usual rule given as to the direction of the saw-cut in the bone is that the 
 exposed bony surface left after removing its articular end should be absolutely 
 horizontal, supposing the patient to be standing upright ; personally, we 
 prefer to make the sections so that the limb shall be left very slightly flexed 
 and in-kneed, a position which greatly adds to the subsequent comfort of the 
 patient. To accomplish this, the saw must be applied parallel to the articular 
 surface, i.e., at right angles to the axis of the body, not of the femur, and with 
 a slight upward slant from before backwards. The bone should be partially 
 sawn through by a side-to-side movement, but the posterior surface of the 
 condyles should be divided by raising or depressing the handle of the 
 instrument, so that the structures lying behind in the intercondyloid notch are 
 not encroached upon. Sufficient bone should be sawn off in the adult to 
 include the greater part of the articular cartilage, but as little as possible con- 
 sistent with removing all the disease, otherwise the limb is shortened to such 
 an extent as to interfere with its subsequent usefulness. The head of the tibia 
 is then protruded, and cleared from the neighbouring soft parts; it is held 
 absolutely vertical, and a saw applied in a horizontal position, the bone being 
 divided from before backwards. Any diseased synovial membrane is now 
 dissected away, special attention being directed to the subcrureal pouch. All 
 bleeding-points having been secured by ligature, the bones are fitted together, 
 and, if considered advisable, secured in position by thick silver wire, or silver- 
 plated nails or screws. The external incision is closed, drainage-tubes being 
 inserted at each angle of the wound. A Gooch's splint is applied to the limb, 
 and in this it remains until sound healing has occurred, after which an im- 
 moveable case either of plaster of Paris or water-glass is kept on until eight or 
 ten weeks have elapsed since the operation. 
 
 The Ankle-joint is excised for tuberculous disease. Two incisions are made, 
 an inner and an outer. The outer incision runs along the anterior border of the 
 fibula and curves round the outer malleolus, being about 3 inches in length. 
 The lower end of the fibula is exposed, and by preference subperiosteally. 
 The external lateral ligament is split vertically, and separated from its attach- 
 ments to the fibula, its continuity with the periosteum being, however, main- 
 tained. The fibula is then divided about 1 inch above the tip of the malleolus, 
 and the latter process of bone removed. The periosteum and ligaments are 
 separated as far as possible from the front and back of the bones. The 
 inner incision is T-shaped, and is made along the inner surface of the tibia, 
 with a short transverse cut at its lower end, which reaches just below the 
 inner malleolus. The periosteum and internal lateral ligament are dealt with 
 as on the outer side, and the front and back of the tibia are easily denuded. 
 The inner malleolus is projected from the wound, and the lower end of the 
 tibia removed by a keyhole saw, the dorsal structures being held aside by a 
 retractor. The articular surface of the astragalus is sawn off from the outer 
 wound, or, if advisable, the whole of the bone may be removed. 
 
 The above subperiosteal method of excision is one of the best that have 
 been suggested. The greatest care should be taken not to open the sheaths of 
 
DISEASES OF JOINTS 627 
 
 the tendons, and in dressing the wound the foot must be kept at right angles 
 to the leg, and no lateral deviation permitted. As soon as possible it is 
 encased in plaster of Paris, windows being left for the dressing of the wounds, 
 if necessary. 
 
 In non-tuberculous cases a transverse incision extending from one malleolus 
 to the other may be employed. Sutures are placed through the tendons above 
 and below, and they are then divided ; the anterior tibial nerve is similarly 
 secured above and below before division, and the vessels are divided between 
 ligatures. By opening the capsule a very free exposure of the joint surfaces 
 is provided, permitting a very thorough excision. The tendons and nerve are 
 carefully sutured together before closing the wound. 
 
 Excision of the Astragalus is sometimes required in the treatment of tuber- 
 culous disease of contiguous joints, as also in some cases of talipes and of 
 fractures or dislocations of the bone. Many methods of operating have been 
 described, but we think it is best accomplished through a single vertical 
 incision over the front of the ankle, running parallel to the vessels and tendons, 
 which are carefully avoided and stripped back from the dorsum by means of 
 periosteal detachers, so that the upper surface of the astragalus can readily be 
 reached. The astragalo-scaphoid and ankle-joint are then freely opened, and 
 the ligamentous and fascial connections on either side severed. The neck of 
 the bone may with advantage be divided at this stage, and its head removed, 
 so as to give access to the under surface and allow of the division of the strong 
 interosseous ligament extending between the adjacent surfaces of the astragalus 
 and os calcis. It may be possible to remove the rest of the bone in one frag- 
 ment, but it is certainly wiser to break it up with chisel or gouge, and take it 
 away piecemeal. 
 
 40- 
 
CHAPTER XXI. 
 
 INJURIES OF THE SPINE. 
 
 The spinal cord is protected from injury in a most complete and 
 efficacious manner, (a) Its position between the bodies and the 
 laminae with the spinous processes arising therefrom is itself 
 mechanically advantageous, since, whether the spine is forcibly 
 flexed or extended, the cord remains midway between the points 
 of chief compression or extension, and hence in a position of rest. 
 (b) The buffer-like action of the intervertebral discs, and the 
 varying curves of the column, serve to distribute some part of 
 any force that reaches it. (c) There is ample space in the 
 medullary canal, in which the cord with its membranes is slung 
 by prolongations of dura mater around the issuing nerves, whilst 
 the cord itself hangs loosely within the dura mater, suspended by 
 the ligamenta denticulata, and surrounded by cerebro-spinal fluid. 
 (d) The cord terminates, in an adult, at the lower border of the 
 first lumbar vertebra, a spot well above the junction of the fixed 
 base and the moveable upper part, a point where the effect of jars 
 and wrenches is mainly felt, (e) Nature has, moreover, intro- 
 duced a whole series of buffers and other means of preventing 
 shock to the spine when a person falls on his feet, e.g., the arches 
 and elasticity of the foot, the changes in direction of the bones at 
 each joint, the interarticular cartilages of the knee, etc. 
 
 The parts of the spine most exposed to injury are those where 
 a fixed and moveable portion meet, e.g., the dorsi-lumbar and the 
 cervico-dorsal regions. The upper part of the dorsal curve, which 
 is relatively weak and projects backwards, is thereby exposed to 
 injury, so that fractures are not at all uncommon about the fourth 
 dorsal vertebra. The close proximity of the head explains the 
 frequency of lesions about the upper cervical region. 
 
 Sprains. 
 
 Sprains and strains of the spine are very common accidents, a 
 fact not to be wondered at, when we consider the complicated 
 
INJURIES OF THE SPINE 629 
 
 muscular and ligamentous arrangements present. They are 
 produced by any sudden or unexpected movements, such as falls, 
 especially from horseback, railway accidents, and the like. The 
 injury is most likely to affect mobile parts of the spine, e.g., the 
 cervical and lumbar regions, and may be limited to the liga- 
 mentous or muscular structures, or may involve both. The 
 resulting Signs are simply those of a severe but localized trauma, 
 viz., pain, tenderness, bruising, and perhaps a little swelling ; the 
 subjective phenomena are much increased by movement, so that 
 the spine is always kept rigidly quiet. If only the muscles or 
 interspinous ligaments are involved, no further consequences 
 are likely to arise ; but when the ligamenta subfiava are lacerated 
 and the spinal canal is thus opened, the gravest symptoms may 
 ensue from blood finding its way into the canal outside the dura 
 mater, leading possibly to paraplegia, which may be of a tempo- 
 rary or permanent nature. Inflammation of the damaged fibrous 
 tissues may also extend to the meninges and cord, and cause 
 compression of the latter or even organic disease. Moreover, in 
 patients of a tuberculous temperament, spinal caries may be set 
 up as a result of such injuries, whilst syphilitic or malignant 
 disease has also been known to follow. 
 
 In the cervical region, sprains are very liable to occur as a result 
 of severe blows on the head, causing rupture of the inter-transverse 
 ligaments, and the displacement may be so great as to simulate 
 dislocation. The head and neck are held immoveable and rigid, 
 and there is often considerable loss of power, the patient being 
 sometimes unable to lift the head spontaneously from the pillow. 
 Sprains in the lumbar region are very common, both as a result 
 of railway injuries, when they are often associated with nervous 
 symptoms (p. 640), and as a consequence of overlifting, when the 
 quadratus lumborum is most likely to be affected. The back is 
 kept fixed and rigid, the patient being unable to turn or stoop 
 without pain. Sometimes hematuria results from injuries in the 
 lumbar region, arising from an associated contusion of the kidneys. 
 
 Treatment. — The patient should be kept at rest, and fomenta- 
 tions applied to the injured part. When the painful or inflam- 
 matory symptoms have disappeared, massage with stimulating 
 liniments is needed. In the severer cases the individual should be 
 kept in bed for six or eight weeks, and in the cervical region some 
 form of mechanical support may be subsequently necessary. The 
 appearance of inflammatory symptoms involving the meninges 
 calls for greater care ; the patient should then be kept as much as 
 possible in the prone position, and a spinal icebag applied. The 
 onset of paraplegia, due either to haemorrhage or inflammatory 
 exudation, would raise the question of laminectomy (p. 644). 
 
6.30 A MANUAL OF SURGERY 
 
 Penetrating Wounds of the Spine. 
 
 These lesions are, fortunately, uncommon in civil practice, 
 being generally due to stabs with pointed instruments, such as 
 bayonets, or to gunshot wounds. They occasionally result from 
 falls, the unfortunate individual becoming impaled on area 
 railings, branches of trees, etc. The Symptoms produced are 
 
 (a) those due to the wound in the soft parts, which may also 
 involve the peritoneal and pleural cavities, or damage some of 
 the viscera ; in the neck, the vertebral artery is exposed to injury 
 from this type of accident, leading to serious haemorrhage ; 
 
 (b) various forms of fracture, the cord being compressed by 
 fragments of bone which have been driven inwards, or by 
 extravasated blood ; (c) those due to laying open the spinal mem- 
 branes, e.g., loss of cerebro-spinal fluid, which in itself might 
 prove fatal by draining the cerebral cavity, and so causing pressure 
 on the base of the brain, or at a later date may determine the 
 patient's death by setting up diffuse septic meningitis (p. 638) ; 
 and (d) those due to wounds of the spinal cord. The effects of a 
 total transverse lesion at different levels of the spine are given at 
 p. 643 ; even if the patient escapes the dangers of diffuse septic 
 meningitis, he will later on develop acute myelitis. Of course, 
 the division of the cord may be only partial, or it may escape 
 entirely, whilst nerve roots or trunks may be involved, and in the 
 lumbar or sacral regions the cauda equina may be divided. 
 
 Treatment consists in thoroughly exploring the wound under 
 an anaesthetic, removing foreign bodies or displaced fragments of 
 bone, and attempting to render it aseptic. Wounds of the vertebral 
 artery or other structures are dealt with secundum artem, and special 
 attention is naturally given to the cord and its membranes. Should 
 the dura mater have been opened, and the cord have escaped 
 injury, an attempt may be made to close the wound in the 
 meninges, and the patient should subsequently be kept in the 
 prone position and with the head low, so as to prevent, as far as 
 possible, the escape of cerebro-spinal fluid. If the cord itself is 
 divided or lacerated, it is useless trying to unite it, since its function 
 in conducting impulses from the brain downwards is inevitably 
 destroyed. Where, however, the cauda equina has been injured, 
 it is perfectly justifiable to lay open the spinal canal to a sufficient 
 extent to expose the divided nerve trunks, and then to suture them. 
 
 Fractures of the Spine. 
 
 Causes. — The spine may be broken as the result of (a) direct 
 violence, e.g., a fall on the back over some projecting body, 
 such as a carpenter's bench or a railing, or a blow on the back 
 with a heavy stone or with a swinging baulk of wood, or a gun- 
 shot wound. This type of accident may involve any part of the 
 spine, and, excluding those arising from gunshot, is less frequent 
 
INJURIES OF THE SPINE 631 
 
 than the class next to be described. Of necessity, the spine breaks 
 at the point struck ; the posterior parts of the vertebra? are most 
 likely to be damaged in this form of injury, (b) Fractures are 
 also due to indirect violence, then usually occurring in the lower 
 cervical or upper dorsal regions. They are caused by forcible 
 flexion of the spine, as by a fall downstairs with the head doubled 
 up, or by taking a ' header ' into shallow water, or when a man, 
 being driven under a bridge, omits to stoop, and so is caught 
 between the arch and the cart, or sometimes by the fall of a heavy 
 weight on the back of the neck, the spine bending and breaking 
 at the weakest spot. 
 
 Fractures of the spine may be divided into two main classes, 
 according to whether or not they are complete — that is, according 
 to whether the continuity of the column is destroyed or not. 
 
 (A) Incomplete Fractures may be met with in various forms, 
 and are most frequently due to direct violence. 
 
 (i.) Fractures of the Spinous Processes rarely occur except in the 
 lower cervical or dorsal regions. In the upper cervical region the 
 spines are short and retracted to allow of extension of the head, 
 whilst in the lumbar they are also short, but very strong. The 
 fracture is almost always due to direct violence, and is charac- 
 terized by the signs of a local trauma, together with great 
 mobility, perhaps crepitus, and irregularity in the line of the 
 spines. The process is occasionally much depressed, and may 
 even cause paraplegia by being driven into the spinal canal. 
 
 (ii.) Fracture of the Lamina is a not uncommon accident, always 
 resulting from direct violence. If only one lamina is broken, the 
 signs are not very distinct, and cord symptoms are rare. When 
 both laminae yield, the posterior part of the neural arch, carrying 
 with it the spinous process, is very likely to be depressed to a 
 sufficient extent to compress the cord and give rise to paraplegia. 
 Crepitus is often obtainable, and a gap in the line of the spinous 
 processes can usually be felt. 
 
 (iii.) Fracture of the Transverse Processes is but rarely met with 
 apart from other lesions of the spine. . 
 
 (iv.) Partial Fracture through the bodies may occur in the form 
 of fissures, which produce but little effect, except pain and 
 rigidity, and cannot be diagnosed with certainty. 
 
 Even in fractures where displacement is not present, paraplegic 
 symptoms may arise, either immediately from concussion of the 
 spinal cord, or later on from the pressure of haemorrhagic or 
 inflammatory effusions. 
 
 The Treatment merely consists in keeping the patient at rest 
 for a time. The question of laminectomy for paraplegia, due 
 either to displacement of the laminae or to haemorrhage, will be 
 discussed later (p. 644). 
 
 (B) Complete Fractures are usually associated with displace- 
 ment, and loss of continuity of the spinal column, and hence 
 
632 
 
 A MANUAL OF SURGERY 
 
 are often termed Fracture-Dislocations. They result either from 
 direct or indirect violence. There is always a tolerably extensive 
 lesion (Fig. 232) ; thus, the spinous processes and laminae may or 
 may not be fractured, the ligamenta interspinosa, snpraspinosa, 
 and subnava torn, the articular processes fractured in the lumbar 
 and dorsal regions, or displaced without fracture in the cervical, 
 and either the intervertebral substance torn across, or the bodies 
 
 broken, thus severing 
 the spine into two 
 halves. The upper or 
 moveable portion is 
 usually driven forwards 
 over the lower or more 
 fixed fragment, and im- 
 paction or comminution 
 is often present. The 
 spinal cord is com- 
 pressed between the 
 upper end of the lower 
 fragment and the la- 
 minae of the upper 
 fragment, and although 
 the displacement may 
 be naturally remedied 
 by the falling back of 
 the bones into position 
 (' recoil '), yet the effects 
 of the crush on the cord 
 are usually irremedi- 
 able. In slighter cases 
 the spinal membranes 
 may be merely punctured by a splinter of bone, or haemorrhage 
 may occur either within the membranes, or outside them in the 
 fatty theca vertebralis. Excessive indirect violence may lead to 
 an associated fracture of the sternum. 
 
 The Signs of a complete fracture are usually very evident, con- 
 sisting of local pain, swelling, and bruising, and a certain amount 
 of angular deformity, more or less according to circumstances. It 
 may be possible to elicit crepitus, if the parts are not impacted, 
 but all unnecessary movement should be avoided for fear of 
 adding to the injury of the cord. Paraplegia below the part 
 injured is present in most cases, and with it some amount of 
 general shock. When the cord is disintegrated or divided, 
 symptoms of spinal myelitis rapidly follow, and a fatal issue 
 often occurs at an early date from toxaemia following septic 
 cystitis or sloughing of the nates. The special phenomena of 
 paraplegia are dealt with at p. 641. 
 
 The Prognosis of these cases turns largely on the situation of 
 
 Fig. 232. — Complete Fracture -Dislocation 
 of the Spine in the Lower Dorsal Region 
 with Displacement, and Compression of 
 the Cord. (After Keen and White.) 
 
INJURIES OF THE SPINE 633 
 
 the injury and the amount of mischief sustained by the cord. 
 The higher the lesion, the greater the danger, although patients 
 with paraplegia from cervical fracture may live for years, and even 
 partially recover, if the cord has not been totally disintegrated. 
 
 The Treatment naturally varies with the character of the case. 
 The patient is carefully placed on a prepared bed, the greatest 
 gentleness being used in handling and lifting him, for fear of 
 increasing the damage to the cord. The bed must be firm, though 
 not hard ; perhaps the best type to employ is a horsehair mattress 
 placed over fracture-boards ; nothing more soft or yielding is per- 
 missible. Spring beds and wire-wove mattresses are most undesir- 
 able. A water-bed is required in the later stages, but should not 
 be used at first, as it is scarcely firm enough. The shock resulting 
 from the accident is treated in the usual way by warmth and, if 
 need be, by stimulants; but it must be remembered that anaesthetic 
 regions of the body can be easily blistered or burnt by hot-water 
 bottles, unless carefully guarded by flannels. When reaction has 
 occurred, a more thorough examination of the patient can be 
 made, and the subsequent course of action decided on. 
 
 (a) In a small minority of the cases operative treatment is justifiable. 
 We shall discuss later on (p. 644) the indications for laminectomy. 
 
 (b) When the displacement persists owing to impaction of the 
 fragments, reduction under an anaesthetic may possibly be under- 
 taken, provided that the lesion is not in the cervical region, and 
 the paraplegia not complete. Of course, if other internal injuries 
 are present which render the case hopeless, nothing should be 
 done. Great care must be used in attempting reduction, since 
 the object is to relieve pressure on the cord, and any undue 
 violence may readily increase the mischief; in the lumbar region, 
 however, considerable force may be employed without much 
 danger. Whether reduction is accomplished or not, the further 
 treatment must be directed in accordance with the indications 
 given in the next paragraph. Where the surgeon fails to reduce 
 the deformity, it may sometimes be advisable to make gradual 
 extension from the feet or neck by the use of weight and pulley. 
 
 (c) In many cases, as soon as the patient is laid flat on a bed, 
 the displacement remedies itself, especially if the spine has been 
 comminuted, and then the treatment must be symptomatic, as also 
 after reduction or operation, where the paraplegia persists or is 
 only slowly recovered from. He is kept in bed, absolutely flat, 
 and with the head low ; perhaps some form of mechanical sup- 
 port, e.g., a plaster of Paris or leather jacket, may be considered 
 advisable ; but its application is always a matter of difficulty, 
 and in the early stages it does but little good. Food is regularly 
 administered, and at first must be light and readily assimilable. 
 
 The chief care of the attendants must be directed to the skin, 
 bladder, and bowels. Bedsores are extremely liable to form on all 
 points of pressure, and hence the nates and heels must be care- 
 
634 A MANUAL OF SURGERY 
 
 fully guarded (p. 80). In turning the patient to attend to the 
 nates, the body must be rolled over as a whole, and not merely 
 the pelvis twisted. It will often be found advisable to have a 
 divided mattress placed beneath the pelvis, so that one lateral 
 segment may be removed at a time, and thus rotation of the 
 body will not be needed. A bedpan can also be used in this way 
 without disturbing the spine. When the bladder is paralyzed, the 
 urine must be withdrawn by a catheter. One of the greatest 
 dangers that the patient runs is from the supervention of septic 
 cystitis, and the extension of the inflammation upwards to the 
 kidneys. This is always due to infection from without, and the 
 greatest care must be taken to prevent it. The penis should be 
 thoroughly purified, and the urethra well flushed out before 
 passing an instrument in these cases ; in the intervals between 
 instrumentation the penis is wrapped in a dry antiseptic or sterilized 
 dressing. Only soft rubber catheters are employed, and these 
 must be kept absolutely aseptic by immersion in 5 per cent, 
 carbolic lotion, or 1-1000 sublimate, which is subsequently re- 
 moved before use by washing with a solution of boric acid. 
 Should sepsis occur, the bladder is irrigated twice daily with 
 some mild antiseptic, such as Condy's fluid, boric acid, boro- 
 glyceride (1 in 20), or sanitas (1 in 20), whilst urotropine, salol or 
 boric acid in 10 grain doses may be administered by the mouth 
 thrice daily. Probably, in spite of all precautions, the condition 
 will persist, and prove fatal from extension to the kidneys. The 
 bowels are always obstinately constipated, and must be opened 
 either by purgatives or simple enemata. 
 
 Under such a regime the patient may gradually recover, but 
 more often succumbs to septic poisoning or exhaustion. Occa- 
 sionally he may live for a long time, although paralyzed, possibly 
 developing some amount of reflex micturition, if the lumbar 
 centres are not involved. Varying degress of restoration of 
 power in the lower limbs are also met with. 
 
 Dislocations of the Spine. 
 
 By dislocation of the spine is meant a displacement forwards, 
 either partial or complete, of the upper part of the spine, with 
 separation of the articular processes, and tearing of the inter- 
 vertebral substance. A pure dislocation can only occur in the 
 cervical region, and even then it is not uncommonly associated 
 with a fracture. The reason for this depends partly on the 
 immobility of the dorsal and lumbar vertebrae in the latter regions, 
 and partly on the direction of their articular processes. In the 
 cervical region these look mainly upwards and downwards, with a 
 slight slope forwards and backwards, so that it is not difficult for 
 one to slip over the other ; in the dorsal region they are placed 
 nearly vertical, looking forwards and backwards, whilst in the 
 lumbar they are also vertical, but look inwards and outwards, the 
 
INJURIES OF THE SPINE 635 
 
 lower enclosing the upper as in a sheath, so that in the last two 
 regions of the spine dislocation is impossible without concurrent 
 fracture of the articular processes and probably of the lamina?. 
 
 Any part of the cervical region may be the seat of a dislocation. 
 The occiput has been displaced from the atlas in a few cases, 
 resulting in sudden death ; but if incomplete, life has been pro- 
 longed for a few hours or days. Dislocation of the atlas from the 
 axis has followed blows on the neck, or has been the cause of 
 death in hanging, whilst the attempt to lift a struggling child by 
 the head has sometimes led to this calamity. In almost all cases 
 the odontoid process has been fractured or the transverse liga- 
 ment torn, causing instant death from compression of the cord, 
 owing to the head and atlas slipping forwards. Lateral displace- 
 ment from rotation has also been observed, the cord symptoms 
 then being of a milder type. 
 
 Dislocation may occur between any two of the lower five cervical 
 vertebra, but perhaps most frequently between the fifth and sixth. 
 It is almost invariably the result of forcible flexion of the head 
 and neck, perhaps combined with rotation, and as a rule the 
 intervertebral articulations are torn open, whilst the supraspinous 
 and interspinous ligaments, the ligamenta subflava, and the 
 anterior and posterior common ligaments, are lacerated, and the 
 intervertebral substance torn across, or a scale of the articular 
 surface detached. The head and upper portion of the spine are 
 displaced forwards, so that the cartilaginous surfaces of the 
 articular processes of the lower vertebra project behind the 
 lamina? and transverse processes of the upper, and the lower 
 articular processes of the upper vertebra lie within the inter- 
 vertebral notch of the lower bone (Fig. 233, A and B, a). Two 
 forms of dislocation are met w T ith — the unilateral and bilateral. 
 
 (a) Unilateral Dislocations of the cervical spine is due to force 
 applied from the back and side of the neck. The head is turned 
 towards the opposite side, and more or less fixed, whilst there is 
 no evidence of compression of the cord, although a tingling and 
 neuralgic pain along the course of the nerves may arise from 
 pressure upon and stretching of the nerve trunks in the inter- 
 vertebral notch. The spinous processes may be irregular and 
 displaced laterally, whilst the line of the transverse processes is 
 similarly altered ; such signs are, however, very difficult to make 
 out in thick necks. If left unreduced, the vertebra becomes fixed 
 in its new position, the head and neck displaced, and permanent 
 neuralgia may result. In such cases, if seen early, replacement 
 may be attempted. The patient is anaesthetized, the body fixed, 
 the head and neck flexed, and traction made in that position, so 
 as to unlock the edges of the articular processes. Reduction may 
 be accomplished with a definite snap or catch. In old-standing 
 cases an operation may sometimes be attempted to relieve pressure 
 on the nerves, but it is impossible to replace the bones. 
 
6 3 6 
 
 A MANUAL OF SURGERY 
 
 (b) Bilateral Dislocation (Fig. 233, A and B), if complete, is 
 always accompanied with pressure upon the cord and paraplegia ; 
 occasionally, however, it is only partial, and then the cord may 
 escape without immediate injury, owing to the large size of the 
 canal in this region ; haemorrhage and inflammation may subse- 
 quently cause grave symptoms. Treatment is of but little avail in 
 most of the cases of complete double dislocation, since probably 
 the cord is irretrievably damaged ; but where paraplegia is incom- 
 
 Fig. 233. — Dislocation of the Cervical Spine. (After Keen and White.) 
 A, As seen from in front ; B, side-view ; aa indicate the lower articular facets 
 
 of the upper or displaced vertebra, which are thus seen to lie in front of 
 
 the upper articular processes of the lower vertebra. 
 
 plete it is possible that benefit may arise from early interference. 
 Replacement by traction on the head with the neck flexed may 
 be first carefully tried, and failing that laminectomy should be 
 performed. After stripping the muscles from the bones, the 
 surgeon will see the two cartilage-covered surfaces of the upper 
 articular processes of the lower vertebra standing out clearly 
 behind the laminae of the displaced bone. Upward traction on the 
 head may now again be made, and reduction thus attempted ; but 
 if this does not succeed, as small a portion as possible of the upper 
 margins of the exposed articular processes is excised in order to 
 
INyURIES OF THE SPINE 637 
 
 allow of the unlocking of the bones ; if the whole processes are 
 removed, reduction is much easier, but Nature's barrier to prevent 
 a recurrence of the trouble has been taken away, and fixation 
 of the spinal column in its natural position becomes impossible. 
 The sudden relief of pressure not uncommonly causes such an 
 interference with the intravascular tension in the cervical cord 
 as to lead to a temporary cessation of the breathing, for which 
 artificial respiration is required. It is usually advisable not only 
 to replace the bones, but also to open the spinal canal and mem- 
 branes, so as to remove any pressure of blood or inflammatory 
 exudation which may exist. The results of such operations are 
 not particularly satisfactory. 
 
 Secondary Effects following Spinal Injuries. 
 
 Injuries of the spinal column are frequently associated with, or followed 
 by, conditions affecting the cord and its membranes which may lead to the 
 gravest results, even when the local lesion to the spine has been comparatively 
 slight. These are frequently combined with one another in the most puzzling 
 fashion, so that it is often difficult to state the exact nature of a certain group 
 of symptoms ; for simplicity's sake we shall discuss them here without attempt- 
 ing to describe the various combinations which may present themselves. 
 
 The following secondary effects may be met with after spinal injuries : 
 (a) Direct spinal concussion ; (b) spinal haemorrhage ; (c) spinal meningitis ; 
 (d) spinal myelitis; and (e) spinal neurasthenia (or railway spine). 
 
 Direct Concussion. — This condition may be due to severe blows in the back, 
 which do but little damage to the spinal column, or may be caused by accidents 
 which lead to the infliction of greater mischief, but without an)' serious dis- 
 placement of parts. The term ' concussion ' should be limited to those cases 
 where energetic traumatic influences (falls, bloics, collisions, etc.) have given rise to 
 severe disturbance of the functions of the cord without any considerable visible anatomical 
 changes in the latter (Erb). In fact, the term is really only applicable to those 
 cases which recover more or less completely ; if recovery does not ensue, 
 minute extravasations or other lesions have been present, constituting a con- 
 dition of contusion rather than concussion. It is somewhat doubtful, however, 
 whether all these cases are not due to minute haemorrhages. 
 
 The Symptoms produced are those of a more or less complete and immediate 
 loss of function of that portion of the cord situated below the point struck. 
 Thus, a varying degree of paraplegia is produced, the signs of which differ with 
 the region affected (see p. 643). In addition, the patient is usually prostrate 
 from general shock to the system, and the reflexes are often totally lost — 
 at any rate, for a time — as a result of the shock to the cord. Death may be 
 caused at once by a blow in the upper cervical region, or varying degrees of 
 loss of power and sensation may be produced in any or all of the limbs. In 
 the lower cervical region the arms are mainly affected, and perhaps some par- 
 ticular nerve may be picked out and paralyzed. In the lumbar and dorsal 
 regions a more typical paraplegia is produced, with loss of power over the 
 sphincters, and loss of reflexes. Priapism never occurs in simple concussion. 
 The temperature of the body may be depressed, and the extremities pallid and 
 cold ; the pulse is rapid and weak, and the respirations shallow. 
 
 The Prognosis is always uncertain, as in cases where there is no displace- 
 ment it is impossible to gauge the extent of the mischief. If merely con- 
 cussion is present, the patient is likely to recover ; if the cord is contused, or 
 haemorrhage has occurred into it, a perfect recovery can scarcely be expected. 
 
 In the Treatment absolute rest to the spine is of the greatest importance, and 
 
£38 A MANUAL OF SURGERY 
 
 this should be maintained if possible in the prone position, so as not only to 
 diminish static congestion, but also to remove any pressure on the spine, and 
 to allow topical applications to be made. A spinal icebag may be applied, or 
 the back may be dry-cupped, whilst the patient is kept absolutely still, and on 
 a low diet. The bladder and bowels need attention, but no special drugs are 
 necessary. Of course, local injuries require suitable treatment. 
 
 Spinal Haemorrhage. — We can here only discuss the subject of spinal haemor- 
 rhage as resulting from injuries. It also occurs apart from traumatism, and 
 it is interesting to note that such happens more frequently in young persons 
 between the ages of ten and twenty than in old people, as with cerebral 
 haemorrhage. The bleeding may take place either into the cord itself, or out- 
 side it, and hence the two following varieties are described : 
 
 (a) Intramedullary Haemorrhage, or spinal apoplexy (hcematomyelia) , is met 
 with as a result of injury, which need not necessarily involve the spinal 
 column ; the lower cervical region is the part usually affected. Extravasation 
 into the cord is rarely extensive, and may occur in the form of one clot, usually 
 not larger than an almond, or more commonly in many spots, the gray matter 
 being more or less ploughed up. The white matter is compressed, and some- 
 times the blood bursts through it into the membranes. Should the patient 
 survive the injury for any length of time, secondary degenerations are estab- 
 lished, and run the usual course. The patient is suddenly struck down with 
 a more or less complete paraplegia, and with perhaps pain in the back, the 
 phenomena being very similar to those of a transverse myelitis. Some degree 
 of recovery follows, but the parts supplied from the damaged portion of gray 
 matter are likely to remain paralyzed. The Diagnosis of haemorrhage turns 
 on the rapid onset of paraplegia, which may be incomplete, without spinal 
 irritation ; fever may ensue for a few days, and if the cervical region is 
 affected, extreme contraction of the pupil (myosis) may result from destruction 
 of the cilio-spinal centre. The Prognosis depends on the size and situation of 
 the clot, a large clot producing more injury than a small one ; haemorrhage in 
 the cervical region may be immediately fatal by interference with the respira- 
 tion, whilst in the lumbar region it is unfavourable on account of the effect 
 upon the sphincter centres. The outlook is best when the dorsal portion of 
 the cord is affected. The Treatment is the same as was indicated for direct 
 concussion, whilst the administration of ergot may be beneficial. 
 
 (b) Extrameduilary Haemorrhage (iiamatoraehis) is a more frequent complica- 
 tion of spinal injuries, such as sprains or limited fractures, than the former. 
 The blood is usually extravasated between the bones and the dura mater, 
 especially in the cervical region, but may occasionally be found within the 
 dura having trickled down from the upper part of the column. The 
 symptoms are, in brief, those of spinal irritation, e.g., pain, hyperaesthesia, 
 spasms, cramps, etc., rapidly followed by loss of power in the muscles 
 supplied from the damaged area, or by ' gravitation paraplegia' (Thorburn), 
 which gradually extends from below upwards, causing death by asphyxia, 
 the whole series of phenomena being afebrile. In intramedullary haemorrhage 
 the symptoms of paralysis are more evident, and those of spinal irritation less 
 marked. If a diagnosis can be made, ergotin may be injected, and ice 
 applied to the spine, or even laminectomy performed to relieve pressure ; 
 later on, prolonged rest may cause the absorption of the clot, and even total 
 restoration to health. 
 
 Spinal Meningitis. — Inflammatory conditions of the spinal membranes may 
 spread downwards from the head, or commence as a local affection. Two 
 forms are met with resulting from injury : 
 
 (a) In Acute Spinal Meningitis the inflammation mainly affects the arachnoid 
 and pia mater (leptomeningitis). It is usually generalized in distribution, and 
 not unfrequently extends to the cerebral membranes. It occasionally follows 
 
INJURY OF THE SPINE 639 
 
 simple injuries, but is always infective in origin, being due to a diplococcus 
 (? pneumococcus) in subcutaneous injuries, or to the ordinary pyogenic cocci 
 in open wounds. Pathologically , it is evidenced by hyperaemia and loss of 
 polish of all the membranes, with an abundant exudation ; later on, lymph or 
 even pus may collect, especially about the posterior surface of the cord ; 
 should the patient live, organization of the effused lymph may lead to ex- 
 tensive adhesions. Clinically, the disease is usually ushered in by a rigor, 
 especially in the septic cases, and then runs a marked pyrexial course 
 The symptoms are : pain in the back, deep-seated, boring, and severe, in- 
 creased on all movements, and often extending down the limbs or around the 
 body ; rigidity of the spine and limbs, accompanied by painful cramps and 
 muscular spasms, almost simulating tetanic convulsions ; extreme hyper- 
 aesthesia, especially of the legs, and increased reflex excitability; whilst rapid 
 emaciation from pain and sleeplessness is soon produced. If the condition 
 is limited to the spine, it is probably followed by signs of myelitis, viz., para- 
 plegia, together with bedsores and vesical troubles, and these may lead to a 
 fatal issue ; cases, however, are met with which pass into a chronic state, and 
 may more or less recover. If the process also involves the cerebral mem- 
 branes, as in septic cases, the symptoms of diffuse cerebral meningitis are also 
 present, and the patient dies of coma. Treatment in the cases due to a 
 penetrating injury is of no avail if prevention of the disease by asepsis fails. 
 In simple cases an icebag should be applied to the spine, the patient remaining 
 in the prone position. Ergot and belladonna may be given internally, and 
 general measures to allay inflammation adopted. The bladder and rectum 
 must be attended to, and bromides and chloral administered to gain sleep. 
 
 (b) Chronic Meningitis is usually localized, and may occur either as an 
 inflammation of the arachnoid and pia mater (leptomeningitis), or be mainly 
 limited to the dura mater (pachymeningitis). It either originates as a chronic 
 affection, or is the sequela of an acute attack, and is more likely to supervene 
 in syphilitic individuals. The membranes become hyperaemic and thickened, 
 and adhesions between the cord and its membranes may occur. The extensions 
 of pia mater into the cord readily explain the fact that a chronic sclerosing 
 myelitis is frequently associated with this affection. The Symptoms are those 
 of localized pain and rigidity in the back, increased on all movements, and 
 accompanied by shooting pains and hyperaesthesia, and perhaps muscular 
 pains and cramps. The reflexes are usually exaggerated, and vesical com- 
 plications may follow. Treatment consists in prolonged rest, with counter- 
 irritation in the* form of blisters or the button cautery applied to the back, 
 whilst mercury is administered internally. 
 
 Spinal Myelitis. — Inflammation of the spinal cord may follow injuries of the 
 spine, either as a direct consequence of depressed or displaced bone, or from 
 simple concussion or contusion with haemorrhage ; it may also be caused at a 
 later date by extension of inflammation from the meninges, or result from com- 
 pression by lymph, pus, granulation or cicatricial tissue, or callus. It may be 
 acute or chronic. In the former the cord becomes red and softened; the 
 nerve elements are destroyed, and finally replaced by cicatricial tissue if the 
 patient live long enough. In chronic cases the connective tissue becomes 
 thickened, and the nerve structures compressed and disintegrated, whilst the 
 meninges are always adherent and thickened. 
 
 Symptoms. — Acute Myelitis is evidenced by the presence of pain in the back 
 and along the course of the nerves arising from the inflamed area, hyper- 
 aesthesia, and muscular cramps in the earlier stages, soon followed by paralytic 
 symptoms, if these are not already present as the result of the injury. The 
 irritative symptoms are, however, much less marked than in acute meningitis 
 The reflexes vary according to the amount of destruction of the cord substance, 
 whilst muscular atrophy is not especially rapid, except in those muscles 
 formerly supplied from the affected area. The sphincters of both bladder and 
 
640 A MANUAL OF SURGERY 
 
 rectum are paralyzed, causing retention of urine and incontinence of faeces; 
 the former is almost invariably followed by septic cystitis, especially when the 
 trophic centres in the lumbar enlargement are involved. Bedsores are very 
 liable to be produced, and may become very extensive and serious. Priapism 
 and hyperpyrexia are often present when the cervical region is affected. The 
 fatal issue is usually due to septic poisoning from the urinary tract, or perhaps 
 from the bedsores. 
 
 Chronic Myelitis gives rise to a great variety of symptoms, but those most 
 marked are a gradually increasing motor weakness, going on to paralysis, 
 together with various sensory phenomena ending in anaesthesia, whilst there is 
 trouble with the bladder and rectum. 
 
 The treatment of each of these conditions is mainly symptomatic. 
 
 Spinal, or Traumatic, Neurasthenia (Syn. : Railway Spine, Indirect Concus- 
 sion of the Spine). — Cases are not uncommonly met with in which, although 
 there has been no direct injury to the spinal column or cord, and no immediate 
 symptoms of importance, the fact is manifestly demonstrated in various ways 
 that considerable commotion and disturbance have been produced in the 
 nervous system. Railway accidents are the most common cause of this con- 
 dition, but it may arise from any jar to the spinal column. The reason why 
 railway accidents are so often responsible for this state is that the forces 
 employed are very great, and the collision unexpected, so that the muscles and 
 ligaments are taken at a disadvantage, being off their guard, whilst the shock, 
 terror, and mental disturbance are also important factors. Ligamentous and 
 muscular lesions — i.e., sprains and strains — are the usual local phenomena 
 produced by such accidents. 
 
 In the majority of cases the symptoms are mainly due to excessive irrit- 
 ability and weakness of the spinal and cerebral centres, constituting a condi- 
 tion of nerve prostration, or Neurasthenia, and the history will usually be some- 
 what of this type : The individual at the time of the accident is thrown from 
 side to side, or severely shaken, but does not lose consciousness, and, although 
 feeling somewhat dazed, is able to alight without help, and may even assist 
 others. He perhaps continues his journey, and goes to his business, but finds 
 in the course of a few hours that his back is painful, his head aching, and that 
 he cannot apply himself to his work. He returns home and goes to bed, 
 sending for his doctor, who will probably prescribe rest and bromides. His 
 condition remains for a time unaltered ; he complains of pain and tenderness 
 over certain regions of the spine, especially the lumbar, and is unable to 
 walk, or to undertake any serious mental or physical effort, whilst all exces- 
 sive sensory stimuli, such as a bright light or noise, are unusually disturbing. 
 Neuralgia is often present, whilst the pulse is weak ; the urine may be retained 
 or may dribble away, and the temperature be for a time subnormal. Accom- 
 modative asthenopia (or the inability to accommodate for near objects), result- 
 ing in a temporary condition of presbyopia, is also a marked feature in many 
 of these cases. All the symptoms are aggravated by mental excitement and 
 exertion, such as are often produced by the necessary interviews with doctors 
 and solicitors pending the financial compensation by the railway company. 
 The immediate improvement which often follows the satisfactory settlement of 
 his claim for damages is not necessarily due to imposture, but may result from 
 the removal of mental tension and anxiety. 
 
 This condition of neurasthenia may develop immediately after the accident, 
 as an acute condition, the patient lying helpless and prostrate, or more 
 often chronically, as in the more common type of cases described above. To 
 it, however, is frequently added a considerable element of Hysteria, in the form 
 either of acute attacks of hysterics, or of a chronic unconscious exaggeration 
 of the sensory symptoms. If the patient is examined in the supposed hyper- 
 aesthetic area whilst his attention is distracted, possibly no pain will be com- 
 plained of. 
 
 The Prognosis is generally favourable, the patient recovering in time, but 
 in a few instances permanent effects may be produced. 
 
INJURY OF THE SPINE 641 
 
 In the Treatment, a good deal of care is needed to judge rightly when the 
 period has arrived for encouraging movement rather than rest, and thus to 
 prevent the patient from developing a condition of chronic invalidism. Re.U 
 in bed is to be recommended at first, bromides given in moderation, and fomen- 
 tations applied locally. Later on, friction with liniments and massage should 
 be employed, and when all chance of secondary inflammatory disturbance is at 
 an end, movement should be encouraged, and change of air advised, whilst a 
 course of strychnine and iron may be administered. 
 
 In a few cases, however, fortunately much rarer, the symptoms run on 
 into those of a chronic inflammatory condition of the spinal cord and its 
 membranes, and these, to which Erichsen formerly applied the term Indirect 
 Concussion, are of the gravest import. In others, nothing may be noticed 
 by the patient for some weeks or months beyond the fact that he feels a 
 little shaken, and not so capable of doing his work as formerly ; but, at the 
 same time, he loses flesh, and looks worn and fagged. Gradually other 
 phenomena develop. His brain power is diminished, and any mental effort 
 causes him to be muddled ; memory fails, the temper is irritable, and his 
 sleep disturbed ; the head is often hot. The vision is usually defective, 
 and he complains of noises in the ears. The sense of touch is impaired, 
 so that all delicate movements are hindered. The spine is kept rigidly 
 stiff, the head fixed, and the gait is somewhat unsteady and shambling ; the 
 walking powers are much diminished, and going up and down stairs is espe- 
 cially difficult. Motor power in all regions of the body is partly lost ; any or 
 every modification of sensation may be met with, whilst the reflexes are 
 increased The bladder may lose its power of retaining urine for a time, but 
 this is not always a marked symptom ; there is great impairment of both sexual 
 desire and power. On examining the back, distinct tenderness is felt over one 
 or more spots, especially in the lower cervical, mid-dorsal, and lumbar regions. 
 In such cases, where the symptoms develop slowly, and remain unaltered by 
 treatment, the Prognosis is most unfavourable, since they are probably due to 
 inflammatory changes in the cord and brain, and although the patient may 
 live for years, yet he is permanently crirpled, and becomes a confirmed invalid. 
 Treatment in the earlier stages consists of rest, preferably on a prone couch, 
 with counter-irritation, such as blisters, or even the actual cautery, over the 
 spine, whilst mercury or iodide of potash, and bark, are administered. Careful 
 nursing and massage of the limbs, or galvanism, are needed, and warm sea- 
 water douches may be most useful. If, however, no improvement follows, the 
 patient must be encouraged to get about as best he can, and to go out in an 
 invalid chair, so as to maintain the general health, whilst careful attention is 
 directed to the personal hygiene. 
 
 Paraplegia. 
 
 Paraplegia arises in the course of spinal injuries from a variety 
 of causes, which may be classified as follows : 
 
 1 . Paraplegia arising immediately after the accident, from : 
 
 (a) Direct concussion without evident lesion, if such a 
 
 condition be possible ; 
 
 (b) Disintegration of the cord from intramedullary haemor- 
 
 rhage, or from contusion without displacement of 
 bone ; 
 
 (c) Displacement of bones, with or without recoil, crushing 
 
 the cord ; 
 
 (d) Penetrating wounds dividing the cord. 
 
 However produced, the same symptoms manifest themselves if 
 the lesion is complete ; recovery is alone possible in the first and 
 
 4i 
 
642 A MANUAL OF SURGERY 
 
 perhaps in the second group, whilst in the other forms the para- 
 plegia is maintained by a subsequent acute transverse myelitis. 
 2. Paraplegia arising after an interval, from : 
 
 (a) Extramedullary spinal haemorrhage, if the symptoms 
 
 show themselves without pyrexia in twenty-four or 
 forty-eight hours ; 
 
 (b) The pressure of inflammatory exudations, as in spinal 
 
 meningitis, when the symptoms are preceded by 
 inflammatory phenomena, and do not appear before 
 seventy-two hours at the earliest ; 
 
 (c) The pressure of callus or of cicatricial adhesions around 
 
 the cord and membranes (i.e., peri-pachymeningitis). 
 
 It is unnecessary to discuss further the special signs and 
 symptoms accompanying each form ; they have been already 
 mentioned. We merely propose to indicate briefly the effects of 
 a total transverse lesion, and then to describe the results of 
 paraplegia as they vary with the situation of the injury. It must 
 be remembered that the nerves are derived from spinal segments 
 which are always at a higher level than the exit of the nerves from 
 the canal — i.e., the nerves travel downwards within the spinal canal 
 for a variable distance, less in the cervical region, more in the 
 lumbar, before escaping through the inter-vertebral foramina. 
 
 A Total Transverse Lesion, destroying absolutely one segment 
 of the cord, will result in the following symptoms : 
 
 i. Paralysis of the muscular area supplied by the destroyed 
 segment, followed by rapid atrophy, reaction of degeneration, and 
 loss of reflexes in this particular group of muscles. 
 
 2. Paralysis of all the muscles supplied by the segments below 
 that which has been destroyed. The trophic condition remains 
 normal, at any rate, for a time, but when secondary descending 
 degeneration in the antero-lateral columns has occurred, the 
 muscles become contracted, tense, and rigid (late rigidity). The 
 condition of the reflexes after a total transverse lesion has been 
 a fertile source of discussion, but it is now maintained that the deep 
 reflexes are entirely and permanently lost, whilst the superficial 
 reflexes, though absent for a time, may reappear. If, however, a 
 portion of the cord remains intact, both superficial and deep 
 reflexes may persist or reappear, and even be exaggerated. 
 
 3. Complete anaesthesia of the sensitive area supplied by the 
 destroyed segment, and of all the sensitive areas below. 
 
 4. A narrow zone of hyperesthesia is found at the upper level 
 of the anaesthetic area, due to the irritation of the nerve roots at 
 the site of injury. 
 
 5. Vasomotor paralysis combined with trophic disturbances in 
 the parts which are paralyzed. 
 
 6. Visceral changes, especially in the bladder and rectum. 
 
INJURY OF THE SPINE 643 
 
 Phenomena of Paraplegia at Different Levels. 
 
 1. At the Upper End of the Sacrum. — Total transverse lesions 
 at this spot are exceedingly rare ; they only involve the cauda 
 equina and cause paralysis of the sacral plexus. The effects 
 produced are : (i.) Paralysis of all the muscles of the legs, except 
 those supplied by the anterior crural nerve, the obturator, and 
 the superior gluteal, whilst the perineal and penile muscles are 
 also affected, (ii.) Anaesthesia of the penis, scrotum, perineum, 
 lower half of the gluteal region, and the whole of the legs 
 except the front and outer part of the thigh, supplied by the 
 cutaneous branches of the anterior crural, and the region supplied 
 by the long saphena. (iii.) The bladder and rectum are both 
 shut off from their spinal centres, and hence there will be tem- 
 porary retention of urine, followed by distension with overflow, 
 and incontinence of faeces. The bladder, however, gradually 
 contracts, its walls become thickened, and its capacity steadily 
 diminishes, so that incontinence becomes more and more absolute. 
 
 2. If the lesion is situated in the Dorsi-lumbar region, or 
 passes through the lumbar enlargement, which corresponds to 
 the twelfth dorsal and first lumbar vertebrae, there is complete 
 paralysis of the muscles of both limbs, including those passing to 
 them from the trunk ; total anaesthesia of the legs, gluteal and 
 perineal regions, and possibly the lower part of the abdomen ; 
 whilst, if the vesical centres are destroyed, there is total paralysis 
 of the bladder, with relaxation of the sphincter, dribbling of 
 urine, which early becomes ammoniacal, and cystitis, due to 
 trophic changes ; if the centres escape, retention with overflow is 
 the usual result : the rectum and sphincter ani are paralyzed, 
 causing incontinence of faeces, the passage of which is unrecognised 
 from the anaesthetic condition of the anus. 
 
 3. In the Mid-dorsal region the same phenomena are met with, 
 but to them are added a more extensive region of anaesthesia, 
 limited above by a hyperaesthetic zone, which feels like a tight 
 painful girdle round the waist ; paralysis of the flat abdominal 
 muscles ; retention of urine, followed by distension with over- 
 flow, which, however, when asepsis is maintained, may occa- 
 sionally be followed by a state of reflex micturition in which the 
 patient passes water unconsciously and involuntarily, whenever 
 there is sufficient present to cause sensory stimuli to ascend to 
 the undamaged centres. The abdominal paralysis is a most 
 important addition to the gravity of the case, for all straining 
 movements are thereby prevented, and thus coughing is em- 
 barrassed and defaecation hindered. The gases developing from the 
 stagnant faeces accumulate and cause distension of the belly 
 (meteorism), and thereby respiration may be seriously impaired. 
 The diaphragm, moreover, is hampered in its action, since the 
 lower ribs cannot be fixed or steadied, and hence its contractions 
 
 41—2 
 
644 A MANUAL OF SURGERY 
 
 tend to pull them inwards, instead of increasing the dimensions 
 of the thoracic cavity. 
 
 4. In the Cervico - dorsal region all these phenomena are 
 present, but the anaesthesia extends over nearly the whole trunk, 
 and the hyperesthesia may involve the arms, whilst the inter- 
 costal and spinal muscles are also paralyzed. Respiration has 
 therefore to be carried on by the hampered diaphragm, with the 
 assistance of a few of the accessory respiratory muscles in the 
 neck, and hence is much impeded ; if bronchitis is present, it 
 will prove fatal by asphyxia in a few days from the inability to 
 expectorate. Priapism is a marked feature of cervical paraplegia. 
 
 5. In the Lower Cervical region the arms also become involved 
 in both the paralysis and anaesthesia, and if the lesion is situated 
 at or above the fourth cervical vertebra, instant death results 
 from paralysis of the phrenics and consequent stoppage of the 
 respiration. 
 
 Death from Paraplegia, therefore, may arise from a variety of 
 causes and at various periods. It may be immediate, from 
 respiratory failure in lesions above the fourth cervical vertebra ; 
 or it may occur from accumulation of mucus or pus in the 
 air-passages, when the lesion is in the upper dorsal region ; or 
 it may be delayed for weeks, or even months, and then is due 
 to sloughing of the nates, or septic absorption from an inflamed 
 or ulcerated bladder, which is often associated with suppurative 
 pyelonephritis. 
 
 The Prognosis and Treatment both depend on the position and 
 character of the lesion causing the paraplegia, and on the previous 
 habits and condition of health of the individual. 
 
 Laminectomy. 
 
 By laminectomy, or, as it used to be badly termed, trephining 
 the spine, is meant an operation for the removal of the lamina? 
 and spinous processes of one or more vertebrae, in order to relieve 
 pressure on the cord, whether due to depressed bone, abscess, 
 granulation tissue, excessive callus, cicatrices, or tumours. The 
 operation consists in making a longitudinal incision in the middle 
 line of the back, extending to the spinous processes ; the muscular 
 and tendinous structures are then cleared from the posterior aspect 
 of the vertebrae as far as the transverse processes, a proceeding 
 usually attended with considerable haemorrhage, which can be 
 checked, perhaps, better by hot sponge pressure than by attempt- 
 ing to secure the individual vessels. The neural arches are then 
 examined for injury, etc., and those which seem to be most 
 affected removed by cutting pliers, Hey's saw, or laminectomy 
 forceps. The posterior aspect of the membranes of the spinal 
 cord is thus exposed, and the various conditions which may be 
 present are dealt with according to circumstances. In this place 
 
INJURY OF THE SPINE 645 
 
 we have merely to consider the use of this operation after injury 
 to the spine. For its employment in other conditions, see 
 Chapter XXII. 
 
 Much controversy has arisen as to the value of this operation 
 and the circumstances under which it may be justifiable. It 
 must be remembered as a fundamental guiding principle that 
 repair is impossible after the spinal cord has been divided, or 
 any one segment totally disintegrated, and hence, if it is certain 
 that a total transverse lesion of the cord has been caused by an 
 accident, it is absolutely useless to operate. Early and complete 
 disappearance of all the reflexes is a suggestive phenomenon, but 
 cannot be looked on as absolute evidence of a total transverse 
 lesion ; if, however, the deep reflexes remain absent for an) 
 length of time, even though some of the superficial ones have 
 reappeared, operation is useless. The presence of the deep 
 reflexes is always an evidence that at any rate a portion of the 
 cord remains uninjured, and would encourage one to operate, 
 This question cannot, however, be absolutely settled in the early 
 stages of the case, when an exploration is likely to be of most 
 service, and therefore there will always be a certain number of 
 cases in which it will be a matter of doubt as to whether or not 
 any benefit will accrue from operation. The final decision undei 
 such circumstances will depend on the special predilections and 
 opinions of the surgeon who is in charge of the case, and the 
 general state of the patient. 
 
 Apart from these doubtful cases, the following are generally 
 admitted as being suitable for operation : (1) Penetrating wounds 
 or fractures with displacement which involve the spine below the 
 first lumbar vertebra ; the cauda equina is present below that level, 
 and not the spinal cord, and it is reasonable to treat it in the same 
 way as one would treat a single peripheral nerve ; (2) when the 
 injury is mainly limited to the neural arch, which has been driven 
 in by direct violence ; (3) in all cases of bilateral dislocation of 
 the cervical spine where the patient is not moribund ; (4) if 
 paraplegia arises with or without inflammatory symptoms, when 
 an interval has elapsed since the accident ; the pressure in such 
 cases may be produced by blood or inflammatory exudations, and 
 benefit may possibly arise from the operation ; if, however, it is 
 due to a total transverse myelitis, no good can follow. (5) When 
 symptoms of irritation or paralysis supervene at a later date, 
 from contraction of cicatrices around the cord or its membranes 
 (peri-pachymeningitis), or from excessive callus formation, lamin- 
 ectomy may be performed with good hopes of a successful result. 
 
CHAPTER XXII. 
 DISEASES OF THE SPINE. 
 
 Spina Bifida. 
 
 By Spina Bifida is meant a condition of imperfect development of 
 some portion of the posterior aspect of the spine, with or without 
 a similar affection of the spinal cord and membranes. 
 
 It must be remembered that the spinal cord is developed as 
 a linear involution of the epiblast, the edges of this medullary 
 groove growing up and uniting, so as to include a passage lined 
 with epithelium, and subsequently known as the central canal. 
 The cord is gradually separated from the overlying skin by an 
 intrusion of mesoblastic elements, from which the vertebrae, 
 together with the spinal muscles and ligaments, are developed. 
 The ossification of each vertebra originates in three main centres 
 — one for the body, and one for each half of the neural arch, 
 whilst epiphyses are developed as plates above and below the 
 body, as also for the transverse and spinous processes. 
 The following are the chief forms of spina bifida : 
 i. A Myelocele results from non-closure of the primitive 
 medullary groove. It is characterized by the appearance in the 
 lumbo-sacral region of a raw surface, which consists of the spread- 
 out structures of the spinal cord, at the upper part of which opens 
 the central canal. The condition is evidently incompatible with 
 life, and the children, if they are not stillborn, as is usually the 
 case, do not live beyond a day or two. 
 
 2. A Syringo-myelocele (Fig. 234) arises from a distension of 
 the central canal of the cord, the posterior portion of which 
 usually remains adherent to the skin, from which it has never 
 been separated, owing to defective development of the meso- 
 blastic tissues. The spinal nerves travel round the walls of the 
 cyst in order to find their way to the intervertebral foramina. 
 Trophic phenomena are nearly always a prominent feature of 
 these cases. 
 
 3. A Meningomyelocele (Fig. 235) is due to a development of 
 fluid within the membranes which remain adherent to the skin, 
 
DISEASES OF THE SPINE 
 
 647 
 
 the spinal cord or nerves of the cauda equina passing down the 
 posterior aspect of the cavity as a strap, and the nerves traversing 
 and perforating the sac to reach the intervertebral foramina. 
 
 4. A Meningocele (Fig. 236) is characterized by a protrusion of 
 the membranes, containing cerebro-spinal fluid, through a defect 
 in the posterior walls of the vertebrae, the spinal cord and nerves 
 being in their normal position. This variety is uncommon. 
 
 Of these forms, the meningo-myelocele is that most frequently 
 seen in living children, although, according to Bland Sutton, from 
 whose book on Tumours the above description is mainly derived, 
 the first is really the most common. 
 
 Clinical Characters. — A spina bifida is recognised by the appear- 
 ance of a tumour in the middle line of the back (Fig. 237), most 
 commonly involving the lower part of the spine ; it may be 
 covered by normal skin, but usually that over the apex is thin 
 and translucent, and not unfrequently a number of small dilated 
 vessels are seen coursing over it. On compressing the tumour, 
 
 Fig. 234. — Diagram of Fig. 235. — Diagram of Fig. 236. — Diagram 
 
 Svringo-Myelocele. Meningo-Myelocele. of Meningocele. 
 
 S C, spinal cord ; CSF, cerebro-spinal fluid in sac ; N, nerves. 
 
 its size can be diminished, and in infants distension of the anterior 
 fontanelle can be felt, showing that the sac is filled with cerebro- 
 spinal fluid, and there is always a distinct impulse on coughing 
 or crying. The defect in the posterior portion of the vertebras is 
 very evident, the edges of the bones being felt at the margins of 
 the tumour. Various other deformities may be associated with 
 spina bifida, especially hydrocephalus and talipes, which are 
 perhaps most common in cases of syringo-myelocele, whilst per- 
 forating ulcer, ankylosis of the terminal phalanges of the toes, 
 and other trophic phenomena, are also developed, perhaps at a 
 much later date. 
 
 The Prognosis of the case depends mainly on the thickness and 
 character of the overlying skin. If it is thin, and the cord 
 evidently adherent to it, as sometimes indicated by a cicatricial 
 depression or dimple, the sac is very likely to give way, causing 
 either death from sudden escape of cerebro-spinal fluid, or a fatal 
 issue in a few days from septic meningitis. If the spina bifida is 
 small, and covered with healthy skin and subcutaneous tissue, the 
 
6 4 S 
 
 A MANUAL OF SURGERY 
 
 patient may reach adult life, but even then trophic phenomena 
 may supervene. Occasionally a meningocele, with only a small 
 aperture of communication with the spinal canal, is cured 
 spontaneously by the gradual development of the bones con- 
 stricting the neck of the sac. 
 
 Treatment. — The majority of these cases are best left alone, the 
 tumour being merely] guarded from injury by the application of 
 
 a suitable cap. If the sac is 
 gradually increasing in size, and 
 threatening to give way, operative 
 interference is absolutely necessary 
 if life is to be saved. Acupuncture 
 through the thinned integument, the 
 cerebro - spinal fluid being allowed 
 to drain away subsequently into 
 an antiseptic dressing, or tapping 
 through the healthier integument 
 around the base, repeated several 
 times, and followed by compres- 
 sion, may lead to a cure in favour- 
 able cases. Statistics, however, go 
 to prove that the best results are 
 obtained by tapping, followed by 
 the injection of Morton's fluid 
 (R : iodi, grs. x. ; pot. iod., grs. xxx. ; 
 glycerinum, ad ^i.). A small 
 quantity of the cerebro-spinal fluid 
 is withdrawn, and then from half a 
 drachm to a drachm of the iodine 
 solution is introduced. It diffuses 
 itself slowly, and tends to act 
 locally, so that if the child is kept 
 quiet, and only semi-recumbent, its 
 effect will be limited to the sac of 
 the spina bifida and its neighbour- 
 hood. In some cases persistent 
 leakage may follow this treatment, 
 
 Fig. 237. — Spina Bifida in 
 Lad aged Sixteen, probably 
 of the meningo-myelocele 
 Type. (From a Photograph.) 
 
 The swelling had not increased 
 much in size since he was a 
 child, but distinct trophic 
 phenomena were being de- 
 veloped in the shape of talipes and such is dealt with by means 
 of both feet. of a fi rm antiseptic compress; in 
 
 many the injection needs to be re- 
 peated more than once. 
 
 Of late years treatment by operation has been coming more 
 and more into vogue. Naturally, it is chiefly applicable in the 
 meningocele type, and infants or those suffering from trophic 
 phenomena do not stand it well. An incision is made over 
 the sac, either in the middle line if it is certain that the cord is 
 not there, or to one side, if it is. The child should be kept with 
 the head low when the sac is opened, so as to limit, as far as 
 
DISEASES OF THE SPINE 649 
 
 possible, the loss of cerebro-spinal fluid. In a meningocele, the 
 protruding membranes are cut away, the wound in them is very 
 carefully sutured, and the spinal muscles drawn together by deep 
 stitches, so as to create an extra protective barrier, in addition to 
 the skin and subcutaneous tissues. When the cord runs down 
 the back of the sac, it is freed by incisions on either side, and if 
 it cannot be separated from the skin, the whole strip is replaced in 
 the vertebral canal, the membranes are closed over it, and finally 
 the muscles and skin are united by rows of sutures. The results 
 obtained by this means have been encouraging, and in suitable 
 cases operation may be recommended with some prospect of 
 success. 
 
 Spina Bifida Occulta is the term applied to a condition in which 
 the posterior portion of the vertebras is absent, but without any 
 protrusion of the cord or its membranes. The overlying skin 
 may be cicatricial in character, or a large growth of hair may 
 arise from it ; occasionally a lipoma develops in this situation, 
 and by its downward growth compresses the spinal cord, causing 
 paraplegia. Unless such a condition is present, spina bifida 
 occulta calls for no treatment, but an exploratory operation 
 should always be undertaken when nervous phenomena supervene. 
 
 Congenital Sacral Tumours. 
 
 Other congenital conditions of the lower end of the spine are 
 described as congenital sacral or coccygeal tumours. The majority 
 of these arise from what is known to embryologists as the neurentevic 
 canal. In early fcetal life it is supposed that the neural and 
 alimentary canals are continuous, the passage of communication 
 being known by the above name. Ordinarily, it entirely dis- 
 appears after the union of the proctodeum with the intestine, but 
 evidences of its existence are occasionally met with, either in the 
 form of a cicatricial dimple adherent to the tip of the coccyx [post- 
 anal dimple), or as one of the following conditions : 
 
 (i.) A dermoid cyst, containing the usual mixture of sebaceous 
 material and epithelial cells, and often a tuft of hair ; it develops 
 in the space between the rectum and coccyx, and may either 
 project posteriorly, below the coccyx, or open into the rectum ; 
 the tuft of hair may thus find its way out of the anus. In a case 
 under the care of Mr. W. Turner, at Westminster Hospital, 
 it was actually connected with the spinal meninges, removal 
 involving the loss of cerebro-spinal fluid. 
 
 (ii.) A tumour of a glandular or adenomatous nature is occa- 
 sionally found in the same region. It is characterized micro- 
 scopically by the existence of alveoli, lined by cuboidal epithelium, 
 held together by connective tissue ; it may attain a large size, 
 but is quite innocent. Such growths are termed by Bland Sutton 
 
650 A MANUAL OF SURGERY 
 
 thyroid-dcrmoids, but a better name would be a congenital adenoma of 
 the post-anal gut. 
 
 Various other tumours are met with in infants in this region, 
 and the same title of congenital sacral or coccygeal tumour has 
 sometimes been applied to them : 
 
 (a) A spina bifida of the meningocele type, which may com- 
 municate with the subdural space, or may have been shut off by 
 a natural process of cure. 
 
 (b) A lipoma may also form here, and in some cases has simu- 
 lated by its shape a caudal appendage. 
 
 (c) A partially developed foetus may be met with, enclosed 
 within the subcutaneous tissues of the sacral region, and is known 
 as a teratoma. 
 
 (d) Sarcoma and cystic hygroma have also been observed. 
 
 The conditions are so exceedingly rare that it is unnecessary to 
 enter into details of treatment, which is conducted in accordance 
 with general principles. 
 
 Inflammatory Affections of the Spine. 
 
 I. Acute Osteomyelitis of the Spine is an uncommon affection, 
 which has only recently been recognised. It is due to the same 
 causes as similar disease elsewhere, viz., infection with pyogenic 
 organisms in an individual of low germicidal power. It is charac- 
 terized by severe pain in a localized portion of the back, and fever ; 
 deformity is not a marked feature, since massive necrosis occurs 
 and not a gradually destructive caries. Abscesses form early, and 
 there is great danger of an extension of the inflammation to the 
 spinal meninges, leading to a fatal issue. The prognosis is ex- 
 tremely bad, owing to this latter complication, and the only 
 possible treatment consists in early incisions to give exit to the 
 pus. Sequestra can easily be removed from the back of vertebrae, 
 but from the front only in the lumbar and cervical regions. 
 
 II. Tuberculous Disease of the Spine or Spinal Caries (Syn.: Pott's 
 Disease, Angular Curvature). — The above names are applied to a 
 condition due to tuberculous disease of the vertebras, originating 
 almost invariably in their bodies, which are more or less destroyed, 
 leading to the so-called ' angular curvature.' This latter title is 
 misleading and inaccurate, since the deformity, though sometimes 
 angular in character, can scarcely partake of the nature of an 
 angle and a curve at the same time. The term ' Pott's disease ' 
 is derived from Percival Pott, who first described it accurately 
 in 1779. 
 
 Etiology. — The causes of tuberculous disease of the spine are 
 much the same as those of tuberculous affections elsewhere, viz. : 
 it affects an individual predisposed to the development of tuber- 
 culous disease either by inherited tendency, or by impairment 
 
DISEASES OF THE SPINE 
 
 651 
 
 of the general health, as from some preceding illness, or expo- 
 sure to defective sanitary conditions. The actual deposit of 
 tubercle is probably determined by some injury which, though 
 slight and perhaps not noticed at the time, is sufficient to cause 
 local diminution of vitality, thereby constituting a favourable 
 nidus in which the Bac. tuberculosis can develop. It is most fre- 
 quently met with in children, but may arise at any age, and 
 equally in either sex. Sprains and strains of the vertebral column, 
 or of the soft parts attached 
 thereto, are the local lesions 
 mainly responsible for it. 
 Any part of the spinal 
 column may be involved, 
 but the lower dorsal is by 
 far the commonest. The 
 cervical region is rarely 
 attacked, except in children, 
 whilst in adults the dorsi- 
 lumbar vertebrae are the 
 favourite seat. 
 
 Pathological History. — 
 The actual changes in the 
 bones in Pott's disease are 
 exactly similar in nature 
 to those we have already 
 described as occurring 
 generally in cancellous 
 bone (p. 514), and no special 
 description need be given 
 here. The disease starts 
 in one of two places, either 
 under the periosteum 
 covering the anterior sur- 
 face of the vertebrae (this 
 
 most often in adults), or at Fig. 238.— TuberculousDiseaseofSimne 
 the line of junction of the 
 upper or lower plate-like 
 epiphyses with the body, 
 the usual situation in 
 children. In the former 
 
 case the subperiosteal tuberculous deposit early extends to the 
 subjacent bone, and spreads to neighbouring vertebrae, either 
 along the under surface of the anterior common ligament, or 
 through^the intervertebral discs, which are disintegrated by the 
 process. When it spreads along the anterior common ligament 
 (Fig. 238), the disease may be very extensive, body after body 
 being eroded, and the intervertebral discs suffering even more 
 than the bones. In such a case the deformity produced is not 
 
 f(4L 
 
 / ! 
 
 showing Destruction of the Bodies 
 of the Vertebr.e, and Abscess For- 
 mation BENEATH THE ANTERIOR COMMON 
 
 Ligament. (Modified from Specimen 
 in College of Surgeons' Museum.) 
 
652 
 
 A MANUAL OF SURGERY 
 
 strictly angular, but rather of a general kyphotic nature. Occa- 
 sionally, however, the disease starts simultaneously in many foci, 
 so that the bodies of several vertebrae become pitted and carious, 
 without producing general destruction. In other cases the process 
 is limited to the bodies and intervertebral discs of two adjacent 
 vertebrae, the periosteum being but little affected. This variety 
 is, perhaps, most common in the lumbar region, where the bodies 
 of the vertebrae are large and permit a limiting zone of sclerosed 
 tissue to form ; it is also not uncommon in this situation to find 
 definite sequestra (Fig. 239). 
 
 The terms already described as characteristic of the different 
 forms of caries may be applied to the varying conditions met with 
 in this disease. Thus, when it runs its course without suppura- 
 tion, caries sicca is said to be present ; if pus develops, as is so 
 
 % 
 
 :v 
 
 -snaba*"-"* 
 
 Fig. 239. — Tuberculous Disease of Two Lumbar Vertebra, showing 
 Sequestrum on the Anterior Aspect, and Lateral Thickening 
 preventing Angular Deformity. (College of Surgeons' Museum.) 
 
 frequently the case, caries suppurativa ; and when sequestra occur, 
 caries necrotica. 
 
 Cure is effected by the bodies of the vertebrae falling together 
 and becoming ankylosed, so that a deformed and immobile condi- 
 tion of the affected portion of the spine is often the best result that 
 can be anticipated. The new bone thus formed becomes in 
 time sclerosed and very dense, and the synostosis also involves 
 the spines and laminae. Occasionally, the tuberculous process 
 extends backwards through the body of the bone so as to im- 
 plicate the posterior common ligament, and paralytic or other 
 symptoms may then arise from pressure on the cord. 
 
 Rare cases have been described in which the disease mainly 
 affected the sides of the vertebrae, as a result of which lateral 
 deformity occurred ; and still more uncommon are those in which 
 the posterior portion of the neural arches is primarily involved. 
 
 In the upper cervical region the disease usually starts in the 
 
DISEASES OF THE SPINE 653 
 
 large joints, either between the occiput and atlas, or between the 
 atlas and axis. For a time it may be limited to one side, but 
 usually the bone is attacked at an early stage, and the trouble then 
 spreads to other joints. A special complication of this variety will 
 be mentioned hereafter (p. 658). 
 
 The Signs and Symptoms produced by tuberculous caries of the 
 vertebrae vary considerably in different situations, but for practical 
 purposes may be described under the following five headings : 
 
 1. Pain is a constant and invariable accompaniment of the 
 disease, although in the early stages it may not be specially 
 prominent, being only elicited by careful examination. It is of 
 two main types, the local and the referred. Local pain is more or 
 less similar in character to that always experienced in disease of 
 bones, although, owing to the cancellous nature of the osseous 
 tissue involved, there is often but little tension, and hence it may 
 be slight. It can, however, be elicited in all cases, either by 
 pressure or percussion over the spines, or perhaps more effectually 
 by pressing upon the transverse processes, so as to induce rotation 
 of the vertebral bodies one on another. Movements of the spine, 
 bending or twisting, are similarly painful, whilst the same result 
 can be brought about by jarring the spine, as by a blow on the 
 head or nates. The old plan of testing for pain by means of a 
 hot sponge applied over the back is comparatively useless in this 
 disease. Referred pain is produced by pressure upon, or irritation 
 of, the roots of the nerves as they emerge from the intervertebral 
 foramina ; consequently it is always noticed in those parts of the 
 body which are supplied with sensation by the nerves issuing 
 from the spinal canal in the diseased area. If the lumbar region 
 is affected, the pain is referred down the legs ; in the dorsi-lumbar 
 region it may follow the last dorsal nerve, and be noticed in the 
 lower part of the abdomen, or in the gluteal region; in the lower 
 dorsal region pain is referred to the epigastrium, children who are 
 unable to differentiate its precise nature complaining of ' belly- 
 ache'; in the upper dorsal and lower cervical regions the pain 
 extends into the arms, whilst in the upper cervical region neuralgia 
 follows the course of the cutaneous branches of the cervical nerves. 
 Thus, if the third and fourth cervical nerves are involved, pain 
 is felt along the course of the descending sternal, clavicular and 
 acromial branches ; if the second and third are implicated, pain 
 may be confined to the great auricular and occipital nerves ; if 
 the atlas and axis are affected, the neuralgic pain, if any, follows 
 the occipital branches. 
 
 2. Rigidity of the spine is a constant accompaniment of Pott's 
 disease. In the early stages it results from muscular spasm, the 
 object being to fix and immobilize the painful part. If the lower 
 portion of the spine is involved, the back is held stiff and straight, 
 the patient abstaining from all movements which would bend or 
 stretch it. Thus, in order to pick up an object from the floor, the 
 
654 
 
 A MANUAL OF SURGERY 
 
 knees and hips are flexed, and the patient gradually lets himself 
 down with an absolutely rigid back into a sitting or squatting 
 posture ; the body is raised in a similar manner by resting the 
 hands upon the thighs, the patient, as it were, climbing with 
 extended arms up his own legs. In a child rigidity in the dorsi- 
 lumbar region can be demonstrated by laying him on his face, 
 grasping the ankles, and ascertaining the amount of movement 
 of the spine at that region by lifting the legs from the table, 
 and also by moving them from side to side. In a healthy child 
 the legs can be elevated, and the spine bent back in the dorsi- 
 lumbar region, nearly to an angle of sixty degrees ; whilst lateral 
 
 B 
 
 Fig. 240. — Diagrams to illustrate Deformities in Spinal Curvature. 
 (After Noble Smith.) 
 
 In A the result of the bodies falling together to form a wedge-shaped mass is 
 seen in the anterior displacement of the upper half of the spine ; in B the 
 compensatory curves utilized by Nature to maintain the erect posture are 
 indicated ; in C the same process is seen in an exaggerated degree. 
 
 mobility to the extent of thirty or forty degrees on either side of 
 the median line is obtainable. When caries is present, neither 
 of these movements can be made without including the thorax 
 and dorsal spine. In cervical caries the patient steadies the head, 
 and at the same time raises the shoulders by the help of the 
 trapezius and sterno-mastoid muscles, whilst the chin is often 
 supported by one hand, and the patient twists his whole body in 
 order to look sideways. 
 
 In the later stages, when repair is taking place, or has occurred, 
 rigidity of the spine is due to osseous ankylosis. After a cure has 
 been established, compensatory^movements of other portions of 
 the spine mask, to a certain degree, the localized rigidity. 
 
DISEASES OF THE SPINE 655 
 
 3. Deformity, the result of Nature's method of repair by means 
 of osseous ankylosis, is necessarily present in almost all instances, 
 although in a few cases, taken in hand early, it is possible that 
 recovery may occur without it. The amount and character of 
 the deformity depend on a variety of circumstances, and perhaps 
 most of all upon the number of vertebrae affected. Where only 
 two bones are involved, a true angular deformity may result, 
 the body of the upper vertebra being welded to that of the 
 lower, so as to produce a wedge-like mass (Fig. 240, A), the 
 surfaces of which are inclined to one another at an angle ; com- 
 pensatory curves of the spine elsewhere enable the patient to 
 assume the erect posture (Fig. 240, B). In the lumbar region, 
 where the affection is often limited to a part of two vertebrae, 
 there is usually little or no displacement, the disease being limited 
 to the centres of the bones, so that the sides may escape alto- 
 gether, and preserve the integrity of the spinal column ; when a 
 distinct projection of the spine is present, the portion of bone 
 which appears most prominent is the spinous process of the lower 
 of the vertebrae. When a large number of vertebrae are affected, 
 as is common in the dorsal region, the 
 curvature is never angular, but the whole 
 region becomes bent forwards, and ky- 
 photic in type, or even almost rectangular. 
 Owing to the obliquity and length of the 
 spinous processes of the dorsal vertebrae, 
 the projection, even when only two bones 
 are involved, is very considerable ; in the 
 latter case the spinous process of the 
 upper vertebrae, by becoming horizontal, 
 is the more prominent. In the cervical 
 region there is rarely much deformity, 
 owing to the small size of the vertebrae, 
 and to the stunted shape and deep posi- 
 tion of the spinous processes; if, however, Fl <*. 241.— Well-marked 
 several bones are involved, the head may A g\ ^result oTpon's 
 be carried forwards, togethei with the upper Disease. 
 
 part of the spine. 
 
 Secondary changes in the shape of the thorax necessarily ac- 
 company the more advanced cases of caries in' the dorsal region, 
 the sternum becoming convex anteriorly so as to compensate for 
 the diminished vertical measurement of the thorax, and the ribs 
 crowded together to such an extent as to almost obliterate the 
 intercostal spaces. The lower floating ribs may, however, retain 
 their normal position, and thus a horizontal groove may be pro- 
 duced corresponding to the line of the tenth rib. In such cases 
 the patient becomes much stunted in grow-th, and dwarfed, con- 
 stituting the typical 'hunchback' (Fig. 241). 
 
 4. Abscess is the most serious result of spinal disease, for, owing 
 
656 A MANUAL OF SURGERY 
 
 to its deep origin, it often attains considerable dimensions before 
 it is recognised or treated, whilst it is usually impossible to deal 
 with the causative lesion in the bones, and if once the cavity is 
 allowed to become septic, an exceedingly grave complication is 
 introduced into the case, which may even determine a fatal issue. 
 The pus collects originally on the anterior aspect of the vertebrae, 
 beneath the anterior common ligament (Fig. 238), which may be 
 stripped from the bones for a considerable distance, owing to 
 the tension within the abscess cavity. It thence finds its way 
 to the sides of the bodies after perforating the ligament, and 
 burrows in various directions, according to the portion of the 
 spine involved. 
 
 In the cervical region a chronic retropharyngeal abscess is first 
 formed ; it pushes the posterior pharyngeal wall forwards, and 
 may be detected from the mouth as an elastic fluctuating swelling, 
 which, by its size, often leads to some difficulty in swallowing and 
 breathing, whilst oedema of the glottis may be induced. Left to 
 itself, various courses are open to it: 1. The abscess may burst 
 and discharge into the pharynx, the cavity necessarily becoming 
 septic, and the osseous lesion thus aggravated. 2. It may travel 
 downwards behind the oesophagus into the posterior mediastinum, 
 and thence extend in the same direction as abscesses in the dorsal 
 region. 3. More often the pus finds its way to the side of the 
 neck, being guided to the posterior triangle by the prevertebral 
 fascia, behind which it is situated ; less frequently it pierces this 
 fascia, and presents in the anterior triangle. 4. In the lower part 
 of the neck, it may spread under the clavicle into the axilla, being 
 directed by the same fascia, which in this region passes down- 
 wards behind the subclavian trunks, and forms the posterior wall 
 of the sheath of the axillary vessels. 
 
 In the dorsal region, the abscess starts in the same way in front 
 of the vertebrae, and may thence extend as follows: 1. Most 
 frequently it passes backwards between the vertebral ends of the 
 ribs to form a dorsal abscess, burrowing along the course of the 
 posterior branches of the intercostal nerves and arteries, and 
 forming a fluctuating swelling, 3 or 4 inches from the spinous pro- 
 cesses, with an impulse on coughing. 2. It may extend between 
 the ribs and the parietal pleura along the anterior branches of the 
 intercostal vessels, coming to the surface at the spot where the 
 lateral cutaneous branches are given off. Tuberculous disease of 
 the ribs, leading to caries or necrosis, or even a localized em- 
 pyema, may be induced in such cases. 3. Very rarely the abscess 
 may travel up to the neck, pointing behind the sterno-mastoid 
 muscle. 4. Not uncommonly, however, it works its way down- 
 wards, passing under the ligamentum arcuatum internum of the 
 diaphragm, thus entering the psoas sheath, and giving rise to a 
 psoas abscess. 
 
 In disease of the dorsi-lumbar or lumbar regions, either a 
 
DISEASES OF THE SPINE 657 
 
 lumbar or a psoas abscess may result. A lumbar abscess is due to 
 the passage backwards of the pus along the posterior branches of 
 the lumbar vessels and nerves to the outer border of the erector 
 spinae, and usually presents superficially in Petit's triangle — i.e., 
 between the adjacent borders of the latissimus dorsi and external 
 oblique muscles. It there forms a tense fluctuating swelling, 
 with an impulse on coughing. A psoas abscess lies within the 
 sheath of the psoas muscle, the pus being usually superficial to 
 the muscular fibres, some of which are probably destroyed. It 
 passes downwards, giving rise to a fusiform enlargement, deeply 
 placed in the back of the abdomen ; at the brim of the pelvis, it 
 usually burrows outwards under the fascia iliaca to form a tense 
 rounded swelling in the iliac fossa (Fig. 5 ; p. 51). It thence 
 travels under Poupart's ligament, behind and external to the 
 common femoral vessels, being constricted at this spot so as to 
 form a narrow neck. The sack then expands behind the common 
 femoral sheath, the vessels being often displaced forwards, and 
 the vein flattened out and compressed. Thence passing along 
 the tendon of the ilio-psoas, to the neighbourhood of the lesser 
 trochanter, the abscess comes into relation with the internal 
 circumflex artery, and usually points at or near to the saphenous 
 opening to the inner side of the main vessels. It may, however, 
 follow the different branches of the internal circumflex amongst 
 the adductor muscles, forming a large swelling on the inner side 
 of the thigh, displacing these structures, or it may even travel 
 along its main trunk behind the neck of the femur to reach the 
 surface behind the great trochanter. In other rare cases the 
 abscess has been known to extend down the leg, and has even 
 been evacuated by the side of the tendo Achillis. Occasionally, 
 the pus finds its way down into the pelvis instead of passing under 
 Poupart's ligament, and then points in the ischio-rectal fossa, or 
 possibly burrows through the sacro-sciatic foramen. 
 
 The constitutional disturbance associated with the formation of 
 these abscesses is usually but slight ; perhaps there is a small rise 
 of temperature, but if, as occasionally happens, ordinary pyogenic 
 organisms find their way into the sac from within the body, this 
 may become more marked. As they come to the surface, con- 
 siderable pain may be experienced from the tension and irritation 
 of the soft parts, and fever of a hectic type is induced. 
 
 5. Paraplegia is fortunately not a common result in tuberculous 
 caries of the spine, only occurring in the worst or in neglected 
 cases. It is scarcely ever due to the acuteness of the curve. It 
 has been known to result from a fracture of the spine, the integrity 
 of which has been weakened by the inflammatory process, but is 
 usually caused by an extension backwards of the disease, so that 
 a nodule or button of tuberculous material forms beneath the 
 posterior common ligament, or pushes through it, compressing 
 the cord against the laminae, and actually invading the dura 
 
 42 
 
658 • A MANUAL OF SURGERY 
 
 mater. It occasionally originates in the pressure induced by an 
 abscess, which extends backwards into the spinal canal. 
 
 The effect produced on the cord varies with the rapidity and 
 acuteness of the process. When the pressure is rapidly developed, 
 a subacute myelitis ensues, but more frequently it is of a chronic 
 or sclerosing type. The cord is then found to be constricted or in- 
 dented by the tuberculous mass, and perhaps considerably reduced 
 in size ; its texture is firmer than normal, and the colour grayish. 
 The onset of symptoms may be suddenly induced by haemorrhage 
 or displacement of bone, but is more usually gradual. The dorsal 
 region (about the eighth vertebra) is that most often involved, 
 since there is plenty of space in the cervical region, and in the 
 lumbar the cord has broken up into the cauda equina. Statistics 
 seem to indicate that paraplegic phenomena occur in about one 
 out of every thirteen cases. 
 
 The symptoms arising from pressure on the cord must be dis- 
 tinguished from those due to irritation of, or pressure on, the 
 nerve roots. The latter causes neuralgic pain along the course of 
 some particular nerve, possibly in the later stages associated with 
 anaesthesia (anesthesia dolorosa), or a limited motor weakness if the 
 anterior roots are involved. In compression of the cord, motor 
 phenomena are more evident than sensory, since the sensory 
 track lies towards the centre of the cord, and so is more protected 
 from injury. At first there is some dragging of the toes on walk- 
 ing, and loss of power in the legs, combined usually with neuralgia, 
 weakness of the sphincters, and exaggeration of the reflexes. 
 Later on the paralysis becomes complete, and, as degeneration of 
 the cord follows, secondary contractions and rigidity occur, and 
 the reflexes diminish. Absolute incontinence sometimes super- 
 venes, the bladder emptying itself periodically and involuntarily, 
 or the urine trickling away continually from either a full or empty 
 viscus. 
 
 Special mention must be made here of a grave complication 
 only occurring in the upper cervical region, and which may result 
 in sudden death. Tuberculous disease of the upper two vertebrae 
 usually originates in one or more of the large articulations on 
 either side of the atlas ; if these joints become disorganized, 
 displacement may occur at any moment, and in this way the 
 occiput slips forwards upon the atlas, and may lead to gradual or 
 sudden compression of the cord and consequent death. The 
 disease sometimes spreads to the body of the axis, and by this 
 means the odontoid process becomes detached, or the transverse 
 ligament gives way ; in either case, the weight of the head carries 
 the arch of the atlas forwards, and death ensues from compression 
 of the medulla. 
 
 Course of the Case and Prognosis. — Left to itself, the disease 
 usually progresses more or less steadily, the bone lesion becoming 
 gradually more marked, and abscesses tending to develop. If 
 
DISEASES OF THE SPINE 659 
 
 treated efficiently, and taken in hand early, repair by ankylosis 
 may be confidently expected. Even when an abscess forms, 
 prolonged rest may lead to its disappearance, the fluid part of 
 the pus being absorbed, and the solid elements becoming in- 
 spissated and dry, forming a putty-like mass lying on the front 
 of the vertebral column ; this may subsequently break down, 
 probably owing to infection with pyogenic cocci, constituting 
 what is known as a residual abscess. Should, however, the 
 abscess burst or be opened, and become septic, symptoms of 
 hectic fever and amyloid disease are almost certain to develop, 
 and the patient is sooner or later exhausted by the discharge, 
 and dies from asthenia. If dealt with judiciously, and sepsis 
 avoided, the abscesses may be cured, and if at the same time 
 the spine is kept at rest, the lesion in the bones is able to con- 
 solidate. The onset of paraplegia, again, must not be looked on 
 as rendering the case hopeless, since with prolonged rest the 
 paralytic phenomena can entirely disappear. Septic cystitis and 
 bedsores often arise as complications, and, if allowed to progress, 
 cause the death of the patient. Occasionally, as a result of the 
 implication of the spinal canal, diffuse meningitis follows, leading 
 to a rapidly fatal termination. As in tuberculous disease else- 
 where, the patient also runs the risk of acute miliary tuber- 
 culosis, whilst other organs, e.g., the lungs, brain, or kidney, may 
 become affected. In spite of these possibilities, however, the 
 prognosis is good as regards life in cases free from complications, 
 and where suitable treatment is practicable. 
 
 The Diagnosis of spinal caries is never a matter of difficulty 
 when the characteristic deformity exists, but in the early stages, 
 when the displacement is not evident, or if there is only a very 
 slight prominence of the spinous processes, it is likely to be mis- 
 taken for a simple rachitic or statical curve ; whilst if neuralgic 
 pain is a prominent symptom, it may possibly be looked on as a 
 case of spinal or intercostal neuralgia, or as rheumatism, or even be 
 ascribed to renal affections. Tumours of the spine, such as cancer, 
 or hydatid cysts, syphilitic disease, and aneurismal erosion, also 
 produce symptoms somewhat resembling those of spinal caries, 
 and in adults it may be impossible to determine from the local 
 phenomena alone which of these conditions is present, although 
 a careful consideration of the general history and of the onset of 
 the symptoms may throw some light upon the case. Frequently 
 the course of the disease and the reaction to treatment must be 
 mainly relied on in forming a diagnosis. The spine should always 
 be examined from before and from behind, and pain on pressure 
 over the transverse processes and rigidity of the back are the 
 symptoms on which most stress should be laid. 
 
 The diagnosis of the abscesses connected with spinal caries 
 is sometimes not devoid of difficulty, especially when they point 
 in the groin or the lumbar region, since similar collections of pus 
 
 42 — 2 
 
66o A MANUAL OF SURGERY 
 
 may arise from a variety of other causes. (a) A pevinephritic 
 abscess is recognised by the association or pre-existence of symp- 
 toms of renal disease, whilst a spinal lesion may be absent. Of 
 course, both conditions may be present in the same individual, 
 and the diagnosis can then only be made by an exploration of the 
 abscess cavity, (b) An empyema occasionally points in the loin or 
 even in the groin, but should be recognised by an examination of 
 the thorax, (c) A chronic abscess, due to appendicitis may present 
 very similar signs to those of a deep-seated abscess in the ilio- 
 psoas region on the right side, if it has not extended below 
 Poupart's ligament. Careful examination, however, will demon- 
 strate the upward extension of the abscess towards the spine in 
 the latter case, whilst the previous history will differ consider- 
 ably in the two conditions. The character of the pus is, more- 
 over, a distinctive element, in that it has almost always an offen- 
 sive smell when due to appendicitis, on account of the presence of 
 the Bac. coli com munis, (d) An iliac abscess may arise from a variety 
 of conditions other than spinal disease, e.g., necrosis or caries of 
 the ilium, or cellulitis in the tissues under the fascia iliaca. It is 
 recognised by being, as a rule, more distinctly limited in extent 
 than an ilio- psoas abscess, and by the absence of symptoms of 
 spinal disease, (e) Abscesses arising in connection with hip disease 
 occasionally point in the groin, but are easily distinguished from 
 a psoas abscess by not extending upwards along the course of 
 the psoas muscle, and by the evident signs of hip disease which 
 are always present. (/) Diffused or ruptured aneurism of the iliac 
 artery may give rise to considerable difficulty in diagnosis, since 
 a non-pulsating tumour in the course of the muscle is sometimes 
 produced. The preceding history, the absence of fluctuation, the 
 oedema and congestion of the leg, the interference with the pulse, 
 and the rapid increase of the tumour, should indicate the nature 
 of the case, (g) The diagnosis of abscess from femoral hernia is 
 given elsewhere. 
 
 Treatment. — The great essential in the treatment of spinal 
 caries is absolute immobilization, perhaps associated with the 
 application of some mechanical support, which takes the weight 
 of the body from the seat of disease. This may be effected in any 
 of the following ways : 
 
 (a) By the Adoption of the Recumbent Posture. — The patient is kept 
 in bed either in the prone or supine position, until the pain in the 
 back has diminished to such an extent as to warrant the applica- 
 tion of a spinal support. In any but the youngest children the 
 prone position on a suitably constructed couch may be adopted 
 with advantage, since by this means the weight of the body is 
 more completely taken off the spine, whilst local applications, 
 such as blisters, or even the actual cautery, can be made. In 
 many cases it is advisable to combine treatment in this fashion 
 with the application of a removable poroplastic or leather spinal 
 
DISEASES OF THE SPINE 
 
 66 1 
 
 jacket. If thought desirable, extension by weight and pulley 
 attached to the legs, as described at p. 476, may also be employed ; 
 pain and irritation due to the pressure of the diseased bones one 
 on the other are thereby minimized. 
 
 (b) By the Application of Sayre's Plaster Jacket. — If the disease 
 exists in the dorsal region, the trunk is encased in plaster of Paris, 
 which should extend from the axillae to just below the iliac crests. 
 The patient is stripped to below the waist, and a closely-knitted 
 woollen vest fitted to the body, and fixed by straps passing over 
 the shoulders. A pad or folded towel is placed beneath it over 
 the abdomen to allow for distension after meals, and in women 
 similar smaller pads may be placed over the mammae to protect 
 them. Coarse canvas bandages, into the meshes of which plaster 
 of Paris has been rubbed, are thoroughly soaked in water, to 
 which a little salt may be advantageously added, and then wound 
 evenly round the body until a layer of five or six thicknesses is 
 obtained. Over this a paste of plaster of Paris, prepared as 
 described at p. 430, is laid, until the jacket has 
 attained sufficient thickness and consistency. 
 It is allowed to dry before the patient's posi- 
 tion is altered. In adults, where the disease is 
 chronic and not acute, the jacket should be 
 applied whilst the spine is extended by sus- 
 pending the patient by the head and axillae 
 from a suitably arranged tripod. In children, 
 or when the disease is acute, it will suffice if 
 the parent or an assistant partially supports the 
 patient from the armpits, or the apparatus can 
 even be applied with the child in the recumbent 
 posture. The jacket must be worn until all 
 pain and evidence of active disease have dis- 
 appeared, and after that the patient should be 
 fitted with a poroplastic support for a time. In 
 disease of the cervical or upper dorsal vertebrae, 
 a special jury-mast is required, in order to steady 
 the head and take the weight off the spine 
 (Fig. 242). It consists of an iron rod, fixed to 
 a plaster or poroplastic jacket, accommodating 
 itself to the curves of the head and neck ; 
 above, it extends forwards as far as the vertex, 
 and has attached to its upper end straps, which pass downwards 
 beneath the occiput and under the chin. 
 
 (c) By the Use of Phelps' Box. — This plan of treatment, which 
 has been advocated by Phelps of New York, consists of a wooden 
 box 6 inches deep, the lower end of which is divided into two 
 portions, one for each leg, a suitable aperture being left at the 
 junction of the divided parts for the passage of the excreta. 
 Careful padding is applied to the whole of the interior, and the 
 
 Fig 242.— Sayre's 
 Plaster Jacket, 
 with Jury-Mast 
 for Cervical 
 Disease. (Till- 
 
 MANNS.) 
 
662 A MANUAL OF SURGERY 
 
 child is strapped and bandaged into this apparatus, and kept 
 there for a period varying from six to twelve months. The 
 whole trunk is thus absolutely immobilized, and the child can be 
 easily carried about in his box, and taken into the open air. 
 Extension can also be made, if necessary, by elastic accumulators 
 attached to the head and neck, or legs. 
 
 (d) In very young children perhaps the simplest apparatus is 
 a double Thomas's splint, with a suitable crutch above to fix and 
 support the head. 
 
 During the whole course of treatment, the general condition of 
 the individual must be carefully attended to, and suitable food 
 and tonics administered. Wherever possible, the child should be 
 taken regularly into the open air, or preferably sent to the seaside. 
 When all symptoms of pain and irritation have disappeared, the 
 patient may be allowed gradually to get about again with a 
 mechanical support, and, indeed, this should not be dispensed 
 with for six or eight months after apparently complete recovery. 
 
 Counter -irritation is but seldom required. It may be useful, 
 however, when severe pain exists in the early stages, especially 
 in adults. The best means to employ is the actual cautery, 
 either applying a button cautery at several spots on each side of 
 the spine, or searing the skin longitudinally. 
 
 Recently it has been proposed by Calot and others to overcome 
 the deformity of Pott's disease by forcible straightening under an 
 anaesthetic. A considerable number of cases have now been 
 treated in this way, and with a moderate degree of success ; 
 unfortunately many deaths have been the direct result of this 
 procedure, whilst the subsequent immobilization needs to be very 
 prolonged, and the deformity may recur. Personally we consider 
 that although it may be safe and desirable to straighten the back 
 in a few cases, yet the risks are so great and the process so 
 opposed to Nature's method of cure that unless future statistics 
 show much better results than hitherto, the proceeding is scarcely 
 justifiable. The most interesting point observed in this connec- 
 tion is the fact that cases of paraplegia seem to be immensely im- 
 proved by this process, and that within a few days. It is also 
 now maintained that no very great degree of force is required to 
 do all that is desirable ; the patient's head and feet are steadied by 
 assistants making traction, and the surgeon merely uses as much 
 force as can be applied by one hand placed over the curve. 
 
 The Treatment of the Chronic Abscesses is always a matter of 
 anxiety, since, when once opened, they usually take a considerable 
 time to heal, and if allowed to become septic, the prognosis of the 
 case is seriously affected. A general description of the methods 
 employed has already been given at p. 55. 
 
 A Retro -pharyngeal Abscess should always be dealt with from the 
 neck, as described in Chapter XXVII. 
 
 A Dorsal, Lumbar, or Psoas Abscess should be tapped with a 
 
DISEASES OF THE SPINE 663 
 
 large aseptic trocar and cannula ; after the escape of the pus, 
 the cavity is thoroughly washed out with a mild antiseptic 
 lotion, or with sterilized water at a temperature of 105 to no° F. 
 In the case of a psoas abscess, this irrigation may be combined 
 with gentle massage of the abscess cavity, in order to detach as 
 far as possible the pyogenic membrane, and to assist in the re- 
 moval of curdy debris. When the lotion returns uncoloured, 
 or but slightly tinged with blood, an ounce or two of a 10 per 
 cent, emulsion of iodoform in glycerine is injected, and diffused, 
 if possible, through the abscess cavity by manipulation. The 
 cannula is then withdrawn, and the external wound closed. 
 Occasionally a cure can be obtained in this way by one tapping, 
 but only when no active disease is present, and when the 
 patient's general health is good ; more commonly the fluid will 
 re-collect, and the same process may need to be repeated two or 
 three times. Sometimes the fluid finds its way along the track 
 of the cannula, and a sinus results ; such must be dressed anti- 
 septically until cicatrization has occurred. The best position 
 in which to tap a psoas abscess is at a spot just internal to 
 the anterior superior spine ; a small incision is made in the 
 skin, sufficient to allow of the insertion of the trocar through the 
 abdominal muscles into the cavity of the abscess, but the surgeon 
 must make certain that the intestines have been previously dis- 
 placed to one side. In a large abscess no fear need be entertained 
 on this score, since the parietal peritoneum is always pushed 
 inwards ; but if there is any doubt, the abdominal muscles must 
 be cleanly divided through an incision about 1^ inches long, so 
 as to expose the abscess sac ; a sinus is, however, more likely to 
 form if this is done. Should the abscess point below Poupart's 
 ligament, close to the saphenous opening, it may be necessary to 
 open it there, perhaps in addition to tapping it in the usual place. 
 It must be remembered that the femoral vessels are displaced 
 somewhat and stretched over the sac, and precautions should be 
 taken to prevent puncturing the vein, an accident which has 
 occurred. 
 
 Some prefer to open the abscess freely, and scrape out its 
 interior with a Barker's flushing gouge. Certainly by this means 
 the tuberculous pyogenic membrane and debris can be more 
 thoroughly removed, but the sharp edge of the instrument is 
 capable of doing a considerable amount of harm in this situation, 
 and there is also more likelihood of a sinus remaining. Personally 
 we are not in favour of its use for this purpose, and maintain that 
 the method which we have advocated above is better, since there 
 is less probability of the wound becoming infected with the tuber- 
 culous material, and hence of the formation of a sinus. 
 
 Occasionally it may seem advisable to freely open the sac of a 
 psoas abscess, and where the disease originates in the lumbar 
 vertebrae it has been recommended by Sir F. Treves and others to 
 
664 A MANUAL OF SURGERY 
 
 cut down along the outer border of the erector spinae, and deal 
 with it from behind. A vertical incision is made in this situation, 
 down to the transverse processes, and the lumbar fascia and 
 quadratus lumborum are divided by a transverse cut opposite the 
 tip of one of these ; the abscess sac is then easily reached and 
 opened. The advantage of this plan is that the bodies of the 
 vertebrae can be examined, and even scraped, or sequestra removed. 
 When symptoms of paraplegia arise in the course of Pott's 
 disease, it is usually unnecessary to do more than maintain the 
 immobilization of the spine, since, as already stated, the natural 
 tendency of these cases is towards recovery. At the same time, 
 extra precautions should be adopted in order to prevent bedsores 
 over points of pressure. Should any difficulty in micturition 
 arise, regular catheterism must be adopted, and the greatest care 
 directed to the sterilization of the catheters, septic cystitis being 
 always due to external contamination. In such cases it would 
 be wise to purify the penis and urethra, and to keep the former 
 wrapped in a dry aseptic dressing in the intervals between 
 catheterism. A certain amount of forcible extension may be 
 permitted in these cases, and will probably do good. Laminec- 
 tomy (p. 644) is required in order to relieve pressure upon the 
 cord in the following cases : (a) When septic cystitis or the 
 existence of deep bedsores is threatening life ; (b) when, in spite 
 of prolonged rest, the symptoms persist or increase ; (c) when 
 paraplegic symptoms develop late in the case, and are possibly 
 due to a development of fibro-cicatricial tissue outside the mem- 
 branes (peri-pachymeningitis). (d) Finally, whenever the tuber- 
 culous process mainly affects the neural arches, there is no reason 
 for not treating it by operation, if necessary. 
 
 III. Syphilitic Disease of the spine develops in the shape of 
 gummata, commencing beneath the periosteum which covers the 
 bodies ; it is of unfrequent occurrence, and gives rise to symptoms 
 exactly similar to those of tuberculous caries, from which, indeed, 
 the condition cannot be diagnosed, except by the history and its 
 reaction to treatment. It usually occurs in adults, and is said to 
 mainly affect the cervical vertebras (Tubby). Suppuration and 
 abscess formation are not commonly observed. The co-existence 
 of a syphilitic history and of specific lesions elsewhere may help 
 one in coming to a decision as to the nature of the affection. 
 
 Treatment consists in the administration of suitable anti- 
 syphilitic drugs, and in the use of a spinal support. 
 
 IV. Rheumatic Spondylitis is a condition occasionally met with 
 arising from the same causes, and associated with much the same 
 phenomena as rheumatism elsewhere. It may involve either the 
 ligamentous or muscular tissues, or may attack the intervertebral 
 joints. Any part of the spine is involved, but perhaps the most 
 
DISEASES OF THE SPINE 665 
 
 marked features are presented in the cervical region. Consider- 
 able impairment in the movements of the head is then produced, 
 and the neck may be laterally deflected, somewhat simulating 
 torticollis. If untreated, adhesions form between the bones, and 
 the loss of movement may be permanent. The treatment is of an 
 ordinary anti-rheumatic nature. 
 
 The so-called Gonorrhoea! Rheumatism also affects the spine 
 occasionally, and brings about much the same results. 
 
 V. Osteo-arthritis sometimes attacks the vertebral column, 
 leading to destruction of the intervertebral discs and of the 
 articular cartilages, together with erosion of the bones and the 
 formation of osteophytic masses around. A large portion, if not 
 the whole, of the spine is usually involved by this disease, and 
 a prominent feature is the almost invariable supervention of 
 ankylosis, either from ossification of the anterior or posterior 
 common ligaments, or from interlocking or fusion of osteophytes. 
 A marked kyphosis results, and great pain is present. Finally, 
 the process spreads to the articulations between the ribs and the 
 vertebrae, and when these become fixed the respiratory move- 
 ments are considerably impaired, and hence death is likely to 
 ensue from pulmonary mischief. Treatment is as for similar 
 disease elsewhere. 
 
 Tumours of the Spine are usually malignant in character, and most com- 
 monly secondary developments of cancer or sarcoma. Simple tumours, such 
 as osteoma and hydatid cysts, do occur, as also primary sarcoma. The chief 
 symptoms are severe and localized pain, which is constant, and unrelieved by 
 rest in the recumbent posture, together with early excurvation and paraplegia. 
 These three phenomena manifesting themselves in an adult should always 
 suggest the presence of a morbid growth. Treatment necessarily is but rarely 
 feasible, although an exploratory operation is quite justifiable if the disease is 
 primary and the patient not profoundly cachectic. 
 
 Tumours of the Spinal Cord and Membranes develop in several situations, 
 and the symptoms are thereby somewhat modified. (a) Outside the spinal 
 dura. Lipoma and sarcoma are here most often seen, and the symptoms of 
 cord pressure, such as loss of power and sensation, are preceded by those of 
 spinal irritation, e.g., neuralgic pain, increased on movement, and are often 
 limited for some time to one side, (b) They may grow from the inner aspect of 
 the dura mater, and thus produce symptoms of cord pressure and meningeal 
 irritation concurrently. Sarcoma, fibroma and gumma, are the commonest 
 forms of neoplasm in this situation, (c) From the spinal cord itself, myxoma, 
 psammoma, and sarcoma may originate. The symptoms are those of para- 
 plegia combined with some localized and referred pain or tenderness, and 
 usually bilateral from the start. Left to themselves, patienlis suffering from 
 any of these growths are certain to die, and hence an exploratory laminec- 
 tomy, with a view to removal of the growth, if practicable, is always indicated 
 when a diagnosis has been effected. The possibility of the disease being 
 syphilitic in origin must not be overlooked, and hence a preliminary thorough 
 course of iodide of potassium should always be instituted before operating. 
 The results hitherto obtained have been distinctly encouraging, although 
 many of the cases are left till too late, and the mortality is certain to be 
 high. 
 
666 A MANUAL OF SURGERY 
 
 The only inflammatory disease of the cord which need be alluded to here 
 is one, the results of which have already been mentioned constantly in the 
 chapter dealing with the deformities of the body (Chapter XVI.), viz., Infan- 
 tile Paralysis. This condition is due to an inflammation of the anterior cornua 
 of the grey substance of the cord (anterior poliomyelitis), as a result of which 
 the multipolar ganglion cells situated therein are destroyed. The symptoms 
 come on abruptly, and are often introduced by a short febrile attack ; paratysis 
 shows itself at once, and quickly attains its maximal proportions, being possibly 
 followed by a certain amount of recovery. The portions that remain paralyzed 
 early lose their nutrition, owing to the destruction of their trophic ganglionic 
 centres, and become cold and bluish in colour ; finally, deformities due to the 
 unbalanced action of opposing groups of healthy muscles may appear, whilst 
 the development and growth of the affected limbs are impaired. The distribu- 
 tion of this affection is very variable, but, speaking generally, the legs are most 
 commonly affected, the lower halves, and not the upper, being mainly in- 
 volved ; various forms of talipes may result therefrom, as also weak and flail- 
 like conditions of the knee and ankle. When the thigh is included, the 
 quadriceps extensor and adductors are usually picked out. In the arm the 
 deltoid is most often paralyzed, and after this the muscles on the extensor side- 
 of the forearm, excluding the supinator longus. The face and neck are rarely 
 involved, but the abdominal and back muscles may be attacked. The Treat- 
 ment in the early stages is directed towards improving the general health, 
 and maintaining the nutrition of the affected muscles as far as possible by 
 electricity and friction. In the later stages, when deformed or weak and 
 flail-like limbs have resulted, various means may be adopted in order to 
 improve the functions of the part, (a) Mechanical support is often needed, and 
 this must be carefully regulated, in order to assist, and not to hamper, the 
 movements of the individual by its unnecessary weight. In paralytic talipes, 
 irons fixed to the boots, and rising above the knee, or even sometimes running 
 up to the pelvis, are frequently required, (b) Tenotomy, or division of muscles 
 or fasciae, may also be needed in certain deformities, (c) Tenoplasty, or the 
 grafting of a healthy tendon into a paralyzed one, has been occasionally 
 utilized, as also the transplantation of the bony attachments so as to put the 
 relaxed and weak muscles on the stretch, (it) Arthrodesis, or the fixation of 
 joints, is a useful proceeding under circumstances where the unnatural 
 mobility is difficult to control, or would necessitate considerable increase in 
 the weight of the apparatus required, or where, from the poverty of the 
 patient, the apparatus cannot be obtained. It is especially serviceable in 
 cases where two joints in a limb are flail-like, one of which may then be 
 ankylosed with advantage. The operation consists in a modified excision, 
 the cartilage alone being sawn or scraped from the ends of the bones. 
 (e) Where the whole limb is hopelessly paralyzed and a great inconvenience 
 to the patient, amputation is often the best practice. 
 
CHAPTER XXIII. 
 HEAD INJURIES. 
 
 Injuries of the Scalp. 
 
 Wounds of the scalp are produced either by sharp or blunt 
 instruments, by falls on the head, or by gunshot injuries. From 
 the tenseness of the scalp over the cranium, it often happens that 
 a blunt weapon, such as a policeman's truncheon, will cause a 
 wound nearly as cleanly cut as if it had been made with a sharp 
 instrument. The depth to which the injury extends is a most 
 important element in these cases, and, so long as it is limited to 
 those parts superficial to the occipito-frontalis aponeurosis, but 
 little harm is done ; if, however, the layer of loose cellular tissue 
 between the aponeurosis and the pericranium is opened up and 
 infected, septic cellulitis (p. 93) is likely to ensue, and fatal conse- 
 quences may result. The superficial extent of the wound is a 
 matter of little moment, since the vascular supply is so good that 
 sloughing is uncommon ; a large portion of the scalp may be torn 
 up and bruised, and yet, if it is carefully washed and rendered 
 aseptic, there is every probability that it will retain its vitality. 
 
 The Treatment of scalp wounds is conducted on exactly the 
 same lines as that of wounds elsewhere ; that is to say, after 
 efficient purification they may be stitched up, provision being 
 made for drainage, if necessary. The hair should, of course, be 
 cut away from the neighbourhood of the wound, and an antiseptic 
 dressing applied. Haemorrhage from the scalp may be severe, 
 owing to the division of some of the large arterial branches ; it 
 is dealt with according to the general rules of surgery. 
 
 Contusions of the scalp may occur without solution of continuity 
 of the surface, and results in the formation of bruises or haema- 
 tomata. A similar condition is found in new-born infants ; it 
 is due either to pressure or injury to the head during its passage 
 through the mother's pelvis, or to the compression of obstetric 
 instruments. Three varieties of the so-called cephallunnatoma 
 have been described, viz. : (a) the Superficial, which, confined to 
 the dense subcutaneous tissue, is necessarily small and limited. 
 
668 A MANUAL OF SURGERY 
 
 (b) The Subaponeurotic, occupying the loose tissue under the 
 aponeurosis, and only limited by the attachments of this structure. 
 It forms a large, soft, fluctuating swelling, upon which the scalp 
 appears to float, bagging down over the eyes or occiput, (c) The 
 Subpericranial is limited by the pericranium dipping down into 
 the sutures around the bone with which it is connected. Most 
 commonly it forms over one of the parietal bones, presenting a 
 soft, fluctuating swelling, which soon gains an indurated margin 
 owing to a deposit of fibrin, and in this condition may simulate a 
 depressed fracture of the skull, inasmuch as the cup-like fluid centre 
 allows the finger to sink in and touch bone below. It is not diffi- 
 cult to recognise, however, since the indurated margin can be 
 readily indented by the finger, whilst the edge is definitely raised 
 above the surface of the cranium, and hence the sensation of 
 depression of bone felt through the fluid is only apparent. In 
 old-standing cases ossification of the walls of this cavity has even 
 been known to occur. Treatment. — All that is required is the 
 application of evaporating lotions. There is hardly ever any 
 need to lay open or drain these swellings. 
 
 Traumatic Cephal -hydrocele is the name given to a rare condition 
 following head injuries, especially in children. It is characterized 
 by the formation of a fluid swelling under the scalp, which pulsates 
 synchronously with the heart-beat, and has a definite impulse on 
 any expiratory effort ; it varies in size from time to time, and is 
 sometimes partially reducible. It contains cerebro-spinal fluid, 
 and is due to a simple fracture of the vault, laying open either 
 one of the lateral ventricles or the subarachnoid cavity. In 
 one case it was proved on operation to be connected with an 
 arachnoid cyst, due to a localized subarachnoid haemorrhage. 
 Probably it is wise to leave this condition studiously alone, 
 although, if one could be tolerably certain that the ventricle was 
 not affected, it might be laid open and drained. 
 
 Injuries to the Cranial Bones. 
 
 Contusions of the Cranial Bones apart from fracture may lead to 
 serious results, i. Many of the inflammatory conditions of bone 
 described elsewhere may be originated ; e.g., if the patient is in 
 a condition of low germicidal power, acute osteomyelitis may 
 follow, associated with pyaemia from thrombosis of the large 
 veins of the diploe ; or chronic sclerosis anfl overgrowth of the 
 bone, local or diffuse, may supervene. Syphilitic or tuberculous 
 manifestations may be similarly lighted up if the patient is the 
 subject of either of these diseases. 2. In addition to such 
 osseous conditions, pus may form within the cranium outside 
 the dura mater [subcranial abscess, p. 690), and necessitate trephin- 
 ing. 3. The dura mater may be detached by a simple contusion, 
 leading to meningeal haemorrhage (p. 68 1). 4. Any of the 
 
HEAD INJURIES 669 
 
 cerebral lesions detailed hereafter may be produced. Contusions 
 of the cranium must obviously never be treated lightly, even 
 when they are associated with unbroken skin ; much more are 
 they serious when compound, owing to the risks of sepsis. 
 
 Fractures of the Skull may be described for convenience 
 under the following headings: Fissured Fractures of the Vault ; 
 Fractures of the Base (usually fissured) ; and Depressed or Punctured 
 Fractures. 
 
 I. Fissured Fractures of the Vault are always due to external 
 violence, direct or indirect. In the former case the skull first yields 
 at the injured spot, but the fissure may extend from it for some 
 distance ; in the latter the fracture results from the yielding of 
 the skull when compressed beyond its natural limits of elasticity. 
 
 A simple fissure gives rise to no symptoms indicating its pre- 
 sence w T ith certainty. There may be some amount of superficial 
 ecchymosis, but nothing more definite. When compound the line 
 of fracture may be seen as a red streak, or even felt with the finger 
 as an irregular ridge. It consists of a mere longitudinal fissure, 
 or may be starred ; if uncomplicated, it is of but little importance, 
 and needs nothing beyond general treatment — of course, the 
 greatest care being taken to ensure asepsis. Occasionally, how- 
 ever, an osseous growth forms from protuberant callus on the 
 inner aspect of the cranium at the site of fracture, and gives 
 rise to traumatic epilepsy or insanity (p. 703). 
 
 II. Fractures of the Base of the Skull are almost always 
 fissured, only occasionally punctured or depressed. 
 
 Causes. — (a) Violence may be directed to the vertex or to some part of 
 the cranial convexity, as from a blow or fall upon a hard substance. 
 There has been a good deal of discussion as to how a fall on 
 the vertex causes fracture of the base. The old idea of contre- 
 coup — i.e., that the force was transmitted from one side of the 
 skull to the other, producing a fracture — may be decently buried 
 and forgotten, whilst two main theories still hold the field, each 
 being probably responsible for a certain number of cases, (i.) 
 Aran's theory of irradiation maintains that a fracture of the base is 
 always due to direct extension of the fissure from the injured vertex, 
 a proposition probably quite true in many cases, but insufficient 
 to explain all. (ii.) A more recent idea, known as the bursting or 
 compression theory, is based on the fact that the cranium is not a 
 solid and totally unimpressionable body, but is highly elastic, as 
 has been proved by the observation that hair and even pieces of 
 skin have been found nipped in a fissured fracture of the vault, 
 which had evidently gaped open and closed again. Severe com- 
 pression necessarily diminishes the diameter of the skull along the 
 axis of greatest pressure, making it bulge in other diameters ; and 
 
670 A MANUAL OF SURGERY 
 
 it this distension exceeds the limits of elasticity, the bone gives 
 way. The direction of fractures produced in this manner varies. 
 Most commonly the lines of fracture are parallel to the direction 
 of the compressing force, the bone thus bursting open along its 
 convexity (fracture by bursting) ; less frequently it gives way at 
 right angles to the direction of the force where the bulging is 
 greatest (fracture by compression). Inasmuch, however, as the 
 force is transmitted equally in all directions, the weakest part is 
 most likely to give way, viz., the base. It has been pointed out 
 by Felicet that the skull consists of alternate strong and weak 
 parts, the stronger buttresses being formed by the occipital ridges, 
 the petrous bone, the greater and lesser wings of the sphenoid, 
 and the frontal crest, and that consequently fractures are more 
 likely to involve the intervening weaker parts. Whether these 
 ideas are justified is a question ; certainly the figures quoted by 
 Phelps* indicate that irradiation is responsible for a very large 
 proportion of fractures of the base, (b) Direct injury to the base 
 of the skull is undoubtedly the cause of a certain number of 
 fractures, and some of these are depressed, and not fissured, in 
 character. Thus, the point of an umbrella or stick may be thrust 
 through the upper wall of the orbit, or up the nose through the 
 cribriform plate of the ethmoid ; the condyle of the jaw may 
 be driven through the glenoid cavity into the middle fossa by a 
 blow on the chin ; direct injury from a fall or a stab may pene- 
 trate the occipital bone, whilst a gunshot wound in the mouth 
 is another illustration of this kind of injury, (c) The impact or re- 
 sistance of the vertebral column against the occipital condyles produces 
 fractures in the posterior fossa which radiate from the foramen 
 magnum, and may even occasion a ring-shaped fracture around 
 it (Fig. 243). They result from falling on the vertex into a soft 
 mass, e.g., a bale of wool, or by alighting from a height on the 
 heels or nates. 
 
 The fracture may run in any direction, longitudinal, oblique, 
 transverse, etc., according to the direction of the compressing or 
 fracturing force, and it may affect any part of the base, either 
 being limited to one of the fossae or involving all; it may 
 follow the sutural lines in part, but it is no uncommon thing to 
 see even the dense petrous bone traversed by a fissure (Fig. 244). 
 Naturally, transverse fractures tend to be limited to one of the 
 fossae, whilst a longitudinal fissure may involve them all. 
 
 Some fractures of the base of the skull are simple in nature, 
 but the majority are compound. In the anterior fossa the fissure 
 extends through the cribriform plate and nasal mucosa, and then 
 lays open the nose ; or a communication may be established with 
 the external air through a penetrating wound in the orbit, or 
 through the ethmoidal or sphenoidal sinuses. In the middle fossa 
 a fracture through the base of the sphenoid opens the roof of the 
 
 * ' Traumatic Lacerations of the Brain.' London : Henry Kimpton ; 1898. 
 
HEAD INJURIES 
 
 671 
 
 naso-pharynx, or the fracture may involve the tympanic cavity. 
 Tn the posterior fossa the basi-occipital may be broken, and the 
 naso-pharynx again opened, although the fracture here is more 
 commonly simple. 
 
 Fractures of the base of the skull, though very serious, are by 
 no means necessarily fatal, and, indeed, during the last twenty 
 years or more the results have immensely improved, owing to the 
 use of antiseptic precautions. The main dangers to be apprehended 
 are : (i.) Damage to the base of the brain, including the pons and 
 medulla, especially in cases where the foramen magnum is splintered 
 from the impact of the spine against the condyles ; (ii.) haemorrhage 
 
 Fig. 243. — Fracture of the Base of the 
 Skull from Force acting against the 
 Occipital Condyles, and producing 
 almost an Annular Fracture around 
 the Foramen Magnum. (Tillmanns.) 
 
 Fig. 244. — Transverse Frac- 
 ture across the Base of 
 the Skull. 
 
 arising either from the venous sinuses, or from the meningeal or 
 cerebral arteries ; and (hi.) septic meningitis, due to the fact that 
 the injury not only fractures the bones, but also lays open the dura 
 mater, a grave addition to a compound fracture. 
 
 The Signs of a fractured base are sometimes exceedingly 
 equivocal, but for convenience may be arranged under four heads : 
 
 1. Signs of severe cerebral mischief, such as concussion of the brain 
 and prolonged unconsciousness. This is, however, by no means 
 always present ; thus, in a case we had in hospital a few years 
 back, the patient was capable of going about his work for ten days 
 after the accident. 
 
 2. Hemorrhage manifests itself in various directions, according 
 to the situation of the fracture. 
 
 In the anterior fossa there may be free bleeding from the nose, 
 
672 A MANUAL OF SURGERY 
 
 owing to the fracture extending through the cribriform plate of 
 the ethmoid ; but a portion of the blood may pass backwards 
 into the pharynx, and, being swallowed, is perhaps subsequently 
 vomited. More often, however, the line of fracture runs across 
 the roof of the orbit, causing escape of blood into the areolar 
 tissue of this cavity. The ecchymosis shows itself as a gradually 
 developing subcutaneous distension, involving the lower lid, bluish- 
 purple in colour at first, but passing later through the other stages 
 of a bruise ; there is probably no contusion of the skin, as in the 
 ordinary black eye, which is at first reddish-purple ; the ocular 
 conjunctiva is considerably involved, but the effusion rarely extends 
 above the cornea, and its posterior limits cannot be seen. The 
 bleeding usually arises from laceration of the dura mater and 
 bone, bnt, when abundant, may come from the cavernous sinus, 
 and the eye may even be pushed forwards (proptosis) ; in some 
 cases pulsation is to be felt within the orbit, and then a traumatic 
 orbital aneurism or aneurismal varix is present. 
 
 In the middle fossa the blood may enter the nose or mouth, a 
 part being swallowed, but more commonly it escapes from the 
 ears. If abundant, it probably comes from one of the vascular 
 channels at the base of the brain ; but if only slight in amount 
 and of short duration, it may be induced by any of the following 
 lesions, as well as by a fractured base, viz. : (a) A simple rupture 
 of the membrana tympani ; (b) separation of the cartilage of the 
 pinna, with tearing of the lining of the external meatus; (c) fracture 
 of the anterior and lower part of the tympanic plate, as by a blow 
 on the jaw, which drives the condyle forcibly against it. 
 
 In the posterior fossa the bleeding is usually subcutaneous, show- 
 ing itself around the mastoid process, and extending downwards 
 amongst the muscles at the back of the neck. 
 
 3. Discharge of cerebrospinal fluid is an indication that a com- 
 munication exists with the subdural space. The fluid may be 
 discharged from one or both ears, but has also been met with 
 coming from the nose or cranial vault ; when from the ear, the 
 dura mater has probably been laid open through the prolongation 
 which accompanies the auditory nerve in the internal meatus by 
 a fracture traversing the petrous bone. It is watery and limpid in 
 character, with a specific gravity of about 1005, slightly alkaline, 
 and containing a fair quantity of chloride of sodium, with traces 
 of albumen, and of a substance known as pyrocatechin, which, 
 like grape-sugar, reduces cupric salts on boiling. At first it may 
 be slightly blood-stained, but this soon ceases, the fluid becoming 
 quite clear. The amount discharged may be small, but not un- 
 frequently it comes away in large quantities, soaking the pillow 
 and dressings, and, indeed, can sometimes be caught in a test-tube 
 as it trickles from the meatus. As a rule, the flow commences 
 soon after the injury, and quickly ceases ; but a few years back a 
 curious case occcured, under the care of Lord Lister at King's 
 
HEAD INJURIES 673 
 
 College Hospital, of a man who had fallen backwards off a high 
 bed upon his occiput ; he was temporarily stunned, but returned 
 to bed, and, on awaking the next morning, found that both eyes 
 were black. He continued work for some days, complaining, 
 however, of headache, and at the end of that time of earache, 
 which grew steadiiy worse, until relieved by something giving 
 way in his left ear. This was followed by a copious discharge of 
 cerebro-spinal fluid, which was maintained for some time, and 
 from the after-history there can be no doubt that it was due to a 
 fractured base. 
 
 Escape of brain substance from the ear has also occurred in a ' 
 few instances, most of them fatal. 
 
 4. Lesions of the nerves issuing from the base of the skull are 
 occasionally produced. For symptoms, etc., see Chapter XIII. 
 The nerve most commonly involved is the facial, as it passes 
 through the aqueductus Fallopii ; the paralysis may develop either 
 immediately, or more often about the second or third week after 
 the injury, disappearing in about a month, and then evidently due 
 to its implication in the callus. A certain amount of deafness is 
 often associated with it from injury to the portio mollis. 
 
 The Prognosis of fractured base has much improved during 
 recent years, as a result of the application of antiseptics to the 
 auditory meatus, thereby preventing the occurrence of sepsis 
 within the meninges. If the patient escapes death from cerebral 
 complications, the bones of the skull unite raqidly, and a good 
 result may be expected, although troublesome sequelae may follow, 
 from the injury sustained by nerves or vessels, or their compres- 
 sion in callus or new bone. 
 
 Treatment. — Seeing that the chief danger to the patient arises 
 from septic contamination of the meninges, the greatest care must 
 be directed towards preventing decomposition of the discharges. 
 Unfortunately, it is impossible to apply dressings to the naso- 
 pharynx, or even to thoroughly wash it out with antiseptics, and 
 the only satisfaction about such cases is that the rarity of the loss 
 of cerebro-spinal fluid suggests that the membranes of the brain 
 are not very often damaged in that situation, whilst it has also 
 been shown that in the majority of cases the upper part of the 
 nasal cavity is aseptic (St. Clair Thomson). With the ear, how- 
 ever, things are very different ; the meatus should be well syringed 
 with carbolic lotion (1 in 20), and plugged with some efficient 
 dressing, a large pad of the same being bandaged over the affected 
 side of the head. This must be replaced as often as necessary. 
 Beyond this, the treatment of fractured base is directed to the 
 cerebral condition, and does not differ from that usually applied to 
 head injuries, viz., cold to the shaved head (preferably by means 
 of Leiter's tubes), a smart calomel purge to start with, low diet, 
 and absolute quiet in a dark room. The patient should be kept 
 from going about his work for at least six weeks. 
 
 43 
 
674 A MANUAL OF SURGERY 
 
 III. Depressed and Punctured Fractures usually involve the 
 vault of the cranium, and are due to direct violence, either from 
 a fall or blow, causing a simple or compound fracture, or from a 
 penetrating injury occasioning a punctured fracture. In both 
 cases there is often a considerable amount of comminution. 
 
 It is quite possible for the outer table to be broken and depressed, 
 without any injury to the inner, where an air cavity exists in the 
 bone, or if the diploe is very thick ; thus, the bone may be driven 
 in over the frontal sinus without injury 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 occurs 
 in adults, but is not uncommon in children. Amongst the latter, 
 it is also possible for a considerable depression to exist without 
 any fracture even 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, especially in the 
 punctured variety (Fig. 245, 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 condition are similar, from whichever side the force comes ; 
 we shall, however, only discuss the case of a wound coming from 
 without, (a) The inner table is less supported than the cuter, 
 having merely the soft brain and dura mater within, and hence is 
 extensively splintered, just as a nail driven through an unsupported 
 piece of wood causes ripping up of its under surface, (b) The loss 
 of momentum of the fracturing body will assist this ; the greater 
 the 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 dis- 
 seminated over a much wider 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 
 septicity 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 ascertained. When there is no 
 external wound, a hematoma 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 
 
HEAD INJURIES 
 
 675 
 
 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 
 
 Fig. 245. — Depressed Fracture of Skull seen from Without and from 
 Within. (From Specimen in King's College Museum.) 
 
 amenable to treatment ; when, however, the depression is sudden 
 and complete, the detached portion lying below the level of the 
 
 43— 2 
 
676 A MANUAL OF SURGERY 
 
 rest of the bone, it is termed a gutter 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, according to the nature of the injury and the means by 
 which it was inflicted. 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 penetrate its whole thickness. 
 Sometimes detached portions of the skull are raised above their 
 ordinary level, constituting an elevated fracture ; it is usually 
 associated with depression of surrounding parts. 
 
 Gunshot 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 con- 
 tusion or a depression with or without comminution. Jf 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 fired from close at hand, considerable additional mischief in the 
 shape of fissures extending widely through the skull is induced. 
 It has been known for some time, and the point has been empha- 
 sized by Professor Horsley, that if a bullet traverses a dry and 
 empty skull, but little harm results, except the formation of the two 
 openings where the bullet entered and left the cavity, and these 
 with the modern weapon are small. If, however, the skull is first 
 filled with damp sand or with water, or if the brain is left in situ, 
 and a bullet fired through it, the effects are much more serious, 
 varying directly with the viscosity of the contents ; such a result 
 is evidently due to the momentum of the penetrating body being 
 transmitted to the molecules of water or brain substance, and 
 thence spreading explosive-like in all directions. Not only does 
 this radiation of the force affect the skull, but the most grave 
 consequences to the brain itself ensue from the displacement of 
 cerebro-spinal fluid, inducing increased pressure upon the centres 
 grouped around the fourth ventricle, and leading primarily to a 
 cessation of respiration. Thus, a bullet fired through the skull 
 and brain of a living dog caused the breathing to stop, although 
 the heart still continued to beat ; by performing artificial respira- 
 tion for a time, natural breathing was re-established. 
 
 In a simple depressed fracture the patient usually suffers from 
 concussion, followed almost immediately by compression, the 
 latter due in part to the depressed bone, but mainly to exudation 
 
HEAD INJURIES 677 
 
 of blood and bruising of the brain, and if this is at all extensive 
 and remains unrelieved a fatal result follows almost immediately. 
 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 
 explanation 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 septic, and 
 inflammation of the bone, brain, or membranes will follow. 
 
 Septic osteitis leads to necrosis of the fragments, which may be 
 seen lying dead and yellow at the bottom of the wound, whilst the 
 inflammation may either spread along the diploe to the surround- 
 ing 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 or localized 
 suppurative meningitis, accompanied or not with a localized 
 suppuration of the brain, will ensue. Even if the dura mater 
 has not been opened by the injury, the irritation of depressed 
 spicules of bone and the presence of a septic exudation often lead 
 to its ulceration at a later date. If there is a free external open- 
 ing, allowing 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 symptoms 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 meningitis, since the opening in the subdural space can be shut 
 off by adhesions of the arachnoid in a very short time. 
 
 When an aseptic condition of the wound is obtained by early 
 interference, and depressed fragments of bone are successfully 
 elevated or removed, the prognosis becomes much better, and the 
 
678 
 
 A MANUAL OF SURGERY 
 
 case may 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 by making even what may prove to be an un- 
 necessary exploration with the trephine. We may, therefore, 
 epitomize the treatment thus : 
 
 (i.) In all punctured fractures, operate. 
 
 (ii.) In all compound depressed fractures, operate. 
 
 (iii.) In simple depressed fractures : In adults, always operate ; 
 in children, if gutter-shaped, operate ; if pond-shaped, wait for 
 symptoms, unless the fracture is a bad one. 
 
 Fig. 246. — Instruments used in Trephining for or Elevating 4 De- 
 pressed Fracture, including Trephine, Elevator, and Hey : s Saw 
 (Down Brothers.) 
 
 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 
 therefore in shallow depressions one should wait for symptoms ; 
 but whilst admitting the fact, we recall cases where the neglect 
 of such treatment has led to serious trouble, and we have been 
 called on not unfrequently to trephine for traumatic epilepsy due 
 to this very type of injury. The operation is so slight, and the 
 risk so insignificant when asepsis is maintained, that the patient 
 should be given the 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 
 
HEAD INJURIES 
 
 679 
 
 thoroughly purified. An anaesthetic may or may not be given, 
 according to the condition of the patient. In a simple depressed 
 fracture the surgeon should never 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 frac- 
 ture, if there is no projecting 
 margin of bone he will have to 
 trephine, placing the centre-pin 
 upon some firm undepressed 
 bone as near the edge of the 
 wound as possible (Fig. 247). 
 An elevator can now be intro- 
 duced, the fragments prised up 
 into position, and the condition 
 of the inner table investigated. 
 The opening in the skull may 
 be enlarged by cutting pliers or 
 a Hey's saw, but all the bony 
 tissue taken away during the 
 operation should be kept in 
 warm boracic lotion, or, better 
 still, in warm saline solution or 
 blood serum, if obtainable. 
 When the loss of substance 
 is small, there is no need to 
 replace 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. 
 
 In a compound depressed fracture, the skin-wound may be 
 enlarged, or a flap turned down, and the bone dealt with according 
 to circumstances. It may suffice to saw off a portion of a pro- 
 jecting fragment, so as to allow entrance to the elevator, or it 
 may be necessary to trephine. In these cases, the fragments 
 of bone removed must be well purified in warm carbolic lotion 
 (1 in 40) before being placed in the saline solution. The brain 
 and membranes will need careful purification if wounded, and 
 this may be accomplished without fear by washing with a 5 per 
 cent, carbolic solution. Protruding brain substance may be 
 removed, and the dura mater lightly stitched across the gap ; the 
 bones may then be replaced, but room must be left for a drainage- 
 tube to pass within the dura to carry away any fresh effusion ; it 
 
 Fig. 247. — Punctured 
 of Skull, showing 
 
 Fracture 
 Spot for 
 
 Application of Trephine. 
 
6So A MANUAL OF SURGERY 
 
 may be removed in forty-eight hours, if the case progresses satis- 
 factorily. 
 
 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. 247), and care 
 must be taken to include all depressed fissures in the field of 
 operation. 
 
 In all cases the patients should be confined to bed with the head 
 low, and the general rules suitable to head injuries followed. It 
 is by no means certain that elevation of the depressed bone will 
 relieve the symptoms, as they may be due to haemorrhagic effusion 
 into the brain which cannot be reached. 
 
 For treatment of gunshot injuries of the skull, see pp. 205 and 
 698. 
 
 Injuries to the Intracranial Bloodvessels. 
 
 1. 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 longi- 
 tudinal, petrosal, lateral, and cavernous sinuses are those most 
 frequently involved, especially the first, because it is more inti- 
 mately connected with the bones than any of the others. When 
 there is no external wound, and only the outer wall of the sinus 
 has been opened, the haemorrhage, if at all severe, will strip 
 up the dura mater and compress the brain, producing effects 
 resembling those due to meningeal haemorrhage, but slower in 
 their onset, and less severe in their course ; if the wound is small, 
 the bleeding is not so great, since comparatively little pressure 
 suffices to arrest it by flattening the sinus against the bone, or 
 the hole may be filled by the spicule of bone, and bleeding does 
 not occur till it is displaced. If, however, 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 intra-meningeal haemor- 
 rhage. When an external wound exists, there is the usual 
 evidence of venous bleeding, but it is readily checked and rarely 
 fatal. Septic 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, possibly re- 
 moving fragments of bone in order to expose it. Where the outer 
 wall alone has been torn, it may be possible to suture it without 
 interfering with its continuity. For symptoms and treatment of 
 septic thrombosis, see p. 694. 
 
 2. Wounds of the Middle Meningeal Artery. — This vessel, which 
 enters the skull at the foramen spinosum, and subsequently divides 
 
HEAD INJURIES 
 
 68 1 
 
 into two branches which ramify between the skull and the dura 
 mater, is occasionally ruptured, with or without a fracture of the 
 skull. The anterior branch is most frequently injured as it crosses 
 the anteroinferior angle 
 of the parietal bone, as the 
 result of a fissured frac- 
 ture ; but it is very liable 
 to be torn by a punctured 
 wound, since the bone is 
 very thin in that locality, 
 or by a depressed fracture. 
 The artery is, however, 
 sometimes 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 
 
 . jf j & f Fig. 248.— Meningeal Hemorrhage. 
 
 ot the canal. Whether (From Specimen in College of Sur- 
 
 or not the dura is geons' Museum.) 
 
 primarily detached, the 
 
 blood soon collects between it and the bone, pressing the brain 
 inwards, and burrowing down towards the base of the skull 
 (Fig. 248). Such 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 conscious- 
 ness ; and (c) the gradual supervention of coma within twenty- 
 four hours, and that usually without any considerable rise of 
 temperature. The interval of consciousness varies widely, but is 
 not often longer than an hour or two, whilst in many cases it is 
 scarcely recognisable. As accessory signs, the following may be 
 mentioned : (a) Since the blod-clot is situated close to the motor 
 area of the cortex, and especially over the centres for the head 
 and arm, twitching of these parts, followed perhaps by paralysis, 
 may be a well-marked feature, and usually supervenes before the 
 
682 A MANUAL OF SURGERY 
 
 onset of coma ; (b) when the clot extends to the base of the skull, 
 it presses on the cavernous sinus, and may induce passive con- 
 gestion of the eyeball, paresis of some of the ocular muscles, and 
 proptosis, with possibly a dilated pupil and high temperature ; 
 and (c) 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 subcranial haemorrhage is easy if there is an 
 open wound, or if the symptoms are at all typical ; but even then 
 one cannot be certain that the middle meningeal artery has given 
 way, and that the symptoms are not due to venous bleeding. An 
 examination of the injury and of the part struck, and the rapidity 
 of onset of the symptoms, may help in this matter, but it is often 
 impossible to make a diagnosis with certainty. 
 
 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 1 1 inches above the zygoma (Fig. 295, F), and this point 
 should be marked on the bone with 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. 72, E). 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 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, how- 
 ever, 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., 1^ inches above Reid's base line ; or, 
 again, it can be exposed nearer its origin at a spot if inches 
 behind the external angular process of the frontal bone, and f inch 
 above the upper margin of the zygoma (Fig. 295, 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 
 
HEAD INJURIES 683 
 
 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. Of seventy-five cases of pulsating exophthalmos, Riving- 
 ton found that forty-one were caused by trauma, and were prob- 
 ably of this nature. Treatment. — -The injury is fatal in the 
 majority of cases before help can be obtained ; if not, compres- 
 sion or ligature of the carotid trunk in the neck is the only hope. 
 See also on intraorbital aneurism (p. 275). 
 
 4. Intrameningeal Haemorrhage 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 localized. 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 wails of which are formed of 
 fibrous tissue stained brown with haematin. 
 
 The Symptoms are those of cerebral compression, and usually 
 supervene directly on concussion without any conscious interval. 
 The coma is often of long duration, though, as a rule, not of great 
 intensity. Perfect recovery may ensue, even though unconscious- 
 ness is prolonged for weeks ; but adhesions may form as the 
 result of a chronic meningitis lighted up by the accident, and 
 these may lead to subsequent trouble. No focal symptoms are 
 produced unless the haemorrhage arises from or presses upon the 
 motor area, when convulsions, or later on paralysis, may ensue. 
 
 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 applied 
 at this spot. It must not be forgotten, however, that the chief 
 haemorrhage often occurs (as will be presently pointed out), 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 con- 
 siderable uncertainty may arise both as to the advisability 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 pulsa- 
 tions will not be detected. It is carefully incised, and the blood- 
 clot removed ; any bleeding-points should be tied or compressed, 
 or 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. 
 
634 A MANUAL OF SURGERY 
 
 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 ; the symptoms of the less serious cases 
 are discussed later on under the heading ' Laceration of the 
 Brain ' (p. 694). 
 
 General Conditions of the Brain after Head Injuries. 
 
 Concussion of the Brain, or stunning, is a clinical condition 
 characterized by a more or less complete suspension of its func- 
 tions as a result of an injury to the head, which may or may not 
 have produced an anatomical lesion. It varies with the severity 
 of the cause from a slight momentary giddiness and confusion of 
 thought to the most complete insensibility, and is closely allied to 
 shock, from which it is often distinguished with difficulty. 
 
 In fatal cases, one finds on post-mortem examination merely 
 the same conditions as obtain in shock, viz., engorgement of the 
 lungs, viscera, and the right side of the heart, whilst the brain 
 presents some lesion of varying severity, from mere punctiform 
 ecchymoses to actual disintegration and disorganization. The 
 symptoms are supposed to be due to a paralysis of the vaso- 
 motor centres in the medulla and subsequent loss of vascular 
 tone, allowing the blood to gravitate to the most distensile parts, 
 viz., the portal system. Reflex inhibition of the heart through 
 the vagus may also assist in their production. More recently 
 Duret has suggested that the blow on the skull causes a tem- 
 porary depression, and this leads to compression of a cone-shaped 
 area of the brain substance. As a result, the cerebro-spinal fluid 
 is displaced and forced downwards to the base of the skull, where 
 it tends to collect, particularly in the fourth ventricle, and thus 
 the vital centres grouped around this space are compressed, and 
 anaemia of the brain (which all authorities admit to be present) is 
 produced. This explanation of concussion is very feasible. 
 
 The Symptoms vary considerably in degree, but in a well-marked 
 case the stage of concussion is evidenced by unconsciousness, 
 more or less complete, although the patient can sometimes be 
 roused by shouting ; he lies on his back, with the muscles relaxed 
 and flaccid ; 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, and in bad cases insensitive even to 
 strong electric shocks. The respirations are slow, shallow, and 
 sighing, whilst the pulse is weak, fluttering, and scarcely sensible 
 to the fingers ; the temperature is 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. 
 
HEAD INJURIES 685 
 
 This condition may last for a considerable time, and then pass 
 slowly into more profound unconsciousness and death, or be 
 followed by the phenomena of inflammation, compression, or 
 cerebral irritation. If, however, the case is going on to recovery, 
 reaction soon begins to manifest itself. The patient is presumably 
 put to bed, and warmth carefully applied to the extremities. 
 The first sign of reaction is probably a slightly increased rate of 
 both breathing and pulse, whilst he may be able to tell his name 
 and address ; sometimes the earliest indication of recovery is that 
 he turns on his side, and pulls the bedclothes up to his face, since 
 he feels cold and chilly as a result of the cutaneous anaemia. 
 Gradually he becomes more and more rational, and the functions 
 of both mind and body are restored, reaction being fully estab- 
 lished by the occurrence of vomiting, due to a condition of cerebral 
 hyperaemia following the anaemia. Probably he suffers from 
 headache for some days, and a slight amount of fever will follow ; 
 but this passes off, and leaves the patient either quite well, or 
 with a somewhat irritable brain requiring prolonged rest. Subse- 
 quent events may, however, prove that more mischief has been 
 done than appears at first. One sequela of concussion may be 
 that some special function of the brain is permanently lost or 
 impaired, such as memory, hearing, or vision ; thus, 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 recurrent attacks of inflammation, 
 one of which may prove fatal. Others are left with an in- 
 ordinately irritable brain, incapable of standing excess of work or 
 errors of diet ; and, in such, a sudden fatal issue is not uncommon, 
 Others, again, seem to suffer from a general loss of nerve tone 
 (neurasthenia), rendering them incapable of fulfilling their ordinary 
 duties in life. 
 
 The Treatment of concussion very closely resembles that of 
 shock, viz., the patient is at once put to bed, with the head low, 
 and is covered with warm blankets ; hot -water bottles may be 
 applied to the extremities, and friction to the surface. Any need- 
 less stimulation must be avoided for fear of exciting haemorrhage ; 
 an enema of hot coffee may be given, or, if in extremis, brandy, or 
 a hypodermic injection of strychnine. On the establishment of 
 reaction, but not before, a good purge, such as 5 grains of calomel, 
 should be administered, and the patient is then kept for some days 
 in bed on a restricted diet, with the bowels freely open and all 
 sources of excitement excluded. 
 
 When the unconsciousness is prolonged, and the absence of 
 signs of fracture in the cranium or of focal symptoms prevents the 
 localizing of the lesion, the head should be shaved, and an icebag 
 or Leiter's tubes applied ; the bowels are kept acting freely, and 
 the state of the bladder attended to ; the room must be kept 
 
686 A MANUAL OF SURGERY 
 
 dark and quiet, the attendants making as little 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. In the former case iced milk and chicken broth or beef- 
 tea must be depended upon. 
 
 Cerebral Irritation. — By cerebral irritation is meant a clinical 
 condition 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 the hyperaemia caused by its subsequent repair. 
 
 The Symptoms are very characteristic, and usually manifest 
 themselves two or three days after the injury. They may be 
 divided into two groups, (a) Bodily Symptoms : The patient lies 
 on his side in a condition of general 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 fully extends himself, or lies supine. The eyes are closely 
 shut, and he resists all attempts to open them ; the pupils are 
 contracted ; the temperature is usually a little raised, but the 
 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. (b) Mental Condition : The patient is by no means 
 unconscious, but he 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 in the most 
 expressive manner. At the end of a few days, or perhaps after a 
 week or two, a marked alteration in the condition of the patient 
 usually shows itself. He is less irritable, begins to stretch himself 
 out, and with this is conjoined an improvement in both pulse and 
 temperature. A change is sometimes noticed in his mental state, 
 since he may be quite childish and weak. ' Irritability gives way 
 to fatuity' (Erichsen). In this stage he may need to be treated 
 as a child, and even taught the names of persons and things ; later 
 on he may glibly detail the history and cause of his accident, 
 giving a fresh story every day, but frequently there is an absolute 
 lapse of memory concerning the accident and the events which 
 led to it. After a time the brain recovers, but more or less serious 
 after-effects are likely to ensue. Sometimes the symptoms pass 
 over, however, into those of subacute or chronic meningitis. 
 
 In the Treatment the surgeon must remember that there is a 
 considerable tendency to asthenia, and hence, while the patient is 
 kept quiet and free from all noise or excitement, he must be well 
 supported by a light and nourishing diet. The head should be 
 
HEAD INJURIES 687 
 
 placed low and shaved, and Leiter's tubes fitted on, if the patient 
 will permit it ; but it is better to omit this entirely than to apply 
 cold intermittently. The bowels must be kept well open, and 
 possibly small doses of bromides, or even opium, may be useful. 
 If any signs of meningeal inflammation follow, such as rise of 
 temperature and pulse, heat of head, and great sleeplessness, 
 blisters or leeches may be applied locally, and mercury ad- 
 ministered internally. 
 
 Compression of the Brain. — Compression is the term given to a 
 clinical condition due to some abnormal and excessive intra- 
 cranial pressure which disturbs the functions of the brain. 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. 
 
 (b) Extravasation of blood within the cranium, either outside the 
 membranes, or on the surface of the brain, or within its substance. 
 If the bleeding is extradural, there will probably be a short 
 interval of consciousness between the concussion and the com- 
 pression ; if the bleeding is cerebral, the symptoms of compression 
 may manifest themselves at once without any interval being 
 noticed, (c) It may be due to an acute spreading oedema, the 
 explanation of which is subsequently given (p. 695). (d) It may 
 arise from a collection 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 may also arise as a result of idiopathic haemorrhage, 
 tumours, gummata, or abscesses, e.g., as a complication of middle- 
 ear disease. 
 
 The Symptoms of compression are essentially those of coma. 
 When the condition is w r ell established, the patient lies on his 
 back absolutely unconscious, and cannot be roused either by 
 shouting or shaking. His breathing is slow, laboured, and ster- 
 torous, the lips and cheeks being puffed in and out. The stertor 
 arises from paralysis of the soft palate, and the puffing of the 
 cheeks from paralysis of the facial muscles. In the later stages 
 the respirations may be more rapid and irregular, somewhat 
 approaching the Cheyne-Stokes type. Death arises from cessa- 
 tion of the respiratory act. The pulse is full and slow at first, 
 but later on becomes rapid and irregular, owing to increased 
 pressure upon and exhaustion of the medullary centres. The 
 surface of the body may either be cool, hot, or perspiring ; the 
 body temperature similarly varies, in some cases being hyper- 
 pyrexial, in others low, and where the compressing force is 
 unilateral, there may be some difference on the two sides of the 
 body. The pupils become dilated without responding to light, 
 
688 A MANUAL OF SURGERY 
 
 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 faeces 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. Naturally the clinical picture is modified according to the 
 cause of the compression, and it is impossible to discuss here 
 more than the general features. The course of the case, too, varies 
 widely according to whether or not the compressing agent can 
 be removed by the surgeon, or absorbed by natural processes. 
 Patients not uncommonly recover from small cerebral and intra- 
 meningeal haemorrhages causing temporary compression, but 
 rarely do so without operation if the symptoms are due to 
 depressed bone, the presence of a foreign body, or large exuda- 
 tions of blood, serum, or pus. 
 
 The Diagnosis of coma from compression, when a complete 
 history of the case can be obtained, is often easy, and, indeed, the 
 whole clinical aspect may be so typical that no question as to the 
 cause of unconsciousness can be raised. But when a person is 
 found in the streets unconscious, where no history either of the 
 patient or of an accident is obtainable, and where no serious 
 lesion of the skull is present, the diagnosis is often 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 con- 
 sequence 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 into the system 
 from without, as in the case of alcohol, opium, or other narcotics, 
 or may be developed within the body, as in uraemia or diabetic 
 
HEAD INJURIES 6S9 
 
 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 a 
 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 
 examination: (1) A rapid note should be made as to the sur- 
 roundings of the patient — whether there is blood or vomit near 
 him, how the body 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 him- 
 self. (3) A most thorough and complete investigation should be 
 made as to his condition. 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. 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 considerably in different 
 cases. The amount of power and the state of the reflexes are 
 then observed, any inequality probably indicating a unilateral 
 lesion in the brain. The urine must be drawn off, and carefully 
 examined for albumen and sugar. (4) in dubious cases, and 
 especially where there is any suspicion of drunkenness or poison, 
 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, 
 the treatment of the condition resolves itself into keeping the 
 patient quiet, with the head low and cool, the room dark and 
 noiseless, the bowels open (using croton-oil on sugar, cr enemata, 
 for this purpose), and the bladder empty. The patient may have 
 to be fed by the rectum, and if the breathing or pulse is very 
 laboured, and cyanosis begins to show itself, venesection may be 
 
 44 
 
690 A MANUAL OF SURGERY 
 
 advisable. Considerable interference with the respiration arises 
 from falling back of the tongue, as often occurs in profound anaes- 
 thesia during surgical operations, and if due to this cause the head 
 may be rolled over to one side, or the tongue pulled forwards. 
 Occasionally patients remain in this condition for weeks or months. 
 
 Intracranial Inflammation. -Inflammation of the cranial con- 
 tents is often met with as a result of injury, and although we 
 shall describe several distinct varieties, it must be remembered 
 that the various forms run into one another, and that in practice 
 mixed types are the more common, giving rise to a corresponding 
 complexity of symptoms. For descriptive purposes the following 
 groups may be distinguished : 
 
 (i.) Subcranial Inflammation. — This may occur in the form 
 either of an effusion of pus between the dura mater and the 
 bone (subcranial abscess), or as a thickening of the dura mater 
 (pachymeningitis). 
 
 The former 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 some- 
 times 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-infection, or to the passage of organisms through the bone. 
 Apart from injury, its most common cause is, without doubt, 
 extension of inflammation either from the superjacent bone or 
 from the middle ear. The Symptoms produced are (1) those 
 generally characteristic of suppuration, viz,, a high temperature, 
 with perhaps rigors. (2) The signs of intracranial pressure in 
 the form of fixed headache followed by coma are also present. 
 (3) If there is no open wound, an oedematous swelling of the scalp, 
 known as Potfs puffy tumour, may develop over the site of the 
 abscess (Fig. 249). 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, with perhaps pus oozing out between the fragments. 
 If the pus burrows towards the base of the skull, optic neuritis 
 may develop. (4) Focal symptoms of spasm or paralysis may 
 complicate the case if the dura over the motor area is involved. 
 The Treatment of such a condition consists in evacuating the 
 abscess cavity through a sufficient opening made by trephining, 
 or by removing loose portions of bone, and providing for drainage. 
 Sometimes more than one opening is required for this purpose. 
 
 Simple pachymeningitis, or thickening of the dura mater, may 
 result from a slight simple depressed fracture, or even from con- 
 tusion with or without a fissured fracture. No immediate symp- 
 
HEAD INJURIES 691 
 
 toms need arise, but those characteristic of chronic meningitis 
 described below are usually met with at a later date ; in fact, it 
 is impossible to distinguish clinically between the two affections. 
 
 (ii.) Acute Diffuse Meningitis is always infective in nature, and 
 generally due to the pyogenic cocci. Formerly some cases were 
 supposed to result from merely mechanical causes, but they also 
 are probably due to bacteria of lesser virulence, such as the 
 pneumococcus. The symptoms vary considerably in their in- 
 tensity, according to the method of inoculation and the activity 
 of the organisms. The superficial part of the brain is involved 
 in the inflammation as well as the meninges, and the term 
 meningo-encephalitis would perhaps be the better appellation. 
 
 The Symptoms appear about forty-eight hours after the injury, 
 
 Inflamed CEdematous 
 bone. scalp tissue. 
 
 Subdural space. 
 
 ^.Scalp. 
 
 s f .Cranium. 
 
 , Brain covered 
 by pia mater 
 and arachnoid. 
 
 Fig 249. — Subcranial Suppuration, involving Overlying Bone and 
 causing an CEdematous Condition of the Scalp — Pott's Poffy 
 Swelling (Semi-diagrammatic). (From Treves' ' System of Sur- 
 gery.') 
 
 although sometimes infection may be delayed beyond this period. 
 In the early stages the patient complains of severe, constant, and 
 increasing headache, associated with heat of head, a forcible 
 pulsation of the carotids, a full pulse, and general irritability of 
 the brain, as indicated by vomiting, intolerance of light and sound, 
 delirium, and perhaps convulsive twitchings of the muscles, not 
 only of the head and back, but also of the extremities. High 
 fever is usually present, and possibly a rigor may occur at the 
 onset. As the disease progresses, the patient gradually becomes 
 comatose, and dies from cerebral compression. 
 
 According to the site of infection, the inflammatory phenomena 
 may manifest themselves more acutely over one part than another, 
 and for descriptive purposes two chief varieties have been distin- 
 guished, viz., meningitis of the convexity, and meningitis of the 
 base. The general symptoms are alike in both forms, but when 
 
 44—2 
 
692 A MANUAL OF SURGERY 
 
 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 con- 
 gested, and the subjacent veins are manifestly distended ; the 
 cerebro-spinal fluid is increased in amount, and turbid from ad- 
 mixture with lymph or pus ; the arachnoid is thick and opaque ; 
 the surface of the convolutions is flattened and cedematous, and 
 lymph occupies all the sulci, matting them together ; the cortical 
 grey matter is usually red and congested ; the underlying white 
 substance of the centrum ovale is injected, numerous puncta 
 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 individuals 
 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 darkened room, and every source of irritation and 
 excitement removed. Even if recovery ensues, it is somewhat 
 delayed, and similar precautions as to quiet, etc., must be main- 
 tained for some time. In the later stages, blistering of the scalp 
 or neck, and the administration of mercury, are advisable. 
 
 Attempts have been recently made to relieve the symptoms 
 and determine a cure by means of operative measures, directed 
 towards reducing the intracranial tension ; the subarachnoid 
 space has been opened below the tentorium, whilst others have 
 utilized Quincke's plan of puncturing the spinal membranes 
 between the third and fourth lumbar vertebrae, i.e., below the 
 termination of the spinal cord. In no case of acute meningitis 
 has a successful result followed, and when one considers the 
 intricate character of the space to be drained, the fact that it is 
 sure to be subdivided into separate cavities by deposits of lymph, 
 and especially when it is remembered that the important fourth 
 ventricle only communicates with the subarachnoid space through 
 the small foramen of Majendie, which is certain to be early blocked 
 — all these considerations go to prove that it is useless attempting 
 any such measures. 
 
 Acute Meningoencephalitis is sometimes limited in character, 
 when resulting from penetrating wounds. Such can only occur 
 when there is no tension from retained discharges, diffusion along 
 the meninges being prevented by the formation of adhesions. 
 Localized suppuration is usually present, involving even the brain 
 
HEAD INJURIES 
 
 693 
 
 substance ; but with care recovery is possible, although an 
 adherent cicatrix will be formed, perhaps giving rise to subsequent 
 epileptic symptoms. A similar condition may result from bruising 
 of the bone and a localized suppurative inflammation connected 
 therewith (Fig. 250). 
 
 (in.) A Subacute form of meningitis is occasionally met with, 
 coming on at a somewhat later date. The patient may have 
 apparently recovered from his injury, with the exception of a 
 fixed pain in the head. The onset of the symptoms is often due 
 to some indiscretion, and may be gradual or sudden. In all 
 probability this affection is also microbic in origin, and the delay 
 in its appearance depends either on the small number of bacteria 
 present, or on their being in a low state of virulence ; or possibly 
 they have been latent for a time, and are aroused into activity by 
 later causes ; or, again, they may have gradually worked their 
 way inwards along lymphatics or vessels from the periphery to 
 
 Collection of 
 
 pus beneath Inflamed 
 
 dura mater. bone. 
 
 pia mater 
 and arachnoid. 
 
 Fig 250. — Superficial Abscess of Brain, spreading from Subdural 
 Space (Semi-diagrammatic). (From Treves' 'System of Surgery.') 
 
 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. 
 
 (iv.) Chronic Meningitis may result from any injury of the 
 meninges, and is very likely to occur in syphilitic patients. 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 
 
694 A MANUAL OF SURGERY 
 
 general health, abstinence from excitement or stimulants, the 
 local application of counter-irritants, and possibly the adminis- 
 tration of mercury ; the bowels must be kept regular, and if 
 epilepsy follows, and the lesion can be localized, trephining may 
 be necessary. 
 
 (v.) Cerebral Abscess. — For pathology, symptoms and treatment 
 of this, see p. 718. 
 
 (vi.) In conclusion, one other form of intracranial inflammation 
 must be mentioned, viz., Infective Thrombosis of the Sinuses. 
 This, though 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 exclu- 
 sively 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 lesions of the 
 face or suppurative conditions of the nose. Putting aside the 
 results of chronic otorrhcea, the cavernous sinus is much more 
 frequently involved than any other. 
 
 Pathologically, the same manifestations are observed as in any 
 case of infective phlebitis. The sinus becomes impervious owing 
 to the presence of a thrombus, and this in turn becomes dis- 
 integrated, and gives rise to multiple emboli, whilst various inflam- 
 matory conditions of the surrounding tissues necessarily result, 
 e.g., necrosis or caries of bones, subcranial abscess, or meningitis. 
 
 The symptoms are mainly of a pyaemic nature. The tempera- 
 ture is high, but with 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 septicemic 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. 820. 
 
 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. For the lateral sinus much can be 
 done, but for the other sinuses all that is feasible is attention to 
 general measures. 
 
 Laceration of the Brain. — Injuries to the brain and its mem- 
 
HEAD INJURIES 695 
 
 branes are very frequent complications of blows and falls on the 
 head, and all the most serious results of these accidents arise from 
 this source. They are produced in many different ways, and 
 cause very varied symptoms ; but the most important distinction 
 to draw is between those wounds which communicate 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 skuil, but not unfrequently the most serious cere- 
 bral symptoms follow injuries in which the bones do not participate. 
 In depressed fractures the brain is usually most contused or torn 
 immediately 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, 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 postmortem 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 localized 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 grey matter ; 
 or the more superficial parts of the brain may be totally disinte- 
 grated 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 circum- 
 stances, 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 cedematous ; 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 process. 
 Under such circumstances the greater part of the brain is cede- 
 matous and glistening, 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 
 
696 A MANUAL OF SURGERY 
 
 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 perfectly, the softened tissue being absorbed ; 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 con- 
 taining haematoidin 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 ahead injury, and the patient 
 recovers slowly after it, the surgeon will rightly suspect laceration 
 or contusion of the brain. 
 
 If concussion is rapidly followed by the symptoms of cerebral 
 irritation, there can be no doubt as to the existence of a laceration, 
 which is probably situated in the frontal region. 
 
 If compression has supervened within twelve or twenty-four 
 hours, it is due to either depressed bone or haemorrhage into the 
 cerebral hemispheres, if there is no interval of consciousness ; but 
 if the patient has rallied for a time before its incidence, haemorrhage 
 from the meningeal vessels or venous sinuses is to be diagnosed, 
 or a rapidly spreading oedema. 
 
 If localized or general convulsions occur within twenty-four 
 hours of the accident, perhaps going on to compression, haemor- 
 rhage into the cortex of the motor area, or diffuse extravasation 
 into the subarachnoid space, is probably present. It is not easy 
 to distinguish between these two, but haemorrhage into the cortex 
 usually produces a more regular extension of the convulsions, 
 which commence by twitching of some part of the body which the 
 patient at the time is perhaps incapable of moving voluntarily. 
 Thus, if bleeding is occurring into the cortical centres for the face 
 on the left side of the body, paralysis of 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 con- 
 vulsion the paralysis is found to have spread. In haemorrhage 
 outside the convolutions the paralysis is less marked and the con- 
 vulsions less regular, though perhaps more generalized, but the 
 symptoms of compression develop sooner. 
 
 If coma supervenes rapidly, and is accompanied by hemiplegia, 
 haemorrhage into the corpus striatum, internal capsule, or perhaps 
 into the ventricles, is likely to be present. 
 
 In simple cases concussion is usually recovered from in a few 
 hours ; the temperature subsequently rises to about ioo° F., and 
 remains so for a few days, whilst the patient complains of fixed 
 
HEAD INJURIES 697 
 
 pain and headache, which under suitable treatment may entirely 
 disappear. Some impairment of sense or function may, however, 
 persist. 
 
 If subacute localized inflammation ensues, pain and headache 
 will be complained of with some fever, and insensibility may 
 supervene in four or five days, preceded by convulsions if the 
 motor area is affected. 
 
 Suppuration in the white substance occasionally results at a 
 later date in this form of injury, giving rise to the symptoms of 
 cerebral abscess. 
 
 The Treatment of these cases is always an exceedingly anxious 
 matter for the surgeon. In the majority of instances it is merely 
 symptomatic, following the usual course adopted in concussion, 
 compression, cerebral irritation, etc., as indicated elsewhere. 
 The patient is kept absolutely quiet in bed, with an ice-bag to the 
 head, and a purge administered. Depressed bone, if present, 
 will, of course, be dealt with by operation. Early convulsions 
 and paralysis are carefully watched to see if any indication as to 
 the site of the bleeding can be obtained, since it is possible that 
 trephining over the injured spot and removing blood-clots might 
 be advisable ; but the clinical records as to such treatment are 
 very scanty. Late convulsions and paralysis due to inflammation 
 are best treated by shaving the head and applying an ice-cap. 
 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 within the dura. 
 
 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 membranes. 
 
 In these cases the general disturbance is often slight, compared 
 with the extent of the local injury, so that, although brain sub- 
 stance may protrude from the wound, there is sometimes but 
 little concussion. Any of the conditions due to haemorrhage 
 detailed above may follow, but they may be less severely felt, 
 except in cases where the bleeding is into the substance of the 
 brain, since the blood can escape from the wound. The inflam- 
 matory phenomena following such lesions are mainly septic in 
 
A MANUAL OF SURGERY 
 
 origin, and may be localized or diffuse. In the latter instance 
 general meningoencephalitis manifests itself in the course of two 
 or three days, and is rapidly fatal ; in the former case adhesions 
 prevent the extension of the trouble beyond the neighbourhood 
 of the wound. Hernia cerebri is very likely to follow, and not 
 unfrequently a deep cerebral abscess will 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 and the possible removal of damaged 
 brain substance diminishes the likelihood of compression from 
 simple or spreading oedema. Where the lesion has involved the 
 motor area, permanent monoplegia may persist. 
 
 The Symptoms arising from a penetrating wound of the brain 
 have been in measure indicated above. In the worst cases im- 
 mediate death may result, or severe concussion, merging quickly 
 into compression, i'rom which the patient never recovers. In the 
 less serious cases there will be a varying degree of concussion, 
 followed after a short interval by the phenomena of inflammation, 
 localized or diffuse, which have already been sufficiently described. 
 Focal symptoms may also arise from destruction of the cortical 
 centres. 
 
 Treatment. — In all cases of punctured or compound depressed 
 fracture, we have stated that a thorough exploration of the 
 wound should be made, and all depressed or injured bone re- 
 moved. Foreign bodies should be also 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 splintered frag- 
 ments 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. When he is 
 evidently moribund, it is better practice not to interfere. Pro- 
 truding 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 within it. Fragments of bone, if kept 
 warm and aseptic, may be replaced (p. 679), and the scalp- wound 
 closed, except at the drain opening ; the gauze or tube should be 
 removed, if all is going well, in about two days' time. If the 
 temperature rises as a result of septic 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 already laid down for 
 dealing with acute meningitis. 
 
HEAD INJURIES 
 
 699 
 
 (In our description of lacerations of the brain we have purposely 
 omitted any mention of the fact that symptoms may arise from 
 inflammatory conditions affecting the bones (p. 711). In actual 
 practice the course of events is often considerably modified by 
 such a complication.) 
 
 Localized Injuries to the Brain. 
 
 Thus far we have merely discussed the general symptoms 
 arising from lacerations and wounds of the brain. We must now 
 
 Fig. 251. — Brain and Convolutions in Situ. 
 
 The fissures of Rolando and Sylvius are indicated, and the situation of the 
 chief motor centres. P. O. F., Parieto-occipital fissure; / /, level of 
 tentorium with cerebellum below it. The position of the lateral sinus is 
 also seen. 
 
 rapidly pass in review the special symptoms resulting from 
 injuries of particular regions. 
 
 Upper and Middle Frontal Convolutions. — Neither motor nor 
 sensory symptoms are noted, but cerebral irritation and subse- 
 quent weak-mindedness are likely to follow, especially if the left 
 side is seriously involved ; lesions to the right frontal lobe do but 
 little harm to a right-handed individual. x\pparently the intel- 
 lectual faculties are limited to one side of the brain, in the same 
 way as the power of speech. 
 
700 A MANUAL OF SURGERY 
 
 Third Frontal Convolution. — Motor aphasia, i.e., the inability to 
 produce or articulate words, results from lesions on the left side 
 in right-handed individuals, and on the right side in left-handed 
 people. Injury to the opposite convolution has no effect. If only 
 one side is damaged, the other convolution can after a time be 
 educated so as to take on the function of the damaged region. 
 
 The Motor Area (Fig. 251) is comprised of the ascending frontal 
 and ascending parietal convolutions, respectively in front and 
 behind the fissure of Rolando, of the posterior half of the third 
 frontal convolution, and of the superior parietal lobule. The 
 centres for the leg occupy the upper part of the ascending parietal 
 convolution and the whole of the superior parietal lobule, those 
 for the hip being in front, and for the feet and toes behind. The 
 arm centres are located on either side of the middle of the fissure 
 of Rolando, the shoulder being in front and above, and the hand 
 and fingers below and behind ; whilst the centres for the head, 
 face, and lips are clustered together at the junction of the ascend- 
 ing and third frontal convolutions, the centre for movements of 
 the angle of the mouth being highest, whilst the lowest part of 
 the ascending frontal convolution governs the movements of the 
 tongue and lips. Lesions involving any of these areas produce 
 either spasm or paralysis of the appropriate region on the opposite 
 side of the body. 
 
 Wounds of one Occipital Lobe may cause a temporary hemiopia, 
 but no persistent loss of vision, unless the angular gyrus is also 
 destroyed. Lesions of the latter region are always associated 
 with permanent disturbances of vision. 
 
 The Upper Temporo- sphenoidal Lobe contains the cortical 
 auditory centre, and lesions in this region cause deafness ; the 
 function of the middle and lower lobes is not yet ascertained with 
 certainty. 
 
 Injury to the Corona Radiata leads to paralysis of the regions 
 represented by the overlying cortex, but without convulsions; 
 whilst if the corpus striatum or internal capsule is lacerated, as by 
 haemorrhage, hemiplegia, with perhaps hemianesthesia, will result. 
 
 Wounds of the Cerebellum cause giddiness, vertigo, and ataxy, the 
 patient reeling about in a most characteristic manner, as if drunk. 
 
 A wound of the Cms Cerebri occasions more or less complete 
 hemiplegia of the opposite side of the body, associated with total 
 paralysis of the 3rd (oculo-motor) nerve on the side of the 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 gth 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 func- 
 
HEAD INJURIES 
 
 701 
 
 tions of the circulatory and respiratory centres, with perhaps 
 Cheyne-Stokes respiration and saccharine diabetes. 
 
 Cranio-Cerebral Topography. 
 
 We cannot do more in this work than give a diagram repre- 
 senting the relations of the convolutions to the sutures (Fig. 251), 
 and, in addition, indicate the usual position of the two most 
 important fissures, viz., those of Rolando and Sylvius, and how 
 
 Fig. 252. — Diagram of Head to indicate Method of finding the 
 Fissures of Rolando and Sylvius by Reid's Method. (After Reid.) 
 
 Sy. a.fiss., Anterior branch of Sylvian fissure ; P. O. Fiss., Parieto-occipital 
 fissure ; trans, fiss., transverse fissure along line of tentorium ; A, external 
 angular process of frontal bone ; B, occipital protuberance ; C D, anterior 
 perpendicular in front of tragus ; E F, posterior perpendicular through 
 back of mastoid process. 
 
 to mark out their situation on the cranium, although it must be 
 premised that their position is by no means constant. 
 
 The Fissure of Rolando may be found topographically by the 
 following methods: (a) The upper extremity of the fissure 
 corresponds to a point half an inch behind the centre of 
 the line extending from the root of the nose to the occipital 
 protuberance. The direction of the sulcus is downwards and 
 forwards 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, 
 
702 A MANUAL OF SURGERY 
 
 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 limit of the folded 
 paper corresponds to the line of the fissure, which is about 
 3§ inches in length, (b) A more 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. 252). From it are 
 drawn upwards two perpendiculars, one (C D) corresponding 
 to the small depression in front of the external auditory meatus, 
 the other (E F) to the posterior border of the mastoid process. 
 The fissure of Rolando extends from the upper limit of the 
 posterior vertical line to the point where the anterior line inter- 
 sects the fissure of Sylvius. 
 
 The Fissure of Sylvius is indicated by a line drawn from a point 
 i|- inches directly behind the external angular process of the 
 frontal bone (Fig. 252, A), and about the same distance above 
 the zygoma, to a spot three-fifths of an inch below the most 
 prominent part of the parietal eminence. The undivided portion 
 of the fissure is represented by the first three-quarters of an inch, 
 and from here the anterior limb (Sy. a. fiss.) rises vertically 
 upwards for about an inch, whilst the posterior limb extends 
 backwards for the rest of the line. If prolonged to the middle 
 line behind, it indicates with tolerable accuracy the situation of 
 the parieto-occipital fissure (P. O. Fiss.). 
 
 Many complicated craniometers have been devised from time 
 to time, but need no description. For practical purposes the 
 above measurements suffice as a foundation to work out a 
 complete topography of the brain ; and, after all, when it is a 
 matter of operation, the surgeon does not usually limit his field 
 to a single small trephine aperture. 
 
 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 
 compression. It is met with in two distinct forms : 
 
 1. When an opening has been made by the surgeon for the 
 treatment of a cerebral tumour, w 7 hich is subsequently found to 
 
HEAD INJURIES 703 
 
 be irremoveable. The disc of bone is not replaced, and the brain 
 substance protrudes through the opening under the scalp ; by 
 this means a temporary relief of intracranial 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. 
 
 2. The other variety, due to a compound depressed or punctured 
 fracture, is the result of sepsis in the underlying brain substance, 
 and the increased pressure within the skull thereby induced leads 
 to a protrusion of inflamed and cedematous brain matter through 
 the wound in the dura, which is usually of small size. The tumour 
 is soft and dusky in colour, and pulsates synchronously with the 
 heart, the pulsations being often evident to the naked eye, and it 
 usually increases in size somewhat rapidly. At first the mental 
 condition 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 cedematous granula- 
 tion tissue covered by blood-clot, without much brain substance, 
 but later on brain tissue itself may protrude. The condition is 
 usually fatal, though recovery is occasionally seen. Treatment. — 
 Prevention of this affection must always be aimed at by en- 
 deavouring to render any wound involving the meninges aseptic 
 and providing for drainage. Punctured wounds and depressed 
 fractures of the skull, even when giving rise to no urgent symp- 
 toms, 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 dressing 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 with absolute alcohol 
 once or twice a day ; it is an efficient antiseptic, and also tends by 
 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. 
 
 Traumatic Epilepsy is the term applied to an epileptic condition 
 resulting from injuries. It may arise from any of the following 
 conditions : (1) 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 particu- 
 larly liable to occur in syphilitic patients ; (5) a single depressed 
 spicule of bone projecting into the cerebral substance. A similar 
 
704 A MANUAL OF SURGERY 
 
 condition is seen apart from injury in consequence of irritative 
 lesions of the dura mater or cerebral cortex, as, for example, 
 from an osteoma on the inner wall of the cranium, or enlarged 
 Pacchionian bodies. The Symptoms produced are epileptic 
 seizures of the Jacksonian type, with or without a definite aura, 
 according to the function of 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 Treat- 
 ment is not particularly satisfactory. If there is any means of 
 determining the site of the irritation, an exploratory operation is 
 always justifiable, since some removeable fragment or spicule of 
 bone may be the cause of the symptoms. If, however, nothing is 
 found except an adherent cicatrix between the membranes and 
 the underlying brain, it is very questionable whether the surgeon 
 should proceed further. In a considerable number of cases the 
 cicatrix and surrounding brain substance have been removed ; 
 the fits have ceased for a time, but in almost every instance 
 recurrence has sooner or later followed, owing to the formation 
 of a fresh cicatrix at the site of operation. Moreover, permanent 
 paralysis of the portion of the trunk governed by the removed 
 cortical area has resulted, and hence the general opinion at the 
 present time is that such an operation is unadvisable, except as a 
 life-saving measure when the fits are extremely numerous and 
 severe. Such a decision emphasizes the importance of the state- 
 ment made before as to the necessity of dealing with all cases of 
 simple depressed fracture in adults by operation. If it is decided 
 that an exploration is desirable, the sooner it is undertaken the 
 better, since the longer the epileptic habit lasts, the less favour- 
 able is the prognosis. 
 
 As an alternative to excision of the cicatrix, various plastic 
 measures have been suggested in order to prevent the scar in the 
 brain and dura being dragged on by the scalp, or irritated through 
 it, when the bone over it is defective. See autoplasty and hetero- 
 plasty (p. 709). 
 
 Traumatic Insanity is sometimes produced by slight depressions 
 or lesions, similar in nature to those causing epilepsy, and can 
 occasionally be relieved by operation. Certainly, when a distinct 
 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. 
 
CHAPTER XXIV. 
 
 DISEASES OF THE SCALP, CRANIUM, AND CRANIAL 
 CONTENTS. 
 
 Diseases of the Scalp. 
 
 It would involve a needless amount of repetition to mention and 
 describe in detail all the many conditions which may be met with 
 in the hairy scalp, and therefore it is only necessary to deal with 
 those which are of the greatest importance. 
 
 Suppuration is of common occurrence, arising mainly from septic 
 infection from without, but being occasionally due to disease of 
 the subjacent bones. The extent of the abscesses is limited by 
 the same anatomical features as obtain in connection with haemor- 
 rhage. Thus, a subcutaneous abscess is necessarily small in size, 
 owing to the density of the tissues in which it is located ; it arises 
 most frequently as a result of eczema or impetigo, and is often 
 due to the presence of pediculi, or to the action of irritants used 
 in the cure of ringworm. A subaponeurotic abscess usually results 
 from a septic penetrating wound, and is associated with cellulitis. 
 A subpericranial abscess is rarely seen except in connection with 
 injury or disease of the bony calvarium ; the pus is limited to the 
 affected portion of bone. 
 
 Erysipelas and Cellulitis have been described elsewhere (pp. 93 
 and 96). 
 
 Tumours occurring in and under the scalp may be considered 
 according to whether they pulsate or not. 
 
 Pulsating Tumours of the Scalp arise from three distinct sources: 
 1. They may be of Extracranial origin, and then are mainly asso- 
 ciated with the superficial bloodvessels, (a) Ordinary aneurisms of 
 traumatic origin are not uncommonly seen ; they rarely attain any 
 considerable size, and are readily dealt with by excision, (b) A rterio- 
 venous wounds give rise either to an aneurismal varix or to a varicose 
 aneurism. They usually involve the temporal trunk, and their 
 symptoms and treatment require no special notice, (c) A curious 
 dilated and tortuous condition of one of the scalp arteries, most 
 often the temporal, is occasionally seen, and is known as an arterial 
 
 45 
 
7o6 A MANUAL OF SURGERY 
 
 varix ; it may be treated by complete excision, (d) A neevus situated 
 over the anterior fontanelle may derive a communicated impulse 
 from the subjacent dura. It has no special features apart from 
 this, and is to be treated in the same way as other naevi of the 
 scalp, viz., by excision or electrolysis, (e) A much more serious 
 and interesting phenomenon than any of the others is that known 
 as a cirsoid aneurism. 
 
 Cirsoid Aneurism is more frequently met with in the scalp than 
 elsewhere, and mainly involves the temporal region, but may also 
 spread in all directions, even downwards into the neck. A tumour 
 of greater or less size is seen under the skin, consisting of dis- 
 tended, tortuous, pulsating, bluish-looking vessels, the arteries 
 opening directly into cavernous spaces without the intervention 
 of capillaries ; it is easily emptied by pressure, but quickly refills, 
 owing to the abundant arterial supply. The rate of growth is 
 variable, and the patient often complains of headache and giddi- 
 ness ; the skin becomes thin and atrophic, the hair falls out, and 
 finally ulceration may occur, the patient probably dying from 
 haemorrhage. The Treatment is eminently unsatisfactory, com- 
 plete excision being the ideal cure, but this in the worst cases is 
 impracticable. If it be attempted, the incisions should be made 
 wide of the disease, and the supplying vessels secured, if possible, 
 between double ligatures before dividing them ; if this precaution 
 is not adopted, frightful haemorrhage may result. It is necessary 
 in some cases to deal with the tumour in separate segments, 
 allowing time between the operations for the patient to recover 
 from the loss of blood. Probably electrolysis, combined with liga- 
 ture of the main nutrient vessels, holds out the best chance of 
 success. (For methods of electrolysis, see p. 309.) 
 
 2. The chief pulsating tumours of Cranial origin are as follows : 
 (a) Sarcomata arising from beneath the pericranium or from the 
 diploe (p. 712). (b) Secondary nodules of cancer may develop in 
 the diploic tissue ; those due to the form known as thyroid cancer 
 are specially noted for their pulsation, (c) Aneurism by anasto- 
 mosis occasionally develops in the cancellous tissue of the diploe, 
 and gives rise to pulsation, which can be felt when the bones are 
 sufficiently expanded and atrophied (p. 537). 
 
 3. Pulsating swellings of Intracranial origin include the following 
 conditions: Encephalocele (vide infra); traumatic cephal-hydrocele 
 (p. 668) ; hernia cerebri (p. 702) ; and sarcoma of the dura mater 
 (p. 712). 
 
 Non-pulsating Tumours of the Scalp. — Almost any of the ordinary 
 connective tissue or epithelial growths may occur, but the follow- 
 ing are the more important : 
 
 Papillomata are not uncommon in the form of small hard warty 
 outgrowths, giving rise to but little inconvenience, unless situated 
 on some spot where the hat rests. They are easily removed. 
 
DISEASES OF THE SCALP 
 
 707 
 
 Epithelioma also occurs, arising either from an irritated papil- 
 loma, or possibly in connection with a sebaceous cyst. As soon 
 as a diagnosis is made, the growth should, if possible, be ex- 
 tirpated, and the resulting raw surface may either be left to 
 granulate, or dealt with by Thiersch's method of skin grafting. 
 
 Fibroma is either seen in the shape of a localized develop- 
 ment of hard fibrous tissue, and often growing on the forehead 
 where the hat crosses it ; or it may attain much larger dimensions, 
 involving perhaps half the scalp, and giving rise to an irregular 
 nodulated outgrowth of soft fibro-cellular tissue, which has some- 
 times been termed a pachydermatocele (p. 163). Either form may 
 be dealt with by excision. 
 
 Sarcomata of various types involve the scalp, presenting as 
 large fleshy tumours which may pulsate or fungate. They usually 
 develop rapidly, but are limited for some time by the aponeurosis 
 of the occipito-frontalis ; glandular infection is uncommon. In 
 their removal it is useless to attempt to save the aponeurosis ; 
 the whole thickness of the scalp must be sacrificed, and the in- 
 cisions should be wide of the growth. The wound is allowed to 
 granulate, or covered in with Thiersch grafts. 
 
 Dermoid Cysts are by no means uncommon in this region, their 
 favourite situation being near the outer canthus, the temple, or 
 the root of the nose. For a general description, see p. 182. 
 They do not attain any great size, and may not become evident 
 till after puberty. The underlying bone is often hollowed out 
 from a defective development of the mesoblastic tissues around 
 them ; and a congenital opening may even exist through which a 
 narrow neck passes, bringing the cyst into direct connection with 
 the dura mater. The treatment consists in removal ; but it is 
 advisable to delay this till after puberty if the tumour seems at all 
 fixed to the skull, or if the bone is felt to be defective beneath 
 it, as in such cases the communication with the interior of the 
 cranium is often shut off by that time. 
 
 Sebaceous Cysts (p. 361) find their most usual situation in the 
 scalp, where they not only are frequently multiple, but also may 
 reach a considerable size. Their removal is best accomplished 
 by transfixion, squeezing out the contents, and picking out the 
 cyst wall by a pair of forceps without dissection. The wound 
 is closed by one or two stitches. 
 
 Affections of the Skull. 
 
 I. Congenital Affections. 
 
 r. Meniogocele, Encephalocele, and Hydrencephalocele consist of 
 a protrusion of the dura mater, with or without part of the brain, 
 through an opening in the cranial wall, due either to defective 
 development of the bones or to the non-closure of one of the 
 sutures. They occur most frequently at the root of the nose, and 
 
 45—2 
 
7o8 
 
 A MANUAL OF SURGERY 
 
 in the occipital region (Fig. 253), occasionally at the anterior or 
 one of the lateral fontanelles, or at the base of the skull. A 
 Meningocele is simply a protrusion of the brain membranes con- 
 taining cerebro-spinal fluid. It forms a soft, rounded, fluctuating 
 swelling, attached to the skull by a base of greater or less size, 
 and covered by skin, which may be thick and healthy, or thinned, 
 bluish, and translucent when the tumour is large. The vessels 
 present in the skin are often dilated and nsevoid. It increases in 
 size and tension on any expiratory effort, such as coughing or 
 crying, and it may be partially reducible, thus allowing the 
 margins of the opening in the cranium to be defined. Symptoms 
 of cerebral compression, convulsions, etc., are likely to be pro- 
 duced by such manipulation. An Encephalocele is a similar type 
 of tumour, but contains brain substance, and pulsates nearly 
 synchronously with the heart ; it is most commonly situated at 
 
 Fig. 253. 
 
 -Congenital Encephalocele of the Occipital Region. 
 (Tillmanns.) 
 
 the back of the skull. A Hydrencephalocele, or Meningo-encephalo- 
 cele, is a condition in which the tumour contains both brain 
 substance and fluid. Two varieties have been described, one in 
 which there is a small protrusion of the brain associated with an 
 ordinary meningocele, and the other in which the fluid is contained 
 in a cavity communicating with one of the ventricles, and covered 
 by a thin layer of brain substance. They are usually of consider- 
 able size, and situated in the occipital region, either above the 
 tentorium, and then possibly associated with distension of the 
 posterior cornu of one of the lateral ventricles, or below that struc- 
 ture, the osseous defect extending in some cases as far as the fora- 
 men magnum, and a portion of the cerebellum being within the sac. 
 The Prognosis of these conditions is exceedingly grave. For- 
 tunately, many of the subjects are born dead, or die soon after 
 birth. In the more severe cases, idiocy and microcephaly are not 
 uncommonly associated. The protrusion may increase steadily in 
 
AFFECTIONS OF THE SKULL 709 
 
 size and finally burst, causing death by purulent meningitis, or in 
 more favourable cases it may remain stationary. In a menin- 
 gocele, the subsequent growth of the cranial bones may suffice 
 to close the communication between the interior and the tumour, 
 which thus becomes shut off, and remains as a cyst-like swelling, 
 with the base fixed, and without pulsation or respiratory impulse. 
 Treatment. — Most cases should be left alone ; but if the tumour 
 is steadily increasing in size, antiseptic puncture and subsequent 
 compression may hinder the process ; a pure meningocele may 
 possibly be cured in this way. Where the communication with 
 the skull is small, it may be feasible to excise the tumour, taking 
 special care to securely suture the base, and attempting when 
 practicable to make good the cranial deficiency by osteoplasty. 
 
 2. In infants the ossification of the bones may be incomplete, 
 constituting what is known as aplasia cranii congenita. It is said 
 to be due to fcetal rickets, arising from a cachectic condition of 
 the mother. Great care is needed in dieting such children and 
 protecting them from injury. Occasionally a similar atrophic 
 condition of the bones may persist through life, exposing the 
 patient to increased risk from injuries which otherwise would do 
 but little harm. 
 
 3. Localized congenital atrophy of the bones is also sometimes 
 met with in connection with dermoid cysts, as mentioned above. 
 
 II. Acquired Affections of the skull are atrophic, hypertrophic, 
 inflammatory, or neoplastic in nature. 
 
 Acquired Atrophy of the skull occurs in many forms : 
 
 (a) Craniotabes is a condition met with during the first year of 
 life, usually as a result of inherited syphilis (p. 524). 
 
 (b) Senile atrophy may affect the whole cranium, which becomes 
 thinned and rarefied, the change commencing from without, a 
 similar condition also occurring in the jaws from the loss of teeth, 
 and subsequent absorption of the alveoli ; or it may be localized, 
 as pointed out by the late Sir G. M. Humphry,- to the parietal 
 bones, constituting hollow depressions which extend antero- 
 posteriorly. No symptoms are caused thereby, but the patient 
 runs a certain increased risk from injuries to the head. 
 
 (c) Localized loss of substance may result from the pressure 
 of tumours, such as Pacchionian bodies and aneurisms, or from 
 necrosis, or traumatic and operative lesions. If these are at all 
 extensive, the cerebral pulsations can be felt distinctly through 
 the skin. It is then advisable to provide the patient with some 
 guard to protect him from injury. This may be accomplished by 
 means of a metal plate worn over the scalp ; but where the lesion 
 is due to injury or operation, surgeons have of late years been 
 endeavouring to remedy the defect in a more satisfactory manner 
 by operation. Autoplasty is the term applied to a proceeding 
 
 * Med.-Chir. Trans., 1890, p. 327. 
 
7io A MANUAL OF SURGERY 
 
 whereby the defect is closed by a plate of bone removed from the 
 patient's own skull. A suitable scalp flap is turned down, and 
 then a portion of the outer table is chiselled up sufficient in size 
 to close the aperture. The pericranium is utilized on one side as 
 a pedicle, and by means of this it is stitched down into the gap, 
 the margins of which have been previously freshened. By hetero- 
 plasty is meant a similar proceeding when the hole is closed by a 
 plate of gold, platinum, or vulcanite let in under the pericranium 
 or inserted between the dura mater and the cranium. The results 
 of these procedures have been on the whole satisfactory. 
 
 (d) Hydrocephalus is always associated with atrophy and thinning 
 of the cranium. It may be congenital, or may commence early 
 in life, but is always a chronic condition. (The so-called acute 
 hydrocephalus is in reality tuberculous meningitis.) It is produced 
 in almost all cases by a distension of the lateral ventricles with 
 fluid, the result of congenital malformation, or of inflammatory 
 affections, causing exudation from the choroid plexuses, pressure 
 upon the veins of Galen or inferior longitudinal sinus, and possibly 
 closure of the foramen of Majendie. The head becomes more 
 and more distended, the bones expanded and thinned, and the 
 sutural areas increased, whilst the brain is subjected to such 
 pressure as may be incompatible with life. Fluctuation is dis- 
 tinctly felt, and the bones may crackle under the fingers ; the 
 face looks abnormally small, and the eyes protrude, owing to 
 the depression of the orbital plates. Treatment. — The ventricles 
 may be tapped at a spot some little distance from the median 
 line, and a considerable amount of the fluid withdrawn, whilst 
 elastic pressure is subsequently maintained ; but as the cause 
 cannot be removed, recurrence is almost inevitable. It has 
 recently been demonstrated that there is a direct absorption of 
 fluid into the veins from the subdural space at any tension above 
 the venous pressure, and hence it is suggested that, by establish- 
 ing a communication between the ventricular and subdural spaces, 
 the excess of fluid in hydrocephalus might be absorbed. This 
 has been attempted in two or three cases, and the results have 
 been encouraging ; but of course, to be of any value, it must be 
 undertaken before the cerebral cortex has been so thinned as to 
 interfere with its functional activity. 
 
 (e) By microcephaly is meant a condition of diminished size of 
 the cranial cavity due to premature ossification of the sutures. 
 It is usually associated with idiocy, and possibly with cretinism. 
 Of late years attempts have been made to relieve this by the 
 operation of linear craniectomy or removal of portions of the 
 cranium, so as to allow of the expansion of the brain. A broad 
 strip of bone is excised on either side of the median -line, from 
 back to front, and sometimes another transversely. A small 
 trephine aperture is first made, and then the opening is prolonged 
 antero-posteriorly by a circular saw driven by electricity, or by a 
 
AFFECTIONS OF THE SKULL 711 
 
 Hey's saw, or by a bone rongeur. The two sides of the skull are 
 usually dealt with at separate times. Temporary improvement 
 has followed in many cases ; but the final result is extremely 
 uncertain, the majority of the patients relapsing owing to the 
 contraction of the dense cicatricial material which replaces the 
 bone. The proceeding cannot be looked on as more than a 
 justifiable experiment. 
 
 Hypertrophic Changes of the Skull result from simple chronic 
 inflammatory affections, or from injury, etc. We have already 
 alluded to the special types of enlargement seen in inherited 
 syphilis (p. 523), rickets (p. 525), osteitis deformans (p. 530), and 
 acromegaly (p. 531). In leontiasis ossea (p. 742) the cranium 
 also becomes thickened and enlarged ; but the cranial cavity 
 is encroached on, constituting what is known as concentric hyper- 
 trophy, in contrast to most of the other forms, which are eccentric 
 in type. 
 
 Inflammatory Affections of the Cranial Bones. — The cranium is 
 liable to any of the diseases which generally occur in bone. 
 
 1. Acute Periostitis, or Pericranitis, is usually septic in origin, 
 following cellulitis of the scalp ; it is likely to result in necrosis of 
 the outer table. 
 
 2. Acute Infective Osteomyelitis, or acute necrosis, consists of 
 an acute inflammation of the diploe, due to pyogenic organisms, 
 and either following a septic scalp wound or a contusion of the 
 bone in a person of low germicidal powers. The symptoms and 
 signs are those generally characteristic of the disease, the peri- 
 cranium being stripped up by diffuse suppuration beneath it, and 
 abscesses opening in many situations. Necrosis of the whole 
 thickness of the skull is likely to follow, whilst pyaomia or 
 extension of the inflammation to the membranes, venous sinuses 
 or brain, are the chief dangers arising from it. The treatment 
 consists in free external drainage ; but in addition it is necessary 
 to remove the outer table with chisel and mallet, and to thoroughly 
 scrape away all the septic diploe, disinfecting the parts beneath 
 with pure carbolic acid. If signs of subcranial suppuration 
 ensue (p. 690), the inner table must also be removed. 
 
 3. Chronic Periostitis of the cranium is occasionally met with 
 in the form of a node. It is usually the result of some long- 
 continued irritation, such as carrying baskets or weights on the 
 head. Treatment consists in the removal of the irritation, and 
 there is no objection to chiselling away the node, if necessary. 
 
 4. Tuberculous Disease of the cranial bones is not common ; it 
 occurs as a primary phenomenon, or is secondary either to a 
 cutaneous lesion, such as lupus, or perhaps more commonly to 
 a meningeal focus. It may start in the periosteum or diploe 
 leading to the formation of a node or perhaps to expansion of the 
 
712 A MANUAL OF SURGERY 
 
 bone, and followed by suppuration and caries. When of menin- 
 geal origin, there is a considerable amount of erosion of the inner 
 table, and possibly some necrosis; sooner or later the outer table 
 is perforated and a subpericranial abscess forms. The amount 
 of mischief in the outer table is no criterion of the extent of the 
 disease within, and hence very thorough exploration is necessary. 
 The prognosis in this variety is not good. 
 
 5. Syphilitic Disease of the cranium, on the other hand, is 
 exceedingly common, occurring usually in the tertiary stage, and 
 affecting most frequently the frontal and parietal bones. It has 
 been already described (p. 522). 
 
 Tumours of the Cranial Bones. — The chief Tumours affecting the 
 calvarium are osteomata and sarcomata. 
 
 Osteoma of the cranium occurs as a localized overgrowth either 
 of cancellous or of compact bone, more commonly the latter. It 
 grows from the outer surface of the calvarium, from the inner, or 
 from both. If arising externally, a smooth, rounded, globular 
 swelling is produced, hard to the touch, quite painless, and attached 
 to the subjacent bone by a broad base ; more than one may be 
 present. If the main growth is internal, the early symptoms 
 will depend on its situation, as to whether evident functional 
 disturbance of the cortex will be produced ; when very large, it 
 gives rise to compression of the brain, and possibly optic neuritis. 
 Osteomata are to be distinguished from inflammatory hyperostoses 
 (usually of syphilitic origin) by their sharp limitations, absence of 
 pain, and slower progress ; whilst osteo-sarcomata are commonly 
 rapid in growth, painful, and of unequal consistency in different 
 parts. Treatment is rarely possible in those developing inside the 
 skull except when situated over the motor area, since the disease 
 has usually progressed too far before coming under observation. 
 The external tumours may be freely chiselled away, but it must 
 not be forgotten that cerebral concussion may follow the pro- 
 longed use of the chisel and mallet against the skull. 
 
 Sarcoma of the cranium originates either from the pericranium, 
 the diploe, or from the dura mater. 
 
 The extra- or peri-cranial variety consists of a round or spindle- 
 celled tumour growing from the pericranium, and possibly attain- 
 ing a considerable size. It may contain a certain amount of ossific 
 deposit, or the tumour remains of a soft consistency, and then often 
 pulsates. The subjacent bone is sometimes absorbed, and the dura 
 mater affected secondarily. General infection of the system follows. 
 
 Central sarcoma of the cranium starts from the diploe as a 
 myeloid tumour. It does not grow so rapidly as the other forms ; 
 it is single, and generally covered with a layer of expanded bone, 
 which gives a sensation of eggshell crackling to the finger. Later 
 on it involves the dura mater and skin, and may fungate. 
 
 Sarcoma of the dura mater may be attributed to some injury to 
 
AFFECTIONS OF THE SKULL 713 
 
 the head, and is characterized by the occurrence of severe cerebral 
 symptoms, e.g., intolerable localized headache, epileptic fits, double 
 vision, optic neuritis, etc., prior to any evident appearance of a 
 tumour. Gradually the bones become expanded and perforated, 
 and a soft and exceedingly vascular pulsating growth is felt beneath 
 the scalp. This sooner or later fungates, and possibly the menin- 
 geal cavity is laid open by ulceration, death from septic meningitis, 
 cerebral compression, or exhaustion ending the chapter. 
 
 Treatment. — These cases have usually gone too far before being 
 recognised. If an early diagnosis can be arrived at, free removal 
 may be undertaken by trephining and the use of the chisel, sharp 
 spoon or gouge. 
 
 Affections of the Frontal Sinuses. 
 
 These sinuses are cavities in the frontal bones lined with a 
 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 super- 
 ciliary ridges is no guide to their extent. 
 
 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 complications. If the mucous membrane is torn, 
 surgical emphysema of the scalp and face may 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 sub- 
 cranial 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 pneumatocele capitis ; it rises and falls 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, failing 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. 
 But little effect is produced, unless the infundibulum becomes 
 blocked, and then distension of the sinus is produced. If occupied 
 by mucus {hydrops), a slowly-forming tumour is noticed without 
 much pain or discomfort, but the bony walls gradually become 
 thinned, and may give a sensation of eggshell crackling. If dis- 
 tended with pus {empyema), similar symptoms result, perhaps with 
 concurrent inflammatory disturbance and pain in the neighbour- 
 hood. In the more acute cases, especially the traumatic, the in- 
 flammation is liable to extend into the frontal bone, giving rise 
 to an acute osteomyelitis, which may spread rapidly. The pos- 
 terior wall of the sinuses is extremely thin so that the membranes 
 
714 A MANUAL OF SURGERY 
 
 are easily invaded, and an abscess may develop in the frontal lobe 
 of the brain. Occasionally extension of mischief to the cavernous 
 or other venous sinuses may follow. 
 
 The case must be treated by laying the cavity open and drain- 
 ing it. F~or this purpose a curved incision is made along or imme- 
 diately below the eyebrow, and the soft parts stripped from the 
 bone, which is trephined or punctured with a gouge, according to 
 its thickness, close to the middle line ; the pus or mucus is removed, 
 the interior very gently curetted, and the passage into the nose 
 explored and dilated so as to aliow 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. It has also been proposed to deal with this 
 condition from within the nose, and in the hands of skilled rhino- 
 logists this is practicable, especially if the anterior half of the 
 middle turbinal is first removed. 
 
 Should acute osteomyelitis develop, vigorous measures are 
 necessary. In a case of this type recently 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 infiltration 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 recovery, although a consider- 
 able amount of dead bone had to be subsequently taken away. 
 
 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. 36, p. 167). Tumours which have attained con- 
 siderable 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 away successfully. 
 
 Cerebral Tumours. 
 
 The chief Varieties of new growth met with in the brain are as 
 follows : (i.) Glioma, or glio-sarcoma, which consists of a small 
 round-celled neoplasm with a very delicate intercellular substance, 
 similar in character to the neuroglia ; it may occur in any part of 
 the brain. It is always continuous with the surrounding cerebral 
 
CEREBRAL TUMOURS 715 
 
 tissue, and is scarcely ever encapsuled, so that to the naked eye it 
 may be indistinguishable from brain substance, although rather 
 harder, and hence its limits can seldom be accurately defined, 
 (ii.) True sarcomata also occur, and occasionally secondary carcino- 
 matous deposits, (iii.) Tuberculous foci are met with apart from any 
 meningeal infiltration, varying in size considerably, and may be 
 either firm and caseous, or with a diffluent centre, (iv.) Gummata 
 of the brain usually spring from the meninges, and are more 
 irregular in shape than tuberculous masses, (v.) 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 life. 
 Thus, glioma and sarcoma are most common at puberty or in 
 middle life ; tuberculous foci, in children ; gummata, in the fourth 
 or fifth decade ; carcinomata, in middle or late life ; 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, if 
 superficial, the membranes may become adherent and the over- 
 lying bone thickened. 
 
 The Symptoms of a cerebral tumour can be classified as 
 follows ; (1) Those due to increased intracranial pressure, such as 
 fixed headache, giddiness, epilepsy, loss of memory, and stupor, 
 finally ending in coma. The headache varies much in character, 
 but is usually localized, occurs in severe paroxysmal attacks, and 
 is often associated with tenderness on deep pressure over the scalp. 
 It is increased by anything that causes passive congestion of the 
 brain, such as coughing, and it is most important to note that the 
 sites of the maximum pain and of the tumour often correspond. 
 Occasionally coma and a fatal issue supervene suddenly as a 
 result of acute spreading oedema (p. 695). (2) Vomiting and 
 constipation are also very marked phenomena, associated with 
 loss of appetite and great emaciation. The vomiting bears no 
 relation to the ingestion of food, and is not preceded by nausea. 
 It often develops concurrently with the pain, or may relieve it, 
 and is most common in subtentorial tumours. The temperature 
 is usually subnormal, but if there is any basal meningitis it may be 
 elevated. (3) Optic neuritis is generally present, and is supposed 
 to be due either to the increased intracranial pressure causing 
 obstruction to the return of blood from the eye to the cavernous 
 sinus, or to a descending neuritis, or possibly to both. In the 
 early stages, the clear definition of the disc margin becomes 
 obscured, and the retinal veins congested and tortuous ; the retina 
 is ©edematous, so that the vessels are only seen at intervals, and 
 linear ecchymoses may also occur. If the patient lives long 
 enough, atrophy of the disc follows. In the early stages vision 
 may be but little affected, but, as a rule, it is considerably im- 
 paired towards the end. In some cases this condition may 
 
716 A MANUAL OF SURGERY 
 
 be more marked on the side of the lesion, but is generally bi- 
 lateral. (4) Focal symptoms (p. 699) are only produced when 
 some area of the brain with definite functions is involved. 
 Irritative phenomena manifest themselves first ; paralytic symp- 
 toms develop later on. General convulsions sometimes occur, 
 but are without much significance. We must refer students to 
 text-books of medicine for a further consideration of these lesions. 
 The surgeon is seldom called upon to make a diagnosis in these 
 cases, and therefore the full details of this intricate subject will 
 not be considered here. 
 
 Treatment. — In every case, the possibility of the symptoms 
 being due to gummatous disease must not be forgotten, and large 
 and increasing doses of iodide of potassium (even up to 40 or 
 60 grains three or four times a day) should be administered before 
 undertaking operative proceedings. Symptoms of gastric irrita- 
 tion must be prevented by giving some alkaline carbonate 
 (especially the ammonium or soda salts), whilst the dose should be 
 freely diluted with water. 
 
 Operation. — It is most desirable that this should be undertaken 
 as early as possible, since, even if no tumour exists, the patient 
 runs but little serious risk, whilst delay until all the classical 
 symptoms are well marked may prevent the total removal of the 
 growth- Occasionally it is divided into two stages, one consisting 
 in the removal of the bone, and the other, six or eight days later, 
 involving the intracranial portion ; but such a modification is not 
 essential, and is sometimes undesirable. 
 
 The scalp should be entirely shaved a day or two previously, 
 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 spot selected for the application of the trephine 
 by drilling the bone 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 trephine opening. A crucial incision is 
 made through the pericranium, which is retracted to a sufficient 
 extent to allow a 2-inch trephine to be applied, the centre-pin 
 being placed in the hole previously made by the bradawl. A 
 Gait's trephine (i.e., an instrument with shelving borders) is to be 
 preferred to one of the ordinary type. The disc of bone is care- 
 fully removed, and placed in warm and sterilized normal saline 
 solution, so that it may be subsequently replaced if necessary. 
 Other methods of removing the calvarium have been introduced, 
 
CEREBRAL TUMOURS 717 
 
 so as to enable a considerable area of the brain to be exposed. 
 Thus, the bone may be partially sawn through in such a way as 
 to divide the portion to be removed into rectangular areas ; then 
 if the whole thickness of the bone is removed at one spot by a 
 trephine, it is easy to cut away the remainder with bone pliers. 
 Other surgeons prefer Wagner's osteoplastic method, which con- 
 sists in turning down a flap of skull with the soft parts. After the 
 superficial incision has been made, the bone is divided along the 
 same line, either by a circular saw driven by electricity, or by 
 one of the ingenious surgical engines — more or less resembling a 
 dental drill — which have been recently introduced, or by a Gigli 
 saw (i.e., a piano wire with a screw thread turned on it). In 
 using the last-mentioned contrivance, two or three trephine open- 
 ings must be made along the line of incision, and the wire carried 
 through on a probe from one to the other. Handles are attached 
 at each end, and the sawing is soon accomplished ; it is advisable 
 to bevel the cut so as to give a shelf for the flap to rest on when 
 replaced. The base of the flap is partially or wholly sawn through, 
 and then the upper portion prised outwards. It is for such severe 
 measures as these that the operation in two stages is recommended. 
 
 The dura mater when exposed under normal conditions is firm, 
 but yields slightly to the finger, and allows the pulsation of the 
 subjacent brain to be felt, if the latter is healthy and no undue 
 pressure is present within ; but if the intracranial tension is 
 markedly increased, 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 meningeal vessels ; the 
 brain substance protrudes if the intracranial pressure is excessive. 
 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. 
 If, however, a cortical neoplasm is found, it is isolated from the 
 surrounding brain substance by blunt instruments, 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 a fine ligature, or by the use of serrefines, 
 or by sponge pressure. 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. If the tumour has 
 
7 i8 A MANUAL OF SURGERY 
 
 been satisfactorily enucleated, the disc of bone may be placed 
 in situ, room, however, being left for the passage of the tube ; 
 but if there is any doubt as to its complete removal, the 
 opening in the bone is left. After the operation, the patient must 
 be kept absolutely quiet, with the head slightly raised. The 
 drainage-tube may be removed in twenty-four or forty-eight hours, 
 and the scalp wound is usually healed in six or seven days. 
 
 Even if the tumour is inaccessible or irremovable, temporary 
 benefit often results from an exploratory operation, since a sub- 
 cutaneous hernia cerebri is thereby allowed to form, and intra- 
 cranial tension relieved, as evidenced by an improved mental 
 condition and loss of pain ; as the tumour grows, however, the 
 patient relapses into his former state, and death sooner or later 
 follows. 
 
 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 maybe due 
 to traumatism, either in the early or late stages of head injuries. 
 In the early, it is usually superficial, and connected with some in- 
 fective lesion of the scalp, cranium, or membranes, with or with- 
 out a penetrating wound (Fig. 250). 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 way into the interior of the brain either 
 through the track of the missile, or along bloodvessels or lym- 
 phatics. Sometimes 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 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, and it appears that the cerebellum is more frequently 
 involved than the cerebrum. In the former the abscess is usually 
 in the anterior portion of the lateral lobe, close to the back of the 
 petrous bone, whilst in the latter the posterior portion of the 
 temporo-sphenoidal lobe is most frequently affected. The inflam- 
 mation 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 direct opening has been found through 
 the tegmen tympani into an abscess cavity, and it has even dis- 
 charged itself and been drained in this way. More commonly a 
 
ABSCESS OF THE BRAIN 719 
 
 layer of brain tissue intervenes between the membranes and the 
 pus, and then infection will have been carried along vessels and 
 lymphatic sheaths running from the middle ear to the brain. 
 
 Abscesses of a similar type occur in connection with suppura- 
 tion in the frontal sinus, the abscess being usually acute and 
 secondary to a frontal osteomyelitis, 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- 
 tina, typhoid, etc. 
 
 (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 con- 
 nection 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 supervention of spreading cedema. 
 
 The Symptoms vary somewhat with the method of onset and 
 the characters of the abscess. If traumatic and due to infection 
 from without, the case runs an acute course, associated with 
 intense pain in the head, recurrent rigors, and rapid development 
 of coma. Diffuse meningitis is often present, and the two con- 
 ditions 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 cavity, and to the onset of an acute 
 spreading cedema. 
 
 When the symptoms are more characteristic, they may be 
 grouped together under the following three heads : (1) Those 
 resulting from the presence of pus within the body. These are, 
 however, not typical, since, although there may be an initial rigor, 
 the temperature is usually normal or subnormal, unless basal 
 meningitis co-exists. (2) Those due to intracranial pressure and 
 irritation. Pain in the head is usually the earliest and most 
 marked of these ; at first it is often general, but later on becomes 
 fixed, and localized to the seat of the abscess. It varies greatly 
 in amount, sometimes being of the most agonizing type, sometimes 
 very slight ; it is usually continuous, but may be intermittent, and 
 entirely disappear for a time. Anorexia, malaise, vomiting, and 
 constipation are often present ; the pulse is usually slow and inter- 
 mittent, and Cheyne-Stokes respiration may occur in the later 
 stages. Epileptic seizures may also be induced, and the patient 
 
720 A MANUAL OF SURGERY 
 
 passes into a state of mental torpor, and even coma. If unrelieved, 
 the patient dies in a state of coma, from interference with the vital 
 centres in the medulla. Optic neuritis, more marked on the 
 affected side, is another symptom, and the pupil on that side is 
 dilated and does not react to light. (3) Focal phenomena arise as 
 in cases of cerebral tumour, varying necessarily with the situation. 
 In most cases of temporo-sphenoidal abscesses they are not marked ; 
 but if the anterior part is involved, irritative or paralytic symptoms 
 may be noted on the opposite side of the face, or aphasia if the 
 lesion affects the left hemisphere, whilst if situated in the posterior 
 part symptoms may arise from pressure on the cerebellum through 
 the tentorium, almost exactly simulating those due to an abscess 
 or tumour in the cerebellum. 
 
 The signs connected with an abscess in the cerebellum are often 
 very indefinite and vague, but if symptoms develop at all they 
 are very characteristic. The patient complains of giddiness, and 
 staggers when attempting to walk, falling towards the opposite 
 side ; the arm on the same side may be paralyzed ; nystagmus 
 and lateral deviation of the eyes towards the opposite side are also 
 present. The condition is more common in adults than in children. 
 
 Diagnosis. — From meningitis, a cerebral abscess is usually 
 recognised by the fact that in the former condition irritative 
 phenomena, such as acute and active delirium, contraction of the 
 pupil, photophobia, 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 within three or four days of an injury, whereas 
 an abscess rarely forms before the end of the first week. Extra- 
 dural abscess (subcranial) is associated with a high temperature, 
 earlier onset after an injury in traumatic cases, and more rapid 
 compression symptoms ; optic neuritis is only occasionally met 
 with, and the vomiting is less troublesome. There is also likely 
 to be some localized cedema or tenderness on deep pressure. 
 The diagnosis from thrombosis of the lateral sinus is, as a rule, not 
 difficult, owing to the fact that in abscess symptoms of compres- 
 sion are associated with a low temperature and marked optic 
 neuritis ; whereas in thrombosis the temperature is high and 
 oscillating, optic neuritis may be absent, and there may be the 
 characteristic tenderness in the neck. It must not be forgotten 
 that the two conditions may co-exist. It is often impossible to 
 diagnose between a chronic abscess and a tumour of the brain ; the 
 symptoms in the latter may, however, 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 usually some 
 causative septic focus, but an exploratory operation is often 
 necessary to clear it up. Tumour is more common in the frontal 
 
ABSCESS OF THE BRAIN 721 
 
 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 symptoms have made themselves evident. The patient is 
 prepared in the same way as for operation on a cerebral tumour. 
 A flap of scalp tissue is raised, and in such a manner as will most 
 effectually serve for subsequent drainage purposes. The trephine 
 is applied according to the rules given below, or in accordance 
 with the special indications given by the symptoms of the case. 
 Professor 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 boracic acid so as 
 to guard them from infection. The dura mater is then carefully 
 incised in a crucial fashion, and this may suffice to open the 
 abscess ; but more usually the brain substance protrudes. It is 
 carefully explored with a trocar and cannula, which is passed 
 directly into it in various directions. In a temporo-sphenoidal 
 abscess the most likely direction to explore is downwards and 
 inwards towards the tegmen tympani. Pus having been dis- 
 covered, a pair of sinus forceps is gently inserted along the track 
 of the cannula and opened, so as to enlarge the passage and 
 give exit to it. A twin drainage-tube (i.e., two tubes sewn 
 together at one end) is then inserted so as to reach the abscess 
 cavity, which is gently irrigated with sterilized salt solution until 
 it comes back clear. The dural flaps are of course left open, and 
 it may be wise to pack gauze around the tubes in order to shut off 
 the meningeal cavity by the formation of adhesions. The tubes 
 must not be dispensed with too early, as pus will re-accumulate, 
 and the wound need re opening. Possibly it is well to remove 
 one of the tubes in twenty-four hours after the operation, and to 
 replace the second by one of smaller calibre in two or three days ; 
 in this matter the surgeon must be guided by the character and 
 amount of the discharge. Of course it is undesirable to keep it in 
 too long for fear of the development of a hernia cerebri. For an 
 abscess in the temporo-sphenoidal lobe, the centre pin of the 
 trephine may be placed ii inches above Reid's base line, and 
 about the same distance behind the centre of the external auditory 
 meatus (Barker), but a better situation is a spot f inch above the 
 posterior root of the zygoma, and directly above the posterior 
 border of the osseous meatus (Macewen ; Fig. 295, D). For an 
 abscess in the cerebellum the point selected is 1^ inches behind 
 the centre of the external auditory meatus, and 1 inch below the 
 base line (Fig. 295, 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 often unnecessary to apply 
 
 46 
 
722 A MANUAL OF SURGERY 
 
 a trephine, as the bone is very thin, and may be broken through 
 with a gouge. 
 
 When the diagnosis is doubtful, the mastoid antrum is first 
 opened and explored ; by carefully removing the bone behind and 
 above this opening, the lateral sinus is next exposed ; and, finally, 
 by working above or below it, the cerebrum or cerebellum can 
 be examined, and, if need be, incised. A similar result can be 
 obtained by applying a f-inch trephine to a spot i inch behind 
 the meatus and h inch above the base line (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. 
 
CHAPTER XXV. 
 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 implicate the bony alveolus and the 
 
 ^im^jsmkt^'. 
 
 Fig. 254.— Single Incomplete Hare- Fig. 255.— Double Hake-lip: com- 
 
 lip, involving merely the tissues plete on the left slde, incom- 
 
 of the llp, and not extending plete on the rlght. 
 into the Nose. 
 
 .■?28+r- P 
 
 A B 
 
 Fig. 256. — Double Complete Hare-lip, with Displacement Forwards 
 of the Central Portion of the Intermaxilla (Os Incisivum). 
 
 A, Front view ; B, seen in profile. 
 
 floor of the 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 
 
 46 — 2 
 
724 
 
 A MANUAL OF SURGERY 
 
 manner, the fissure being central below, and bifurcating above 
 into each nostril. 
 
 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 
 involved; 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, 
 alveolar, and accompanied by a complete cleft of the palate. The 
 
 Fig. 257. — Head of Fcetus, of about 
 Five Weeks, from Ventral Aspect 
 (after His), showing the Primi- 
 tive Stomod^um bounded above 
 by the Undivided Fronto-nasal 
 Process, laterally by the Max- 
 illary, and below by the still 
 separate Mandibular Processes. 
 (Sutton.) 
 
 The quinque-radiate appearance is 
 well represented. 
 
 Fig. 258. — Head of Fcetus of a 
 Little Later Date (Six to Seven 
 Weeks), from the Ventral 
 Aspect. (Sutton.) 
 
 The mandibular processes have now 
 united ; the ocular vesicle is seen 
 on either side towards the upper 
 end of the orbito- nasal fissure, 
 and the fronto- nasal process has 
 developed internal and external 
 nasal processes on either side of 
 the still unclosed anterior nares. 
 
 central portions of the lip and alveolus (os incisivum) may either 
 retain their normal position, or, as is more frequently the case, 
 project forwards at the end of the nose, forming a proboscis- 
 like appendage (Fig. 256, A and B). 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 talipes — and it is 
 frequently transmitted from one generation to another. Occa- 
 sionally 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 
 
AFFECTIONS OF THE LIPS AND JAWS 
 
 725 
 
 of the raphe of union of the labial segments ; a slight groove in 
 the alveolus may also be observed at a corresponding point. 
 
 Development. — (For fuller details of the development of bare-lip and cleft 
 palate, we must refer readers to 'Harelip and Cleft Palate,' by W. Rose; 
 Lewis and Co., 1891. Space only permits a very brief summary here.) 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 quinque-radiate appearance, 
 due to the manner in which these processes are formed (Fig. 257). A broad 
 median lappet (fronto-nasal process) descends from above ; this is separated 
 by a fissure on each side from the symmetrically-placed maxillary processes, 
 and these again below from the more prominent mandibular processes, which 
 early unite across the middle line, to form the lower jaw. The fronto-nasal 
 process soon, however, changes, developing four rounded buds, the relations 
 of which are indicated in Fig. 258. On either side of a slight depression in 
 the median line is placed the internal nasal process, from which are produced 
 
 Fig. 259. — Diagram to represent the Albrecht Theory of Hare-lip, 
 showing the situation of the cleft in the alveolus between 
 the Inner and Outer Segments of the Intermaxilla. 
 
 EG, Endognathion ; MG, mesognathion ; XG, exognathion ; i x , central 
 incisor; » a , lateral incisor; c, canine; m lt m„, first and second molars. 
 
 superficially the central portion of the upper lip, and from its deeper aspect 
 the inner segment of the intermaxilla (endogathion, Fig. 259, EG), carrying 
 the central incisor. Separated from this by a hollow, which subsequently 
 forms the anterior nares, is the rounded external nasal process, from which 
 develop the side of the cheek, the ala nasi, and from its deep side the outer 
 segment of the intermaxilla (mesognathion, MG) and probably the lateral 
 incisor. External to this a fissure runs up to, and even beyond, the primitive 
 eye (naso-orbital fissure), 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, 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 
 
726 A MANUAL OF SURGERY 
 
 of all these elements is taking place from the sixth to the tenth week, and by 
 that date even the uvula, the last part to unite, should be complete. 
 
 Ordinary hare-lip 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 
 inner and outer segments of the intermaxilla (Fig. 259), and is thus bounded 
 on the inner side by the central incisor, on the outer side by the lateral incisor. 
 Occasionally two teeth are found growing from the endognathion, the outer of 
 the two being an accessory tooth, whilst the lateral incisor, and presumably 
 the outer segment of the intermaxilla, are often undeveloped, or exist in a very 
 rudimentary condition attached to the maxilla. 
 
 The os incisivum, or projecting portion of the intermaxilla, consists of 
 two segments of bone, the two endognathia, united in the median line, and 
 in a child contains two milk central incisors, and the rudiments of the two 
 permanent ones; occasionally, as we have just stated, there may be an 
 accessory 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 Avhich 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 giving nutrition 
 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 anaesthetist and assistant one on each side. 
 The operation may be described in three stages : 
 
 1. The lip is thoroughly dissected up from the maxilla and alveoli 
 by 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 different 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 
 
AFFECTIONS OF THE LIPS AND JAWS 
 
 727 
 
 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 
 
 Fig. 260. — 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. 
 
 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. 260), so that a 
 slight angular projection is formed to constitute a prolabium. 
 
 Fig. 261. — 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. 
 
 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 symmetrical. By this means the depth of the 
 lip is increased to allow of subsequent contraction, whilst the red 
 margin can be made continuous. 
 
728 A MANUAL OF SURGERY 
 
 (b) Miraulfs Operation (Fig. 261). — -The inner margin and apex 
 of the cleft are pared, so as to leave a raw surface ; a flap of red 
 marginal 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. 
 
 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, 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 
 accurately preserved, and the cut edges of the mucous membrane 
 upon the deeper aspect being sutured, each stitch, after it is tight- 
 ened, being used to elevate and evert the lip and thus assist the 
 insertion of the next. The wound is dressed with a small piece 
 of gauze, and secured by another dry piece cut in the shape of a 
 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 the fourth day, and the superficial ones about the eighth 
 or tenth. Careful feeding by the spoon is necessary, the mother's 
 milk being drawn off and given in this way, if possible. In simple 
 cases the child may be returned to the breast about the fifth day. 
 In order to prevent the child from picking at the lip or disturbing 
 the dressing, it is well to put a splint on the flexor side of each 
 arm to control the elbow-joint. 
 
 The Treatment of Double Hare-lip may be discussed under two 
 headings, viz., the treatment of the os incisivum, and that of the 
 soft parts. 
 
 The os incisivum need not be touched if it retains its normal 
 position, and the labial clefts are then alone dealt with ; but if it 
 projects forwards, as is often the case, it must be either removed 
 or replaced, (a) In the former case 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, (b) Re- 
 position 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 splint to maintain it in situ. 
 The advantages 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 
 
AFFECTIONS OF THE LIPS AND JAWS 
 
 729 
 
 from rotation of the process, and that its presence prevents the 
 maxillae from falling together and increases the difficulties of 
 subsequently closing the palatal cleft. Personally we recommend 
 
 Fig. 262. — 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. 
 
 extirpation in bad cases, since the disfigurement can to a large 
 
 measure be removed by adding a projecting cheek-plate to that 
 
 which carries the artificial incisors, thus pushing the upper lip 
 
 forwards, (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 \ 
 maxillse, and the edges pared, ^fc 
 as shown in Fig. 262, the central ^ 
 portion being cut into a V, and 
 no attempt made to incorporate 
 it into the free margin for fear of Fig 
 depressing the tip of the nose, 
 whilst the lateral segments are 
 pared as in the single operation. 
 
 These latter are now drawn together and united in the middle line 
 below the central portion, so that a Y-shaped cicatrix results. One 
 of the deep silver stitches should 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 breathing owing to the diminution in the 
 size of the oral aperture, but this is obviated by the nurse drawing 
 
 263. — Median Hare-lip. 
 (Pitts' Case.) 
 
730 
 
 A MANUAL OF SURGERY 
 
 down the lower lip with the fingers, or by painting it in a vertical 
 direction with collodion. 
 
 Other congenital abnormalities of the lip are met with, which, however, can 
 only be briefly mentioned here. 
 
 Median Hare-lip may occur in one of two forms : either a simple cleft exists 
 in the middle line (Fig. 263), 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. 
 
 Oblique Facial Cleft is an uncommon deformity, characterized by a cleft or 
 sulcus in the face, starting from the usual situation of a hare-lip below, but 
 running up outside the nostril to the inner side of the lower lid (Fig. 264). 
 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 
 
 WITH 
 
 (Fer- 
 
 Fig. 264 — Oblique Facial Cleft, or, 
 rather, Cicatricial Deformity 
 
 along the llne usually traversed f ig - 2 ^5 • macrostoma 
 
 by such a Cleft. (Kraske's Case.) Auricular Appendages. 
 
 GUSS(5N.) 
 
 the line of the nasal duct. It may be limited to the soft parts, or may involve 
 the bones, even laying open the antrum. 
 
 Macrostoma (Fig. 265) 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. 
 
 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. 
 
AFFECTIONS OF THE LIPS AND JAWS 
 
 731 
 
 Macrocheilia, or hypertrophy of the lip, occurs in three forms : 
 1. The congenital variety, a condition analogous to macroglossia, 
 and due to a congenital distension of the lymphatic spaces, or 
 chronic 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 consists in the removal of a V-shaped portion from 
 the centre. 2. An acquired form occurs in children and young 
 people with a tuberculous inheritance, constituting the so-called 
 ' strumous lip.' Either lip may be affected, but perhaps more 
 frequently the upper ; the thickening is probably of a chronic 
 cedematous nature, maintained by the persistent irritation of 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, macrocheilia is in almost all cases due to tertiary syphilis. 
 The lower lip is most often enlarged, and becomes thick and hard. 
 It is due to the diffuse sclerosis characteristic of tertiary mischief. 
 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, dis- 
 charging a small amount of sero- 
 pus, resting on a mass of infil- 
 trated tissue which may extend 
 over the whole lip (Fig. 266). 
 The induration is not so great 
 as in chancres upon the genital 
 organs, but the infiltration is 
 much more extensive. An indo- 
 lent enlargement of one or more 
 of the submaxillary lymphatic 
 glands occurs very early, and 
 the disease usually runs an acute 
 course. Ordinary specific treat- 
 ment is all that is needed. A 
 labial chancre may closely re- 
 semble 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 be- 
 come 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 appearances. The 
 surface is usually flattened, and less warty and irregular than in 
 
 Fig. 266. — Chancre of Upper Lip. 
 (From a Photograph.) 
 
 The enlargement of the submaxil- 
 lary lymphatic glands is very 
 evident. 
 
732 A MANUAL OF SURGERY 
 
 epithelioma, whilst the skin is more involved than the mucous 
 membrane. Should the chancre have existed for any time, the 
 presence of a rash or sore throat may materially assist in forming 
 a diagnosis. Moreover, it is said to be more common on the 
 upper lip, whilst epithelioma is usually seen on the lower (com- 
 pare Figs. 266, 267). 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 con- 
 stantly present, and may be so extensive as to leave cicatrices 
 radiating from the mouth, which are very characteristic (Fig. 17). 
 
 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 persistence 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 appli- 
 cation of a little lanoline or cold cream, but if they persist, it may 
 be advisable to touch them with nitrate of silver. 
 
 Herpes Labialis is a condition usually associated with catarrh, 
 and not unfrequently with pneumonia or other fevers. Either 
 lip may be affected, and the herpetic eruption is quite limited in 
 extent. It consists of a number of little vesicles situated on a 
 hyperaemic and painful base ; after a few days the vesicles become 
 transformed into pustules, and these in turn burst and dry up, 
 the whole affection lasting perhaps a week or ten days. No 
 special treatment is required. If the inner aspect of the lip is 
 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 
 dissected out, and the wound closed by stitches. 
 
 Nsevi are frequently met with in the lip. If confined to the 
 inner aspect they may be dissected out, but when large and 
 involving the whole thickness, they should be dealt with by 
 electrolysis. 
 
 Warty Growths are often seen on the lower lip, especially near 
 the angle, and may then simulate epithelioma. They are dis- 
 tinguished, however, by the fact that ulceration is not often pre- 
 
AFFECTIONS OF THE LIPS AND JAWS 
 
 733 
 
 sent, that the lymphatic glands are not involved, and that there 
 is but little infiltration of the base. They should, however, 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 stated to be due to the irritation pro- 
 duced 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 fric- 
 tion 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 of these, 
 according to Hutchin- 
 son, half are clay-pipe 
 smokers, whilst in 
 Warren's female cases, 
 amongst the Irish in 
 
 Glasgow, three-quarters were smokers. It is also more common 
 amongst country folk who use the short clay pipe than amongst 
 the cigarette and cigar smokers in towns. 
 
 The disease may start as an induration around a crack or 
 fissure, which gradually extends, forming a typical malignant 
 ulcer ; or as a wart-like growth, which fungates and ulcerates ; or 
 as a chronic infiltration leading to an irregular nodular thickening 
 of the lip (Fig. 267). 
 
 If allowed to run its course unchecked by treatment, the disease 
 steadily progresses, forming an ulcerated mass of greater or less 
 size, and even involving the jaw. The submental and sub- 
 maxillary glands are early implicated, and secondary deposits are 
 also found in the glandulae concatenatae. Beyond this, however, 
 
 Fig. 267. — Chronic Epithelioma of Lower 
 Lip. (From a photograph.) 
 
734 
 
 A MANUAL OF SURGERY 
 
 the disease rarely extends, visceral complications being uncommon. 
 When a fatal issue results, it 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 variable amount 
 of discharge escapes, varying with the septicity or not of the 
 wounds. Haemorrhage is also likely to follow from erosion of 
 some of the vessels in the neck. 
 
 The Diagnosis of epithelioma is rarely doubtful, but occasionally 
 warty growths, or even a primary chancre (p. 731), may be mis- 
 taken for it. The clinical history generally suffices to determine 
 the nature of the mass, as also the character of the base and the 
 appearance of the parts ; but in uncertain cases the removal of a 
 small portion under cocaine, and its microscopic examination, are 
 required to set doubts at rest. 
 
 Treatment. — The primary growth can almost always be excised 
 completely without much difficulty ; if glands are also enlarged, 
 
 these should be removed 
 where such is feasible, 
 but when once the con- 
 catenate group has been 
 attacked, they often con- 
 tract such adhesions as 
 to render their extirpa- 
 tion impracticable. If 
 the growth is limited to 
 one part of the lip, a 
 V-shaped wedge extend- 
 ing half an inch beyond 
 it in all directions may 
 be taken away (Fig. 268), 
 and the wound closed, as 
 in a case of hare-lip, with- 
 out much deformity re- 
 sulting. 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 some- 
 what 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 usually be 
 brought together, whilst the mucous membrane is united to the 
 skin along the margin of the new lip. 
 
 When the whole lower lip requires removal, Symes' opevation 
 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 ex- 
 tending downwards under the chin, to terminate below the angles 
 of the jaw, an inverted V-shaped portion of skin between them 
 
 Fig. 
 
 268. — V-shaped Incision for Removal 
 of Epithelioma of Lip. 
 
AFFECTIONS OF THE LIPS AND JAWS 735 
 
 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 alae 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 under- 
 cutting, to be drawn together in the middle line. In such cases 
 care must be taken not to encroach on Stenson's duct. 
 
 Affections of the Gums and Alveolar Processes. 
 
 Spongy Gums are not unfrequently met with as a result of the 
 administration of mercury, or from scurvy. They are characterized 
 by being soft and congested, bleeding readily on pressure, and 
 perhaps showing signs of ulceration. All that is necessary is the 
 correction of the determining cause and the use of an alum 
 mouth- wash. 
 
 Alveolar Abscess (Fig. 269) is almost always associated with 
 suppuration around the fang of a carious tooth. The alveolar walls 
 become expanded, and the pus finds its way over the edge of the 
 bone (C, D), or even through the osseous tissue (A), under the 
 external periosteum. If limited in extent, it perforates the gum 
 directly, and is then known as a gum-boil ; but it occasionally 
 burrows beneath the periosteum, which is stripped from the bone, 
 and may thus lead to an abscess of larger size, possibly resulting in 
 necrosis of the jaw. The formation of an alveolar abscess is almost 
 always associated with a considerable amount of pain of a very 
 irritating nature, and when extensive may give rise to serious con- 
 stitutional disturbance. Occasionally graver complications ensue ; 
 thus, in the upper jaw the antrum may be opened, and suppura- 
 tion in this cavity follow, whilst in the lower the abscess may 
 travel downwards and burst externally, either close to the lower 
 margin of the bone or in the neck. A troublesome sinus results, 
 which can only be cured by the removal of the tooth, and 
 even then a depressed and adherent cicatrix ensues, which is 
 very unsightly. The most essential point in the treatment neces- 
 sarily consists in the removal of the offending tooth. Often 
 this is quite sufficient, and possibly the tooth may come away 
 with an abscess cavity attached to one of the fangs. When 
 suppuration occurs beneath the periosteum, the pain can at first 
 be relieved in measure by fomentations, but as soon as fluctua- 
 
736 
 
 A MANUAL OF SURGERY 
 
 tion is detected an incision should be made through the mucous 
 membrane, 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 required 
 is repeated and frequent irrigation, preferably with peroxide of 
 hydrogen. If a small sinus persists after removal of the tooth, it 
 must be opened up, and any carious or necrosed bone removed. 
 
 Pyorrhoea Alveolaris (or Riggs's Disease) consists in an inflam- 
 matory condition of the margins of the gums, accompanied by 
 a muco-purulent discharge, which arises from pockets or pouches 
 which may extend a greater or less distance along the roots of 
 the teeth. In consequence of this the tissues of the gums shrink, 
 and, together with the alveolar border, become atrophic ; the 
 
 Fig. 269. — Diagram of Alveolar Abscess, resulting from Disease of 
 Molar Tooth. (After the American System of Dentistry.) 
 
 A, Abscess arising from escape of septic material from the pulp chamber, 
 B, 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 t)'pical 
 alveolar abscess ; E, cheek ; F, antrum ; G, nasal cavity. 
 
 fangs are thereby uncovered, and the teeth loosened, so that after 
 a while the patient is likely to become edentulous. The process 
 is limited to a few teeth, or may involve many. It is always pre- 
 ceded by an excessive deposit of tartar, beneath which bacterial 
 infection occurs, the inflammation spreading down along the peri- 
 odontal membrane. Treatment consists in the removal of the 
 tartar and the application of astringents and antiseptics, prefer- 
 ably peroxide of hydrogen, not only to the exposed mucous 
 membrane, but also into the pouches and pockets where pus 
 collects. Treatment is often prolonged and tedious, but must be 
 
AFFECTIONS OF THE LIPS AND JAWS 737 
 
 persisted in, not only to save the teeth, if possible, but also 
 to prevent or remedy the toxaemic and dyspeptic symptoms which 
 are due to the absorption of the pus. In many cases, however, 
 the teeth have to be sacrificed. 
 
 Hypertrophy of the Gums is met with in the form of a sessile over- 
 growth, sometimes almost cauliflower-like, around and between 
 the teeth ; it occurs most frequently in children, but occasionally 
 in older subjects. It is sometimes associated with carious teeth, 
 and should be cut away with a scalpel. 
 
 Dental Cysts are by no means uncommon, resulting from the 
 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 condition presents as a rounded tense elastic 
 swelling, around the margins of which the remains of the ex- 
 panded bone can be detected. The tooth which is the cause of 
 the trouble is always dead, and frequently merely a septic root is 
 present. 
 
 The cause of these cysts is probably the proliferation of certain 
 embryonic remains of the enamel organ, brought about by the 
 irritation of septic matter which has escaped from the pulp cavity. 
 These fcetal residues are lighted up into activity, develop into 
 masses or cylinders of epithelial tissue, and then undergo cystic 
 degeneration. Their pathogenesis is practically identical with 
 that of the epithelial odontome, but merely one cyst develops 
 here instead of many. The fluid contained therein is thick and 
 mucoid in character, and broken-down epithelial cells and choles- 
 terine are seen in it on microscopical 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. 
 
 Epulis. — By this term is meant a tumour growing from the 
 alveolar periosteum. Two varieties are described, viz., the simple 
 and the malignant. 
 
 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. 270), of an elastic consistency, 
 and possibly associated with a little superficial ulceration. It is 
 
 47 
 
738 
 
 A MANUAL OF SURGERY 
 
 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 accomplished by extracting a tooth on either side of the 
 tumour, and cutting vertically through each socket with a saw, the 
 two incisions being united below with a chisel, so as to remove 
 a quadrangular portion of bone without interfering with the con- 
 tinuity of the jaw. 
 
 Malignant Epulis. — This title is applied to a myeloid sarcoma 
 
 growing from the 
 medullary substance of 
 the alveolar process. 
 It forms a soft rapidly 
 increasing mass of a 
 dusky purple colour, 
 which runs on to 
 ulceration or fungation. 
 The deeper portions of 
 the growth may contain 
 an ossific deposit. As 
 with all forms of 
 myeloid growth, it is 
 only locally malignant. 
 Treatment consists in 
 free removal of the 
 mass and of the portion 
 of alveolus from which 
 it arises. In the upper 
 jaw this usually neces- 
 sitates excision of the 
 complete palatal seg- 
 ment 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 occasionally met with. Epithelioma in this 
 situation rarely fungates, but rather tends to invade the bony 
 tissues, and in the upper jaw extends upwards to the antrum ; 
 hence, it is sometimes termed a ' creeping or burrowing epithe- 
 lioma.' 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. 
 
 Fig. 270. — Simple Epulis. 
 
AFFECTIONS OF THE LIPS AND JAWS 739 
 
 Necrosis of the Jaw. — Causes : (1) 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 septic periostitis or osteomyelitis, owing to the lesion 
 becoming compound. It is also not uncommonly caused by 
 the use of dirty forceps or elevators in extracting a tooth. (3) In 
 tertiary syphilis necrosis also occurs, affecting most frequently the 
 palate or alveolar borders. (4) It occasionally results from mer- 
 curial poisoning, bu< such is rarely seen 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 grey and porous, like dirty pumice-stone, 
 is always slow in separating. Either jaw may be affected, but per- 
 haps the lower a little more commonly than the upper. (6) Necrosis 
 may follow one of the exanthemata, arising as an infective idio- 
 pathic or embolic osteomyelitis, 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 
 pyogenic or tuberculous infection, previous to the eruption of the 
 permanent incisors. An abscess forms, and caries, or a limited 
 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. The 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. In the acute 
 form, inflammatory symptoms are well marked, the face becoming 
 swollen, red and shiny, and severe pain is experienced. 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 case of bone sometimes forms in the lower jaw, enclos- 
 ing the 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 mouth should be fomented, 
 and as soon as there is any suspicion of pus a free incision is made 
 down to and along the bone. 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. 
 
 47—2 
 
74 o A MANUAL OF SURGERY 
 
 Affections of the Antrum. 
 
 Suppuration within the Antrum frequently arises from disease 
 connected with the fangs of the first or second molar or bicuspid 
 teeth ; it not uncommonly extends from the nasal cavities in con- 
 nection with disease of the middle turbinated bone, or may be 
 secondary to suppuration within the frontal sinus ; it is occasion- 
 ally lighted up by injury. In chronic cases it is not unusual to 
 find the antrum filled with soft polypi. 
 
 The Symptoms produced are often extremely equivocal, and the 
 condition may be present for some time without being recognised. 
 In the chronic forms there is usually a little local tenderness over 
 the antrum, and perhaps some swelling of the mucous membrane 
 or of the cheek, whilst there is an intermittent discharge of pus 
 into and from the nose. This varies considerably in amount and 
 character, being sometimes extremely offensive. It is stated by 
 Heath that, although the patient notices the fcetor himself, it is 
 not, as a rule, discerned by other people, thus differing from 
 ozaena. On holding the patient's head forwards, it can be demon- 
 strated that there is an overflow of pus into the nostril, and some- 
 times when the patient reclines it flows back into the pharynx. 
 Should the opening into the nose become blocked, all the symp- 
 toms are aggravated, the pain becoming more marked and the 
 swelling increasing. Signs of distension of the cavity may also be 
 produced in this way ; such are manifested in four directions : 
 (a) Inwards, causing obstruction to nasal respiration, and possibly 
 epiphora, from compression of the nasal duct ; (b) upwards, lead- 
 ing to protrusion of the eyeball 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 characteristic 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 disten- 
 sion has lasted long, eggshell crackling may be noticed, or the 
 whole anterior wall may be absorbed and an elastic swelling take 
 its place. Infraorbital 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 mem- 
 brane is closely adherent to the periosteum. 
 
 The Diagnosis of suppuration within the antrum is by no means 
 readily made, since there are many conditions which simulate 
 it somewhat closely. Perhaps the most important sign is the 
 periodic discharge of pus from the nose, and if this can be induced 
 
AFFECTIONS OF THE LIPS AND JAWS 741 
 
 by change of position of the head, it is pathognomonic of disten- 
 sion with pus of one of the accessory sinuses connected with the 
 nose, probably of the antrum. The association of such a pheno- 
 menon with a dead or painful first molar or bicuspid is also a 
 most suggestive occurrence. Another method which has been 
 recommended is that known as transillumination of the antrum. A 
 small electric lamp is placed within the mouth, and if the patient 
 is in a dark room, and his antra are normal, the cheeks, lips, and 
 lower margins of the orbits become of a rosy-red colour. If, 
 however, 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 diminished. The 
 presence of illumination excludes intra-antral growths or abscess, 
 but its absence, unless unilateral, is not of much significance. 
 
 The Treatment of this affection consists in freely opening and 
 curetting the antrum from the mouth, so that the cavity may be 
 washed out and drained. Various methods have been adopted to 
 mttain this end, and perhaps the most satisfactory consists in 
 making an incision through the anterior wall above the first molar 
 after dividing the mucous membrane. This tooth, the fangs of 
 which encroach upon the cavity, should also be drawn, and the 
 anterior wall of its socket cut or gouged away. In bad cases a 
 good opening must also be established into the nasal cavity so as 
 to allow a thorough flushing of the antrum two or three times a 
 day. To prevent the opening from closing too quickly, a tube 
 made of gold, silver, or platinum, and fitted to a small tooth- 
 plate, should be inserted. It is taken out and cleansed night and 
 morning, and plugged during meals. In those cases secondary 
 to intranasal disease, the first essential is to deal with the origin 
 of the mischief in the nose by scraping away all granulation tissue 
 and diseased bone. The antrum is often opened in this way 
 from the nose, and in the majority of cases this will suffice to 
 enable the cavity to be irrigated and drained. In old-standing 
 cases where chronic suppuration persists, the cavity should be 
 freely opened up from the mouth, examined by the finger, scraped, 
 flushed, and stuffed with gauze. 
 
 Hydrops Antri is the term 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 pain- 
 less, and free from inflammatory phenomena, and as the ex- 
 pansion 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 re- 
 tention of secretion, but it is in reality due to a cystic tumour 
 forming from the mucous membrane and the glandular elements 
 contained therein, or to a dental cyst (p. 737) which has en- 
 croached on the antral cavity. The treatment required is to 
 thoroughly open the antrum from the mouth after dividing the 
 
742 A MANUAL OF SURGERY 
 
 mucous membrane, subsequently removing a sufficient portion of 
 the anterior wall to enable it to be washed out and drained. 
 
 Various Tumours may originate in the antrum, e.g., mucous 
 polypi, fibromata, odontomata, osteomata, sarcomata, and cancers. 
 If limited to the cavity, they produce no definite symptoms, 
 except when large enough to cause expansion of its walls. 
 Malignant growths, however, usually 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, without interfering with the integrity of the maxilla. 
 This may be accomplished by reflecting the overlying cheek, as 
 in incision of the upper jaw. For malignant tumours, removal 
 of the whole bone is the only possible remedy. 
 
 Tumours of the Upper Jaw. 
 
 Many of the Simple Tumours springing from the upper 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 it is 
 occasionally met with as a diffuse symmetrical overgrowth, con- 
 stituting the condition known as Icontiasis ossea. . A few cases of 
 Chondroma have also been repeated. 
 
 By Leontiasis Ossea is meant a disease, fortunately very rare, 
 characterized by the formation of diffuse hyperostoses from either 
 the cranial or facial bones, or from both. It usually commences 
 in young adult life, and both rickets and syphilis have been 
 suggested as playing some part in its causation, although really 
 nothing definite as to its origin is known. Nodular outgrowths 
 of soft spongy bone are gradually developed, increasing slowly 
 in size, and giving rise to irregular bony protuberances projecting 
 beneath the skin, and when affecting the maxillae and mandibles 
 leading to an extremely repulsive appearance of the individual. 
 Sometimes merely the cranial bones are affected, at other times 
 only the jaws, whilst occasionally the whole skull participates in 
 the change, which is almost always symmetrical. As growth pro- 
 gresses, the new bone tends to encroach on the cavities contained 
 within the skull, so that the antrum may be obliterated, the eyes 
 may protrude owing to the contraction of the intra-orbital space, 
 and even coma and death may supervene from cerebral compres- 
 sion. Prior to this, however, a variety of symptoms, especially 
 neuralgia, may be induced by pressure on the cranial nerves. 
 Treatment is only occasionally possible, and consists in the removal 
 of the projecting masses of bone by the chisel. A few fairly satis- 
 factory results of such a procedure have been recorded. 
 
AFFECTIONS OF THE LIPS AND JAWS 743 
 
 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, or from the 
 spheno-maxillary fossa behind the bone. Sarcomatous naso- 
 pharyngeal polypi also spread from the nose, and involve the 
 maxilla secondarily. Not unfrequently these growths have a con- 
 siderable ossific deposit within them, and this is occasionally so 
 extensive as to obliterate the antral cavity, and convert the bone 
 into a solid mass. 
 
 Cancer develops in the form of squamous epithelioma, springing 
 from the gums ; or as a columnar or acinous cancer starting in 
 the glandular tissue, found both in the nasal and antral cavities. 
 
 The Clinical Features of all forms of malignant disease are 
 practically identical. 
 
 If arising from the anterior aspect of the bone, a tumour is pro- 
 duced which projects under the cheek, the tissues of which are 
 invaded by it ; it tends to travel down towards the mouth, and is 
 readily detected through the mucous membrane. It may, how- 
 ever, spread deeply, and in time involve the cavity of the antrum. 
 It causes no obstruction to nasal respiration, and no epiphora 
 except in the later stages. 
 
 If it originates within the antrum, the usual signs of distension 
 of that cavity 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 
 pressure 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. 
 
 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 or burrow in all directions. Thus, it may perhaps push 
 the whole bone bodily forwards 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 spheno-palatine foramen, or even up into the 
 orbit ; whilst more rarely it spreads downwards along the posterior 
 palatine canal, so as to appear at the postero-external corner of 
 the palate ; in the later stages it is not uncommon to find the 
 antral cavity also involved, and even the base of the skull is not 
 exempt from the ravages of the disease. 
 
 The General Signs of a malignant growth of the superior 
 maxilla consist in the appearance of a tumour which, according 
 to its origin, produces various effects, but finally tends to destroy 
 the bones and occupy the whole of the maxillary region. It 
 is usually accompanied by nasal obstruction, epiphora, and 
 
744 A MANUAL OF SURGERY 
 
 frequently by a discharge of blood or pus from the nares. Severe 
 pain sometimes 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 jaw from a simple 
 tumour should be readily made ; the later age at which it appears, 
 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 and to encroach 
 upon surrounding structures, all point to malignant disease. In 
 some cases, however, an exploratory incision must be made into 
 the antrum, in order to make certain of the diagnosis. More 
 frequently 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. 
 
 Treatment consists in free removal of the growth, if such be 
 practicable, together with total or partial ablation of the superior 
 maxilla. Where, however, the tissues of the cheek have been 
 invaded, or where the growth has spread beyond the limits of the 
 antrum, the surgeon may well hesitate before recommending an 
 operation, since complete eradication is always a matter of un- 
 certainty and difficulty, and often secured only at the expense of 
 terrible mutilation and considerable risk to the patient's life. Of 
 course, in those cases which spring from behind the maxilla, 
 operative treatment should never be lightly undertaken. 
 
 Excision of the Superior Maxilla. 
 
 The operation is performed for the purpose of removing new 
 growths, simple or malignant, either originating in the upper jaw, 
 or extending into it, whilst it is also sometimes employed as a 
 preliminary in dealing with tumours of the base of the skull. 
 Naturally the exact steps vary considerably in different cases 
 according to the character and extent of the disease. 
 
 Operation. — The patient's head and shoulders are well raised, 
 and anaesthesia is maintained by means of chloroform given by 
 Junker's apparatus. Some surgeons undertake a preliminary 
 tracheotomy, and plug the pharynx, in order to prevent the 
 entrance of blood into the air passages, but such is scarcely 
 necessary or desirable if good assistance is to hand, since it 
 increases to a certain extent the risks of the operation. The 
 proceeding may be described in stages as follows : 
 
AFFECTIONS OF THE LIPS AND yAWS 
 
 745 
 
 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 
 as high as the columna nasi ; the 
 incision is now carried round the 
 ala and along the side of the nose, 
 to a point half an inch below the 
 inner canthus ; it thence extends 
 on the same level along the lower 
 orbital margin to a point below its 
 outer border, or even to the zygoma 
 (Fig. 271, A). The flap thus marked 
 out is raised from the bone, and 
 reflected outwards so as to clear the 
 zygomatic eminence, the knife being 
 carried as near to it as is considered 
 wise, and the more important arteries 
 secured, as they are divided, by 
 Spencer Wells' forceps. 
 
 Stage II. : Division of the Bony 
 Attachments. — A keyhole-saw is now 
 passed into the nose, and the alve- 
 olus and hard palate divided from 
 before backwards through the 
 empty socket of the central incisor 
 tooth. There is no need to incise 
 the muco-periosteum previously, as is sometimes recommended ; 
 division by the saw causes less bleeding than the use of the knife. 
 The side of the nose is then freed from its bony attachments, and 
 the periosteum stripped from the floor of the orbit, the eyeball 
 being protected by a spatula. It is most desirable that the orbital 
 periosteum should be preserved intact, so as to prevent septic 
 invasion of the orbit. The nasal process of the superior maxilla 
 is now cut through with a saw, and also the malar bone divided so 
 as to open into the spheno-maxillary fissure. The surgeon then 
 takes a pair of long-handled cutting pliers, and completes the 
 division of each of these bony attachments, but reversing the 
 order, dealing with the malar bone first, next with the nasal attach- 
 ments, and finally with the palate. 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 (Fig. 272). When the section of the 
 palate is completed, the cutting pliers are used as a lever to prise 
 the bone out of its bed, the sound bone acting as a fulcrum, 
 the posterior attachments being thus fractured. The pterygoid 
 processes are broken through close to their origin from the 
 sphenoid, and the lateral mass of the ethmoid yields along the 
 inner orbital margin. 
 
 Fig. 271. — A, Incision for Re- 
 moval of Superior Maxilla ; 
 B. for Removal of Lower 
 Jaw; C. for Kocher's 
 Operation for Removal of 
 Tongue. 
 
746 
 
 A MANUAL OF SURGERY 
 
 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, and twisted out ; the mouth is 
 gagged open, and the soft palate, if free from disease, is divided 
 from its attachment to the hard by a transverse incision, and all 
 other muscular connections severed. Some care is needed in the 
 removal of the projecting hamular process. Considerable haemor- 
 rhage may occur at this stage from some of the branches of 
 the internal maxillary artery, especially the infra-orbital and 
 posterior palatine ; it is checked temporarily by plugging the 
 wound firmly with a sponge, and subsequently the chief vessels 
 
 Excision of the Superior Maxilla. 
 
 are secured by ligature, whilst smaller bleeding points may be 
 touched with the cautery. Any outlying portions of the tumour 
 are now dealt with, and the cavity, after being dabbed over with 
 a solution of chloride of zinc (40 grains to the ounce), is plugged 
 with strips of cyanide gauze soaked in the iodoform glycerine 
 emulsion. The wound in the cheek is closed, the greatest care 
 being taken to obtain accurate apposition of the flap, especially at 
 the lip margin, and dressed with gauze secured with collodion. 
 
 In the majority of cases there is comparatively little shock, and 
 the patients do remarkably well — at any rate, for a. time — although, 
 unfortunately, recurrence is only too likely to follow. The plug 
 in the nose is left in situ for twenty-four hours, and then removed 
 through the mouth, and the wound irrigated with some antiseptic 
 solution. The plug may be replaced, but can usually be dispensed 
 
AFFECTIONS OF THE LIPS AND JAWS 747 
 
 with if the patient washes out the cavity several times a day. 
 Healing is effected by granulation, and of course a large gap 
 communicating with the mouth remains. This can be sub- 
 sequently remedied by an obturator, to which is attached a cheek- 
 plate to prevent falling in of the cheek. 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. 
 
 Partial Operations. — Many modifications of the above may be 
 undertaken in order to minimize, as far as possible, the amount 
 of tissue removed, and to prevent any unnecessary scarring. 
 When the alveolus alone needs removal, the external incision 
 may be limited to division of the lip, the soft tissues of the cheek 
 being stripped up as far as necessary from the bones. If part of 
 the body of the bone requires removal as well as the alveolus, only 
 the nasal half of the incision need be made, and indeed, wherever 
 it is possible, the orbital plate should be left in order to prevent 
 displacement downwards of the eye and subsequent diplopia. In 
 such cases a saw is carried from the anterior nares across the front 
 of the antrum to the malar bone. The alveolus and palate are 
 now divided, and the growth with this portion of bone detached 
 from its posterior connections. The upper part can also be re- 
 moved separately, the palate and alveolus being left intact; the 
 operation should, in fact, never be looked upon as a fixed and 
 definite proceeding, but may be modified to suit the particular 
 exigencies of the case. 
 
 Various forms of osteoplastic resection of the superior maxilla 
 required for the treatment of tumours of the naso-pharynx are 
 mentioned later (p. 766). 
 
 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 Epulis, have been already described. 
 
 Dentigerous Cysts form around teeth which are so misplaced 
 that they cannot erupt ; though occasionally seen in the upper 
 jaw, they are much more common in the lower. Their characters 
 and nature have been already described under the title of follicular 
 odontomes at p. 171. They are met with in young people, and 
 give rise to expansion of the jaw (Fig. 273) ; the tumour thus 
 formed is at first hard and solid to the touch, but later on egg- 
 shell crackling and even true fluctuation are observed when the 
 encasing wall has become thin or absorbed. Irregularity in 
 the line of the permanent teeth may sometimes be noted, but 
 not necessarily, since the milk tooth corresponding to that which 
 is misplaced is not always shed, owing to the absence of pressure 
 from below. Occasionally suppuration within the cavity may be 
 caused by an extension of inflammation from the fang of a neigh- 
 
74 8 
 
 A MANUAL OF SURGERY 
 
 bouring tooth, or by the cyst being opened during its extraction. 
 
 A sinus discharging offensive pus will then form, and the 
 
 surrounding tissues become red 
 and congested. Treatment con- 
 sists in freely opening the cyst 
 through the mucous membrane, 
 and removing a sufficient por- 
 tion of the bony wall to allow 
 of the removal of the misplaced 
 tooth. The cavity is left open 
 and allowed to heal by granu- 
 lation, during which process 
 strict attention to cleanliness 
 must be observed. 
 
 Fibrocystic Disease of the 
 Jaw (epithelial odontome, p. 171) 
 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 organ (Fig. 274). It 
 occurs most frequently in young 
 people, and, as a rule, runs a 
 perfectly benign course, although 
 when of large size it may lead to 
 
 „ serious results. The only Treat- 
 Fig. 273. — Dentigerous Cyst, show- , ... , . 
 
 ing Expanded Condition of the mmt consists in complete re- 
 
 Lower Jaw, and Unerupted Tooth moval of the affected portion of 
 
 LYING HORIZONTALLY WITHIN IT. the jaW. 
 
 (College of Surgeons' Museum.) Myeloid Sarcoma is met with 
 
 in the lower jaw, not only in the 
 form of a malignant epulis, but also occasionally as a central 
 growth, usually attacking the median portion of the bone, which 
 becomes expanded in the same way as when a similar disease 
 invades the end of a long bone. It presents but slight evidences 
 of malignancy, and may be treated in the first place by opening 
 the outer shell of bone 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. 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 trouble. If the whole thickness of the bone 
 is excised, a wire frame or splint should at once be introduced 
 between the fragments with the same object. It is replaced later 
 on by a suitable plate carrying artificial teeth. 
 
AFFECTIONS OF THE LIPS AND JAWS 
 
 749 
 
 Round- or Spindle-Celled Sarcoma also occurs, usually springing 
 from the periosteum, the deeper parts undergoing ossification. 
 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 
 of a portion of the bone together with the primary disease is 
 always required, unless it has extended so far as to render extir- 
 pation impracticable. 
 
 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. 
 
 u 
 
 Fig. 274. — Fibro-Cystic Disease of the Lower Jaw. 
 (By kind permission of the Council of the Royal College of Surgeons.) 
 
 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 immediately below the symphysis, and thence along the 
 under surface of the body of the jaw as far as the angle ; it is 
 then prolonged upwards as far as the posterior border of the 
 vertical ramus, not extending further than the attachment of the 
 lobule of the ear, so as to avoid the facial nerve (Fig. 271, B). 
 When a large tumour is being dealt with, the whole thickness of 
 the lip should be divided, and the flap thus marked out dissected 
 off the bone, and turned outwards. Where, however, the upper 
 portion of the lip is left, the incisions are carried down to the 
 bone, the facial vessels being secured above and below before 
 division. The soft parts are then freed from the outer aspect of 
 the bone, and the cavity of the mouth opened. The central incisor 
 tooth is drawn, and the jaw divided through the empty socket 
 with a saw and cutting pliers. By this means the genial tubercles 
 and their attached muscles are not encroached on, and the move- 
 
75o A MANUAL OF SURGERY 
 
 ments of the tongue are left unimpaired. The bone is seized and 
 drawn outwards, so that its internal connections as far as the 
 angle may be divided. It must then be firmly depressed, and the 
 muscular attachments of the masseter on the outer side, and of the 
 internal pterygoid on the inner, cut through. The inferior dental 
 nerve and artery will also be met with at this stage. By still 
 further depressing the bone, the temporal tendon is exposed 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 of the ligaments of the temporo- 
 maxillary articulation. The proximity of the internal maxillary 
 artery to the inner aspect of the neck of the bone must be remem- 
 bered, and hence it is important to keep the blade of the knife 
 directed towards the bone. After haemorrhage has been arrested, 
 the wound is stitched together and dressed with collodion and 
 gauze ; possibly a drainage-tube may be inserted with advantage 
 for a few days through the floor of the mouth. Considerable 
 deformity usually results from this operation, owing to the remain- 
 ing half of the bone being drawn across the middle line. 
 
 Diseases of the Temporo-Maxillary Articulation. 
 
 Acute Synovitis may supervene in the course of an attack of 
 rheumatic fever, and is evidenced by pain on movement of the 
 jaw, with swelling due to a serous effusion into and around the 
 joint. Resolution usually follows, but fibroid thickening of the 
 ligaments and impairment of movement may result. 
 
 Acute Arthritis arises from pyaemic infection after the ex- 
 anthemata, or from gonorrhoea, but may be caused by direct ex- 
 tension 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 localized inflammation, with the forma- 
 tion of abscesses, and results commonly in ankylosis. Rest and 
 the antiseptic opening of abscesses constitute the only early treat- 
 ment, although 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 symmetrical, 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 prcjects. The articular cartilage undergoes the usual 
 changes, the inter-articular cartilage disappears, and the glenoid 
 cavity becomes enlarged and flattened, so that the eminentia 
 
AFFECTIONS OF THE LIPS AND JAWS 751 
 
 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. 
 
 Immobility or Closure of the Jaw may be caused by a variety 
 of conditions : 
 
 1. True ankylosis of the 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 regions upon the roots of the fifth nerve, from 
 cancrum oris, or very rarely from myositis ossificans. 
 
 3. Spasm of the muscles of the jaw (or trismus), due to reflex 
 irritation, 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 
 and various forms of tumour the size 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 treat- 
 ment 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, the skin and mucous membrane being not only 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 unsatisfactory, 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, 
 
752 A MANUAL OF SURGERY 
 
 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 
 operation, since the space at the surgeon's disposal is very limited, 
 owing to the presence of the zygoma above, of the facial nerve 
 below, of 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 subcutaneous tissue, and the 
 flap thus marked out is turned forwards. A transverse incision 
 is now made through the deep fascia immediately 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. 
 
CHAPTER XXVI. 
 
 AFFECTIONS OF THE NOSE AND NASOPHARYNX. 
 
 Affections of the Outer Nose. — Several forms of Injury, including 
 fracture of the nasal bones and separation of the cartilages, have 
 been already noticed (p. 439). 
 
 Depression or Flattening of the Bridge of the Nose is either a 
 result of traumatism, such as a fracture of the nasal bones, or 
 may arise from defective growth of the ethmo- vomerine septum, 
 due to disease either of syphilitic or tuberculous origin early in 
 life, whilst it may also result from similar conditions occurring in 
 the course of tertiary syphilis. 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 well-nigh 
 impracticable. Several cases have been lately 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 introduced, 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. 
 
 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. 
 
 It is impossible to discuss all the different affections of the skin 
 of the nose. Many of them are associated with the sebaceous 
 glands, which in this region are very large and abundant. 
 
 48 
 
754 
 
 A MANUAL OF SURGERY 
 
 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 suffering severely. When the superficial capillaries 
 become markedly dilated and the face readily flushes on the 
 imbibition of hot or stimulating fluids, the term rosacea is attached 
 to it, whilst if acne pustules are also present, it is known as acne 
 rosacea. Sometimes the spots become much enlarged, and there 
 is a considerable amount of infiltration of the base, a condition 
 described as acne hypcrtrophiaim. In the most exaggerated stage 
 the sebaceous glands become overgrown and form large protu 
 berant nodular masses projecting from the end of the nose, and 
 covered with red greasy skin, in which the dilated orifices of the 
 glands are very evident, and with dilated capillaries coursing 
 
 freely over them. This condition is 
 generally known as lipoma nasi, rhino- 
 phyma, or hammer -nose (Fig. 275). 
 The treatment of simple acne con- 
 sists in correcting the dyspepsia, and 
 limiting the amount of, or interdicting 
 entirely, alcohol or tea. Capsules of 
 ichthyol (3 to 10 minims), may also 
 be administered thrice daily, and 
 soothing applications should be used 
 locally, such as a lotion consisting 
 of calamine, oxide of zinc and pre- 
 cipitated 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 either left to cicatrize, or dealt 
 with by Thiersch's method of skin-grafting. 
 
 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. Epi- 
 thelioma sometimes attacks it, and requires total removal of the 
 nose for its cure. In any of these conditions the resulting de- 
 formity is so repulsive that the surgeon is certain to be asked to 
 undertake some proceeding to remedy it. Indian surgeons have 
 had a good 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, which, however, we can only indicate briefly 
 here, referring students to larger works of operative surgery for 
 fuller details. 
 
 Fig. 275. — Rhinophyma, or 
 
 Hammer-nose, (Tillmans.) 
 
AFFECTIONS OF THE NOSE AND NASO-PHARYN.X 
 
 755 
 
 The chief methods of Rhinoplasty are as follows : 
 
 i. The so-called Indian method* consists in the formation of a nose from a 
 flap of skin obtained from the forehead. The flap (Fig. 276) 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 attachment 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 completing the anterior 
 nares. The columna itself is formed by the free end of the forehead flap. 
 Drainage-tubes are inserted through the anterior 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 portion is 
 sufficiently firm, the nose is made more shapely by partially dividing the 
 twisted pedicle, but if possible the integrity of the frontal artery should still 
 be retained. The wound in the forehead is drawn together as far as possible 
 by 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 forearm 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. Absolute fixation of the arm is an 
 essential, and as this may need to be maintained 
 for two or three weeks, the patient needs a con- 
 siderable amount of pluck and perseverance 
 When the pedicle has been detached, subse- 
 quent plastic measures are required to mould p 
 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 objec- 
 tion that the new nose only consists of soft 
 tissues, and hence 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 nose, attempts have been made 
 to utilize a finger 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. 
 
 * For full details of this plan we would refer to Keegan's ' Rhinoplastic 
 Operations.' Bailliere, Tindall and Cox, 1900. 
 
 48—2 
 
 276. — Indian Method 
 of Rhinoplasty, showing 
 the Shape andPosition of 
 the Forehead Flap. 
 
 The points A and B are 
 brought down to A 1 and B 1 
 when the flap is twisted 
 into position. 
 
756 A MANUAL OF SURGERY 
 
 Examination of the Nose and Naso-Pharynx. In order to under- 
 stand fully the diseases of the nose, it is essential that the interior 
 of the organ be efficiently examined, and to do this three chief 
 methods are resorted to. 
 
 1. 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. Perhaps Thudichum's speculum 
 is one of the best ; it consists of two unfenestrated blades, con- 
 nected by a U-shaped spring, which is held in the hand, whilst 
 the blades are inserted into the nostril, the nasal 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 
 turbinated bone 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 application of a 5 per cent, solution of 
 cocaine, allowing the free convex border of the middle turbinated 
 bone 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 line, 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 sterilized 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 pos- 
 terior 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 choanae) are seen, separated by the vertical 
 posterior free margin of the septum, and within each cavity the 
 rounded ends of the turbinated bones with the meatuses inter- 
 vening. The inferior meatus often looks very small owing to 
 the prominence of the velum palati, whilst the middle meatus 
 may be encroached on by the tumefaction of the erectile tissue 
 
AFFECTIONS OF THE NOSE AND NASO-PHARYNX 757 
 
 at the back of the inferior spongy bone. Outside the choanae 
 are seen the yellowish openings of the Eustachian tubes, whilst 
 above and between them Luschka's tonsil, a raised collection 
 of lymphoid tissue in the roof of the pharynx, is occasionally 
 observed. 
 
 3. Palpation of the Posterior Nares, with the index finger, pre- 
 viously disinfected, will, however, give better results in the 
 majority of cases to those who are not specially practised in the 
 above method. The index finger is passed behind the uvula and 
 velum, and the nares can then be well explored, and the existence 
 of adenoids or other growths determined. 
 
 Foreign Bodies are rarely impacted in the nasal passages except 
 in children, in whom the condition is not uncommon. Any uni- 
 lateral purulent discharge from a child's nose should suggest the 
 likelihood of such an occurrence, peas, beads, or buttons, being 
 the substances usually introduced. A certain amount of unilateral 
 obstruction to nasal respiration is caused thereby, followed by a 
 catarrhal or even suppurative rhinitis, and in old-standing cases 
 a rhinolith or nasal calculus may be caused by the deposit of 
 inspissated mucus upon the outer surface of a foreign body. 
 Removal is often effected by syringing out through the unaffected 
 nostril, the lotion rushing back through the other side, and 
 carrying the intruding body before it. Failing this, the child 
 should be anaesthetized and a forceps or scoop employed, the 
 surgeon's manipulations being guided by a rhinoscope and frontal 
 illumination. Necessarily, all instruments used for this purpose 
 should be thoroughly sterilized. After the removal, the nostrils 
 are carefully washed out for a few days with a weak alkaline 
 antiseptic lotion, such as salt and water to which a little sanitas 
 has been added. 
 
 Acute Rhinitis. — Several distinct varieties of this affection are 
 described. 
 
 1. The Catarrhal form is extremely common, constituting what 
 is popularly known as a ' cold in the head.' Not only is the 
 nasal mucosa involved, but the inflammation 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 extreme narrowness of the nasal passages, 
 and this may be so marked as to interfere for a time with breast 
 feeding. Apart from the usual domestic remedies directed to in- 
 creasing the action of the bowels, kidneys, and skin, considerable 
 relief can often be obtained by washing out the nasal cavities three 
 or four times a day with a weak warm alkaline lotion containing 
 borax and possibly a little menthol. 
 
 2. A Suppurative form arises not unfrequently as a result of acute 
 
758 A MANUAL OF SURGERY 
 
 suppuration in one of the accessory sinuses (acute empyema), and 
 then treatment must be mainly directed to the sinus. Occa- 
 sionally it is due to gonorrheal 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 1 ounce) once every day as long as the suppuration 
 continues. 
 
 3. True diphtheria also occurs in the nasal fossae, usually as a 
 complication of the same disease elsewhere, and requiring a similar 
 form of treatment. 
 
 Chronic Rhinitis. — So many distinct types of chronic inflamma- 
 tion of the interior of the nose have been differentiated of late 
 years that it is impossible for us to give more than the barest 
 outline of them. For fuller details we would refer readers to 
 Dr. Greville Macdonald's excellent work on diseases of the 
 nose.* 
 
 One of the forms most commonly met with is characterized by 
 engorgement of the erectile tissue covering the inferior turbinated 
 bone, causing considerable obstruction to nasal respiration and an 
 abundant discharge of muco-pus. It usually occurs in patients 
 with long, prominent noses of the Jewish type, where the nasal 
 passages are narrow, and in consequence the air pressure is 
 diminished ; it may be lighted up by some slight local irritant, 
 such as a sudden change of temperature. The anterior end of 
 the inferior turbinated bone is swollen, red, and rounded, the 
 mucous covering being cedematous, and the mass feeling, on 
 touching it with a probe, like a sac full of fluid. The local appli- 
 cation of a 5 per cent, solution of cocaine causes its complete, 
 though temporary, collapse in a few moments. If it is allowed 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 inflam- 
 matory hyperplasia, and not a new growth ; true papillomata of 
 the nose are extremely rare. The posterior end of the bone may 
 be similarly affected, and the mucous covering of the middle 
 turbinated may participate in the same process. A certain 
 amount of pharyngitis or laryngo-tracheitis may also be present. 
 
 Treatment. — In the early stages all that is required is to wash 
 out the nasal cavity night and morning with some simple nose 
 lotion, such as borax or bicarbonate of soda (5 grains to 1 ounce). 
 This may be accomplished either by sniffing the solution from 
 the palm of the hand, or by using some form of nasal douche ; 
 Basdon's douche is perhaps ihe best for this purpose. If such is 
 
 * ' Diseases of the Nose.' Alex. P. Watt and Son. Second edition, 1892. 
 
AFFECTIONS OF THE NOSE AND NASO-PHARYNX 759 
 
 insufficient to give relief, or if collapse is not produced by cocaine, 
 the surface may be swabbed over with some diluted caustic, 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. 
 
 Another group of cases of chronic rhinitis is associated with 
 collapse of the erectile tissue, and then there is but little discharge, 
 since the exudation dries within the nasal cavities and forms 
 inspissated crusts or scabs which are often difficult to remove 
 (rhinitis sicca). The nasal fossae are in this case more patulous 
 than usual, and a dry pharyngitis and chronic laryngitis are often 
 present. Both nostrils may be involved, but occasionally the 
 affection results from deviations of, or cartilaginous excrescences 
 (spurs) from, the septum, and then is unilateral, the discharge 
 coming from that side which is most patulous, whilst the narrowed 
 side remains healthy. When symmetrical, the disease is rather 
 due to constitutional than to local causes, occurring in weakly, 
 anaemic women, and is to be treated by general rather than local 
 measures. In the unilateral form, deviations of the septum from 
 the middle line must be rectified, or the spur removed by the 
 saw. 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 be also advisable 
 to plug the dilated side with cotton-wool for some time daily, so 
 as to enforce respiration through the other nostril. Treatment 
 is always likely to be prolonged, and it is possible that a daily 
 alkaline nose lotion may be needed permanently. Stimulating 
 applications are never borne well, and hence should rarely be 
 ordered. 
 
 Ozsena. — This term was formerly applied to any offensive muco- 
 purulent discharge from the nostrils, whatever the cause, and thus 
 was made to include such conditions as tuberculous 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. Improvements in differential 
 diagnosis have reduced the cases of ozaena to a very small number, 
 and the term is now limited to one particular affection, and that a 
 special form of rhinitis sicca. 
 
 The disease is usually met with in young females, and may 
 sometimes originate from traumatism, or after one of the exanthe- 
 mata, oris associated with inherited tuberculosis or syphilis. The 
 nose is almost always wide and roomy, and may be of the special 
 strumous type ; the lips are often thick and everted, and the 
 mouth is usually held open owing to the impediment to nasal 
 respiration caused by inspissated mucus. The fcetor of the 
 breath is the special feature that calls attention to the complaint ; 
 
7 6o A MANUAL OF SURGERY 
 
 it is peculiarly searching and objectionable, but the patient 
 fortunately is not cognizant of it. It is due to the decomposition 
 of the muco-pus collecting in the nasal cavity, and although 
 Lowenberg's diplococcus is constantly present, the causative 
 organism has not been determined with certainty. There is not 
 much discharge, but at varying periods large crusts come away, 
 giving relief both to the nasal respiration and to the fcetor. Both 
 nostrils are usually involved. 
 
 On examination, the shape and size of the nares are the first 
 things that claim attention ; vibrissae are scanty, and on inserting 
 a speculum the unusual patency becomes evident ; in fact, after 
 clearing away all the dried mucus and scabs, it is often possible 
 to see the posterior pharyngeal wall, and even the orifices of the 
 Eustachian tubes. The mucous membrane over the turbinated 
 bones is dry, collapsed, and pale, and crusts may be found cover- 
 ing any or every part of them. The pharyngeal wall is also dry, 
 and may be coated with a film of inspissated mucus. No ulcera- 
 tion is present, although the removal of the crusts may be 
 associated with a slight amount of bleeding owing to their close 
 attachment to the mucous membrane. The examination of a 
 case of suspected ozaena 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. 
 
 As to etiology, it is important to note that ozaena is never seen 
 in patients with stenosed and narrow nostrils, and is almost always 
 associated with wide, roomy noses. In consequence, it is difficult 
 to obtain sufficient air pressure within them to expel the exudation 
 arising from any ordinary rhinitis, and hence the discharge tends 
 to collect and necessarily to putrefy. The irritation thus induced 
 is likely in weakly children to lead to suppuration. For the same 
 cause the mucous membrane becomes dry and the erectile tissue 
 collapses, so that an atrophic form of rhinitis sicca results, followed 
 in time by sclerosis and shrinking of the turbinated bones. It is 
 always a prolonged process, although in the course of years it 
 improves and gradually disappears. 
 
 Treatment. — The first essential is to keep the nose clean and 
 free from putrefying masses of dried secretion. This must be 
 accomplished by irrigating the cavity once or twice daily, and 
 preferably with warm water, to which a little alkali, such as 
 common salt, and an unirritating antiseptic, such as sanitas, has 
 been added. At first it is well for the surgeon to see to this him- 
 self, 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 
 
AFFECTIONS OF THE NOSE AND NASO-PHARYNX 761 
 
 medicated 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 partially plugging the nostril with an 
 indiarubber 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 Middle Turbinated Bone and Ethmoid is sometimes 
 the cause of an offensive purulent discharge from the nose, which 
 is often wrongly called ozaena. It occurs in individuals of all 
 ages and classes, arising from syphilitic or tuberculous disease, but 
 is perhaps most commonly due to septic infection from without, 
 the result of meddlesome and careless surgery. It must be 
 remembered that the upper part of the nose is normally sterile, 
 and the introduction of dirty instruments is often responsible for 
 this affection. It commences as a submucous infiltration, usually 
 of the middle turbinal, and thence spreads, with or without 
 ulceration, to the periosteum covering the bone, which becomes 
 carious or necrosed. Various parts of the ethmoid, including the 
 cribriform plate, may also be involved, and adjacent bony cavities 
 (antrum, frontal and ethmoidal sinuses, etc.) are filled with pus. 
 In bad cases the venous channels in the base of the skull — e.g., 
 the cavernous sinus — may be thrombosed and infected, and even 
 abscess of the brain has followed. The disease affects one or 
 both sides of the nose, perhaps most frequently but one. On 
 examining the interior of the nostril, there is no patency of the 
 cavity, as in ozaena, but a large polypoid mass of granulation 
 tissue may be seen blocking the middle meatus and covered with 
 a half-dried scab, w"hilst pus can be seen to exude from it when 
 pressed upon ; this usually comes from the antrum or frontal 
 sinus, the mass of granulation tissue lying both above and below 
 the entrance. A probe passed into the mass always impinges on 
 diseased or bare bone. 
 
 When due to syphilis, distinct sequestra are usually present, 
 sometimes involving the septum and hard palate, but the accessory 
 cavities are not generally invaded. 
 
 The Diagnosis from ozaena is made by remembering that in the 
 latter the characteristic features are the abnormal width of the 
 nasal fossae, the bilateral symmetry, the collapse of the erectile 
 tissue, the more complete inspissation of the secretion, and the 
 pathognomonic stench, which are all absent in these cases. A 
 certain amount of odour is present, but it is mainly noticed by the 
 patient, not so much by outsiders. 
 
 Treatment consists in the removal of all dead and carious bone 
 that can be safely dealt with, together with the destruction of all 
 
762 
 
 A MANUAL OF SURGERY 
 
 fungating granulation tissue, and the drainage of such accessory 
 cavities as can be reached, whilst attention is given to maintain 
 cleanliness and asepsis as far as possible. Thus, the middle 
 turbinated bone and its accompanying mass of granulation tissue 
 may be removed by the sharp spoon, snare, or polypus forceps. 
 The antrum must, if necessary, be opened and drained, and the 
 walls of the ethmoidal cells may be broken down, and exit thus 
 given to pus. The greatest gentleness and care must be exercised 
 when any attempt is made to deal with the roof of the nose. 
 
 Nasal Polypi. — Two forms of nasal polypus are described, viz., 
 the simple or mucous polyp and the fibrous or fibro-sarcomatous. 
 Other malignant tumours occur in the nasal, fossae, to which, 
 however, 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 ciliated columnar 
 epithelium, and supplied freely 
 with bloodvessels. There has 
 been a good deal of discussion 
 as to whether or not these polypi 
 are really of a myxomatous 
 nature, but the general opinion 
 of rhinologists is in favour of the 
 view that they are inflammatory 
 in origin, consisting merely of 
 cedematous hypertrophic tissue. 
 The growths are usually situated 
 on the middle and superior tur- 
 binated bones ; they rarely start 
 from the roof of the nasal fossae, 
 occasionally in the sinuses, or at 
 the orifices leading into them ; 
 they hardly ever involve the 
 septum or inferior turbinated bone. The polypoid masses are 
 generally multiple, a large one projecting downwards and forwards 
 towards the anterior nares, and covering or hiding a whole series 
 of smaller ones, which readily spring into prominence when that 
 in front is removed. They are sometimes dependent on, and kept 
 up by, suppuration in one of the adjacent sinuses. 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 epithe- 
 lium covering the anterior portion becomes squamous, and the 
 whole mass firmer in texture and papillomatous in appearance. 
 Sometimes they project backwards into the pharynx, and are then 
 more distinctly globular and usually single. Occasionally they 
 
 Fig. 277. — Mucous Polypi of Nose, 
 springing from the back and 
 Front of the Middle Turbinated 
 Bone. 
 
AFFECTIONS OF THE NOSE AND NASO-PHARYNX 763 
 
 are the starting-point of a myxo-sarcomatous growth, which 
 develops rapidly, and early tends to invade the surrounding 
 bones. 
 
 The main Symptom arising from nasal polypi is obstruction to 
 the passage of air along one or both sides of the nose, according to 
 the location of the growths. This is always of gradual onset, and 
 is invariably worse in wet weather, on 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 greyish 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 deviation 
 of the septum, though causing unilateral obstruction, is recognised 
 by the exercise of a very small amount of intelligence. (Edema- 
 tous masses of granulation tissue, associated with tuberculous or 
 syphilitic disease of the bones, are recognised by usually involving 
 the septum as well as the turbinals, by the purulent discharge, 
 by the absence of superficial epithelium, and by not being dis- 
 tinctly pedunculated ; carious bone can usually 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, red, and diminished con- 
 siderably in size by the application of cocaine. 
 
 The Treatment of mucous polypi consists in their removal either 
 by forceps or the snare. The former plan is usually condemned 
 by rhinologists as unscientific and barbarous, and as utilized by 
 many of the old class of surgeons, such it certainly was : but if 
 employed in the way described below, it is just as efficient as the 
 snare, and gives the patient very little, if any, more pain. Person- 
 ally, we must plead guilty to a very distinct preference for the 
 forceps. 
 
 In undertaking avulsion by forceps, the patient is seated in a 
 chair, and the surgeon sits or stands in front of him. The nasal 
 cavities are fully cocainized, and the situation of the pedicle ascer- 
 tained, as clearly as possible, by illuminating the interior and by 
 the use of a probe. The forceps employed should be long, with 
 delicate, though strong, blades, which are deeply serrated on 
 either side of a median groove. They are introduced open, with 
 a blade placed horizontally on either side of the growth, and are 
 gently pressed upwards until the pedicle is grasped as close to the 
 
764 A MANUAL OF SURGERY 
 
 turbinated bone as possible. The blades are then closed firmly, 
 and the polyp twisted off and removed, a certain amount of 
 haemorrhage resulting. The same process is repeated to the 
 smaller tumours until the nostril is clear. It may be plugged 
 with a strip of boric lint if the bleeding continues, but such 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. This cannot be so accurately accomplished immedi- 
 ately after removal, as the bleeding interferes with clear vision. 
 The cauterization of the base is a most important item in the 
 treatment, as without it the growths are sure to recur. The 
 patient should be again examined after a short interval, so that 
 any smaller polypi which have commenced to develop may be 
 suitably dealt with. 
 
 To remove polypi with the galvanic ecraseur or snare, a 
 speculum is inserted, and the wire loop passed round the growth 
 so as to encircle its base, and gradually tightened until it has cut 
 through. This plan is specially adapted to large masses which 
 project downwards behind the palate. 
 
 Whichever method is adopted, recurrences are not uncommon, 
 and the treatment may in consequence be very prolonged ; but if 
 the surgeon will persevere in the way described above, the disease 
 can in time be eradicated without having recourse to such a muti- 
 lating procedure as removal of the turbinated bones ; indeed, after 
 such an operation, considerable trouble may arise from the nasal 
 cavity being too patulous. 
 
 A Fibrous Polypus is the term applied to a fibroma, which tends 
 sooner or later to become sarcomatous, springing from the base 
 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 over- 
 lying 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,' and encroach upon the cranium. It is rare for any 
 of these latter manifestations to occur until after the tumour has 
 taken on a distinct sarcomatous type. 
 
 The disease usually attacks young people, and mainly those 
 in the second decade of life. It progresses with considerable 
 
AFFECTIONS OF THE NOSE AND NASO-PHARYNX 765 
 
 rapidity, and the fatal issue may be due to haemorrhage, asphyxia, 
 or cerebral complications. 
 
 Treatment. — Unfortunately this condition is but rarely recog- 
 nised in the early stages, owing to the fact that the majority of 
 practitioners are quite unable to use the rhinoscope. We would 
 impress upon students the immense importance of thoroughly 
 exploring both by the mirror and the finger passed behind the 
 velum every case of nasal obstruction or of chronic discharge 
 from the nose. When the growth is small and polypoid, it can 
 often be dealt with from the anterior nares by means of a galvano- 
 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, as otherwise recurrence is 
 almost certain to follow. Nelaton's operation, described below 
 (p. 766), 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. If treat- 
 ment is attempted, one or other of the many plans for exploring 
 the nose or naso-pharynx must be resorted to, and the operative 
 measures must be modified according to the peculiar requirements 
 of the case. Probably total ablation of the superior maxilla will 
 give the best approach to the mass. 
 
 Other forms of Malignant Disease of the Nose are met with, 
 and may originate in any part of the nasal fossae. Squamous 
 epithelioma is that which occurs most frequently ; the symptoms 
 consist in the presence of a blood-stained discharge, and a certain 
 amount of respiratory obstruction, together with pain and cachexia. 
 The lymphatic glands at the angle of the jaw are early enlarged, 
 and the course of the disease is usually rapid owing to the great 
 vascularity of the part. Up to within quite a recent period such 
 growths have been almost always looked on as inoperable, but 
 within the last ten years attempts have been made to remove 
 them, and although necessarily the mortality is great, and the 
 liability to recurrence considerable, yet the results have been such 
 as to encourage the practice of attacking the disease, even in such 
 a difficult region to explore as the interior of the nose. 
 
 Sarcoma may also commence in the nose itself, quite apart from 
 that which originates in the superior maxilla. It gives rise to 
 the usual signs of an intranasal growth, and may be dealt with 
 in a satisfactory manner by local means, such as curetting and 
 the application of caustics. Not a few cases are on record in 
 which such treatment has proved efficacious in curing the disease. 
 
 The operations which have been devised for dealing with disease of the nose 
 and naso-pharynx are so numerous and complicated that it is impossible for us 
 to mention more than a few of the most useful and important 
 
766 A MANUAL OF SURGERY 
 
 (a) In many cases of intranasal disease considerable assistance can be 
 derived by opening up the anterior naves, 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 detach- 
 ment of the mask of the face from the maxillae by everting the upper lip and 
 incising the mucous membrane and subjacent tissues until the nasal cavities 
 are opened. The septum nasi is divided by cutting pliers, and the nasal 
 cartilages completely separated. The soft tissues of the face can then be 
 retracted upwards, and the nasal fossae fully exposed. The bleeding is always 
 considerable, and the space gained in children is but slight. When the opera- 
 tion is completed, the mask of the face is allowed to fall back again into posi- 
 tion, union occurring without difficulty, although no sutures are employed. 
 
 When the upper and anterior portion of the nasal cavity is to be dealt with, 
 Langenbeck's plan can sometimes be utilized with advantage. An incision 
 down to the bones is made along the outer border of the nose from the root 
 downwards and outwards towards the ala. The soft parts are retracted on 
 either side so as to expose the nasal bone and the nasal process of the superior 
 maxilla, a wedge-shaped portion of which can be divided by cutting pliers and 
 prised upwards, but left with their superior connections untouched, so that 
 after the operation they can be replaced. 
 
 When the septum alone is involved in malignant disease, it is possible to 
 deal with it by an operation, which consists in splitting the upper lip in 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 in this way 
 be removed without difficulty. The parts can be afterwards brought together 
 quite naturally, and the deformity is very slight. 
 
 (b) When the disease is located further back, originating rather in 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 
 Nelaton. This consists in a median section of the velum and of the mucous 
 membrane covering 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-periosteal flaps reflected, exposing a quadrilateral 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 subse- 
 quently sutured together. 
 
 (e) Various methods of osteoplastic section of the superior maxilla have been 
 practised, and Langenbeck's name has been associated with one or two 
 different plans, which are, however, only suited to particular cases of disease, 
 and at best give but poor access to the parts behind or above the superior 
 maxilla, whilst they usually leave extremely ugly cicatrices. Perhaps the best 
 plan to adopt is to temporarily detach the superior maxilla from its bed, turning 
 it outwards together with the cutaneous and subcutaneous tissues overlying it, 
 and then, after completing the operation, replacing the bone and suturing the 
 soft parts into position. The results of such practice have been encouraging. 
 
 Adenoids. — Although it is only twenty years ago since Meyer 
 first drew attention to this condition, it is not too much to say 
 that at the present time a large proportion of our children and 
 young people are subject to it in a more or less aggravated form. 
 Adenoids are very common in children with an inherited tuber- 
 culous history, and are of considerable importance from the 
 results to which they give rise. 
 
AFFECTIONS OF THE NOSE AND NASO-PHARYNX 
 
 767 
 
 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 may 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 analo- 
 gous to the chronic hypertrophic form of tonsillitis, with which, 
 indeed, it is often associated. They may occur in the form of 
 broad, cushion-like masses springing mainly from the roof or 
 posterior walls, or occasionally as pedunculated tumours hanging 
 down into the posterior nares. Fig. 278 represents such a condi- 
 tion as seen by posterior 
 rhinoscopy. The tumours 
 are extremely soft and 
 vascular, bleeding very 
 readily. In the recesses 
 or folds between the dif- 
 ferent portions of the mass 
 bacteria lodge and give 
 rise to various inflam- 
 matory troubles, both 
 locally, and in neighbour- 
 ing 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 Symptoms induced by adenoids are mainly due to obstruc- 
 tion to nasal respiration. The mouth is generally held half open, 
 so as to allow the child to breathe through it, thereby exposing 
 the upper central incisors (Fig. 279) ; for 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 aspect being very characteristic ; the children often look 
 sleepy and half silly, and indeed may be very backward in their 
 studies. Not uncommonly there is a certain amount of semi- 
 purulent discharge from the nose, or it may be hawked up from 
 the pharynx, perhaps mixed with blood. Deafness also results 
 from extension of the catarrhal condition to the mucous lining of 
 the Eustachian tubes, and acute or chronic otitis media may be 
 thereby induced ; both taste and smell are sometimes impaired. 
 The palate also becomes high and arched, owing to the defective 
 intranasal air pressure, and as the patient grows up, the incisor 
 1eeth 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 considerable 
 
 Fir, 27S — Adenoids as seen by Posterior 
 Rhinoscopy. (Tillmanns.) 
 
768 
 
 A MANUAL OF SURGERY 
 
 deformity of the thoracic parietes is induced, owing to the inability 
 of the child to take a really deep inspiration, the ribs in conse- 
 quence being drawn in, and the spine kyphotic (Fig. 280). 
 
 Physical Examination consists in posterior rhinoscopy, by means 
 of which the growths can be seen, or in palpation of the posterior 
 nares, a process more suitable to children, who rarely have suffi- 
 cient control to permit of the former. On passing the 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. 
 
 jwt*^S| Bfe> 
 
 
 
 w- 
 
 Mm. *" '" 
 
 
 pPP^^ 
 
 
 
 
 I 
 
 
 Fig 279. — Adenoid Facies. (From a Photograph kindly lent by 
 Dr. 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. 
 
 Treatment consists in the great majority of cases in removal of 
 the adenoids by operation. If left alone, there is a tendency for 
 these growths to gradually disappear, but during this interval 
 development may be considerably hindered, and hence a cure by 
 natural processes in children should never be relied on. Much 
 may be done in milder cases, however, by enforcing respiratory 
 exercises with the mouth shut ; and in young adults attention to 
 the general health, combined with irrigation of the nose with salt 
 and water, and perhaps the local application of a weak solution of 
 nitrate of silver (5 grains to 1 ounce) to the naso-pharynx, may 
 suffice to bring about an amelioration of the condition. 
 
AFFECTIONS OF THE NOSE AND NASO-PHARYNX 
 
 -69 
 
 Operation. — Much diversity of opinion exists as to the character 
 and extent of the operation ; some authorities consider that all 
 that is required is to scrape the 
 growths away with the finger-nail, 
 and undertake this proceeding either 
 under nitrous oxide gas, or even with- 
 out an anaesthetic. Such a measure 
 is, to our minds, unsatisfactory, in 
 that the adenoids cannot possibly be 
 entirely removed, and recurrence may 
 ensue. As a general rule, the child 
 should be anaesthetized with chloro- 
 form, and if enlarged tonsils co-exist, 
 these should be dealt with in the first 
 place. Lowenberg's forceps, curved 
 so as to allow of them being passed 
 behind the soft palate, are then intro- 
 duced with the right hand, whilst the 
 velum is protected by the left index- 
 finger passed behind it. The protu- 
 berant masses are grasped and torn 
 off, special attention being directed 
 to clearing the posterior nares. The 
 orifices of the Eustachian tubes are 
 readily detected, and must not be 
 injured. Care must also be taken not 
 to lay hold of the uvula by mistake. 
 The surgeon's finger-nail may be 
 used to complete the removal of any 
 tags of tissue that remain. Of course, 
 there is considerable bleeding, but 
 this quickly stops of itself, and as 
 soon as the operation is over, the head 
 should be turned to one side, or the 
 child held face downwards, so as to 
 allow the blood to run out of the 
 mouth and nose. The after-treatment 
 
 consists in washing out the nose and throat with either salt and 
 water, or a weak solution of sanitas ; the patient is kept indoors 
 for a few days, and only fluid food allowed. Gottstein's curette 
 is preferred by many rhinologists, and we have often used it with 
 advantage. 
 
 Fig. 280. — Lateral View of 
 a Child with Neglected 
 Adenoids. (From a Photo- 
 graph lent by Dr. St. 
 Clair Thomson.) 
 
 This is the same child whose 
 face appears in Fig. 279. It 
 will be seen that the chest is 
 shallow and retracted, and the 
 spine kyphotic. The arms are 
 small, but the legs are well 
 developed. 
 
 Epistaxis, or bleeding from the nose, may arise from a variety 
 of causes, including traumatism, directed either to the mucous 
 membranes or the bones, or from the presence of ulceration or 
 tumours. Some of these local causes are very evident, if only 
 they are carefully looked for with a rhinoscope and frontal mirror. 
 
 49 
 
770 A MANUAL OF SURGERY 
 
 One of the commonest lesions is a small abrasion or ulcer of the 
 septum, due to detaching by the finger a scab or dried crust of 
 mucus which causes irritation within the nostril ; each time the 
 nose is ' picked ' in this way bleeding recurs. Another 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 also cause haemorrhage, as also 
 ulceration of an angioma on the septum. It frequently occurs in 
 young people about puberty in consequence of local disturbance 
 in the vascular arrangement of the parts ; again, cerebral conges- 
 tion 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 epistaxis, whilst in 
 
 5 
 
 Fig. 281. — Belloc's Sound. 
 
 abnormal states of the blood it may be associated with haemor- 
 rhage elsewhere, as in haemophilia, purpura, and scurvy. 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 rhino- 
 scope. 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 firmly, 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 ulcerated 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. Failing these measures, 
 the nostrils may need to be plugged, but such a proceeding ought 
 to be seldom resorted to ; it is practically a confession of want of 
 
AFFECTIONS OF THE NOSE AND NASO-PHARYNX 
 
 771 
 
 skill in the use of the rhinoscope. It may suffice merely to stuff 
 the anterior nares with long strips of boric lint, but, as a rule, 
 the posterior nares also require plugging. For this purpose 
 Bellocq's sound (Fig. 281) is usually 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 catheter may be used instead. To the 
 lower end of this thread a pledget of lint about 1^ inches by 
 1 inch in size is attached, and this, guided by the finger round 
 the soft palate, is drawn tightly forwards into the posterior nares, 
 whilst the two ends of the thread are tied together round the 
 upper lip to prevent it from slipping. The plug is retained for 
 twelve hours, and then removed, and the nasal fossae irrigated 
 with a weak warm alkaline antiseptic lotion in order to prevent 
 sepsis. 
 
 Another method of arresting epistaxis is by Cooper Rose's 
 inflating plug ; it consists of a piece of gum catheter, surrounded 
 by a thin indiarubber bag, which can be inflated through the 
 hollow stem. It is oiled and passed well into the nose from the 
 front ; the indiarubber bag is then inflated to the required extent, 
 the air being retained by a stop-cock. This generally acts most 
 efficiently, and can be introduced and removed with scarcely any 
 pain to the patient. 
 
 49—2 
 
CHAPTER XXVII. 
 
 APFECTIONS OF THE MOUTH, THROAT, AND 
 OZSOPHAGUS. 
 
 Stomatitis, or inflammation of the mucous membrane of the 
 mouth, is by no means uncommon, especially in children. 
 
 i . Simple Catarrhal Stomatitis results from mechanical irritants, 
 such as roughened teeth, from irritating chemicals, or from that 
 septic form of inflammation which is so liable to follow operations 
 involving the mouth. It may also arise in the course of fevers, 
 and in conditions of debility such as follow measles and other 
 exanthemata in children ; or be associated with disturbances in 
 the alimentary canal, as by improper feeding, dyspepsia, etc. 
 The mucous membrane becomes 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. The treatment consists in the removal 
 of all sources of irritation, and the administration of drugs to 
 correct intestinal derangements. Chlorate of potash, possibly com- 
 bined with dilute hydrochloric acid, is very useful, both locally 
 and internally. In the more severe cases antiseptic mouth- 
 washes should be employed, such as the liquor soda? chlorinatae 
 (i ounce to i pint of water), sanitas (i in 10), boro-glyceride 
 (i in 20), etc. 
 
 2. Aphthous Stomatitis occurs in badly-fed children, in the 
 form of small whitish spots on a hyperaemic base, which run 
 together, and produce ulceration. Attention must be directed to 
 the general condition, and a little borax and honey or a solution 
 of boro-glyceride (1 in 20) applied locally. 
 
 3. Thrush, is a very singular condition, but due to the presence 
 of a parasitic fungus, the Oidium albicans. It occurs in patches 
 somewhat resembling curdled milk in appearance, and requires the 
 same treatment. In both these types there is often considerable 
 
AFFECTIONS OF THE MOUTH, THROAT, AND OESOPHAGUS 773 
 
 enlargement of the lymphatic glands, which, however, frequently 
 subside without suppuration on removal of the cause. 
 
 4. Gangrenous Stomatitis is much the same in origin as the 
 preceding, but more acute in its course. It occurs in debilitated 
 children or elderly people, the subjects of albuminuria or diabetes, 
 and is usually due to foul and dirty teeth. The gums and adjacent 
 tissues become gangrenous, and severe toxic symptoms result. 
 Active treatment by scraping and the use of antiseptics, such as 
 peroxide of hydrogen, is urgently necessary. 
 
 In children this condition is known as Canerum oris (p. 83). 
 
 5. 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 pain- 
 ful, 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. 
 
 6. For Syphilitic Stomatitis, see Chapter VI., p. 127. 
 
 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 entirely 
 absent. (I)) One half of the tongue is defective in size 
 (hemiatrophy), (c) Tongue-tie is said to be present when the fraenum 
 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 
 persist, 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 fraenum, thus put on the stretch, across its centre with 
 a pair of blunt-pointed scissors, (d) The tongue may be adherent 
 to the floor of the mouth, being bound down by folds of mucous 
 membrane (Ankyloglossia). This may also exist as an acquired 
 condition due to cicatricial contraction after ulceration. In con- 
 genital cases the adhesions are but slight, and the organ can be 
 readily freed ; in the acquired condition this cannot always be 
 accomplished, (e) The fraenum and tongue are occasionally too 
 long, allowing of increased mobility, and even fatal results have 
 
774 A MANUAL OF SURGERY 
 
 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) Macvo- 
 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 
 membrane looking almost like skin, although saliva dribbles 
 freely from beneath it. In old-standing cases the teeth are dis- 
 placed outwards and the jaws deformed, 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. Recurrent 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 lymphosarcoma. 
 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 substance, 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 sepsis 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 stoma- 
 titis, and needs no special notice. 
 
 Acute Parenchymatous Glossitis, or acute inflammation of the 
 tongue, may arise from penetrating, and of necessity septic 
 wounds, or from the bites or stings of insects, or may be asso- 
 ciated 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, 
 
AFFECTIONS OF THE MOUTH, THROAT, AND OESOPHAGUS 775 
 
 usually ends in resolution ; but diffuse or localized suppuration 
 may ensue, as well as the most urgent dyspnoea, arising either 
 from cedema 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 beneath 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 symptoms 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 it is more usually of a chronic nature, and 
 situated at the anterior part of the organ. It is usually due to 
 the admission of micro-organisms through some superficial lesion 
 which has quickly healed. It presents as a tense swelling, 
 fluctuation in which may be masked by the amount of inflam- 
 matory thickening which surrounds it. A free incision both 
 settles the diagnosis and cures the case. 
 
 Chronic Superficial Glossitis is an interesting and important 
 disease, which may be associated with a similar condition of the 
 mucous membrane lining the interior of the cheeks and lips. It 
 is most commonly due to syphilis, occurring as a tertiary pheno- 
 menon, but may arise from excessive smoking, ragged and rough 
 teeth, or spirit-drinking, chronic dyspepsia, perhaps of a gouty 
 nature, being also present in many cases. It is very liable to be 
 followed by epithelioma, 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 following five stages, although it must be clearly under- 
 stood that they are artificial, and several of them may be present 
 in different parts of the same tongue, (i.) The papillae become 
 enlarged and swollen, leading to the appearance of red hyperaemic 
 patches, which cannot be recognised for certain unless the tongue 
 is thoroughly dried with a handkerchief, towel, or piece of clean 
 blotting-paper, which must not be carelessly dabbed over the 
 organ, but should be firmly pressed down upon it so as to absorb 
 all the moisture, (ii.) Overgrowth of epithelium follows, and as 
 it increases in thickness, it becomes opaque and horny, so that 
 the red patches are replaced by white ones, leading to the appear- 
 ance which has been designated Leucoplakia. Sometimes the 
 papillae become much enlarged, and stand out definitely and 
 separately from the organ ; or the whole surface may be covered 
 with dense white patches. To this condition the term Ichthyosis 
 has been applied, (iii.) Later on, the excess of epithelium is shed, 
 leaving red smooth patches in which the papillae are atrophied, or 
 have entirely disappeared. If this occurs over the greater part of 
 
776 A MANUAL OF SURGERY 
 
 the organ, the glazed red tongue so characteristic of tertiary syphilis 
 is produced. If, however, this process only occurs in smaller 
 areas intermixed with portions covered with white epithelium, a 
 patchy appearance of the tongue results, wrongly termed Psoriasis 
 lingua', (iv.) At varying periods of the disease, sometimes earlier, 
 sometimes later, the organ becomes 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. 
 
 All these stages of the disease are accompanied with much 
 discomfort, the tongue being sometimes so tender that the patient 
 cannot drink hot fluids, or take condiments or stimulants with- 
 out pain. The speech, too, is interfered with, becoming thick 
 and indistinct. The course of the case varies considerably, 
 and if cancer does not follow, the affection usually settles 
 down after a time, and causes but little discomfort, so long as 
 the patient conforms to the restrictions as to diet, etc., which 
 are essential. 
 
 The treatment of the case is usually a matter of some difficulty. 
 All sources of irritation are excluded from the mouth as a first 
 precaution. Thus, smoking or chewing tobacco must be rigidly 
 prohibited. 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 morn- 
 ing, and all stumps and rough excrescences removed. Condi- 
 ments, 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 1 ounce), or borax (10 grains to 
 1 ounce), especially after meals, so as to exclude all risk of acid 
 fermentation in the debris of food. A solution of perchloride of 
 mercury (2 grains to 1 ounce) may be painted on twice daily when 
 the organ is cracked or ulcerated, and in the latter case powdered 
 calomel dusted on once a day may be beneficial, or the sores may 
 be touched with solid nitrate of silver. 
 
 General antisyphilitic remedies are employed where necessary ; 
 
AFFECTIONS OF THE MOUTH, THROAT, AND CESOPHAGUS 777 
 
 the digestion is attended to, and if the new formation of epithelium 
 is excessive, arsenic may be administered. 
 
 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. Thus, writable ulcers are due to 
 rough and carious teeth. 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 always secondary to pulmonary 
 phthisis, the organ being infected by the sputum. They com- 
 mence 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. Treatment is chiefly needed on account of the pain 
 and discomfort caused by them ; it consists in cocainizing and 
 scraping the sores, touching the base with pure carbolic acid, and 
 dressing with iodoform. Applications of cocaine may also be 
 made before meals, as a palliative measure where radical treat- 
 ment is not undertaken on account of the extent of the pulmonary 
 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 con- 
 sists in scraping and cauterization. Syphilitic and cancerous ulcera- 
 tions are described below. 
 
 Syphilitic Disease of the tongue occurs in a variety of different 
 forms. A primary sore presents a characteristic indolent and 
 inactive surface with subjacent infiltration, and much chronic 
 enlargement of the submental lymphatic glands, which, how- 
 ever, do not tend to 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 longi- 
 tudinal 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 the median line, and generally towards the middle or pos- 
 terior part. 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 
 
778 A MANUAL OF SURGERY 
 
 characteristic contents. The ulcer thus produced is oval or 
 round in shape, and deeply excavated, the base being constituted 
 by a slough, looking like ' wet wash-leather.' There is but little 
 induration either of the base or edges, and one of the most 
 characteristic features is the fact that neither the floor of the 
 mouth nor the base of the tongue is involved, so that the organ can 
 be freely protruded, whilst deglutition 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 absorbing, 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. 
 The treatment consists in the administration of iodide of potassium 
 with or without mercury, whilst the mouth is kept clean with a 
 simple mouth-wash. 
 
 Innocent Tumours are not frequent in the tongue, papilloma, 
 cysts, lipoma, and nasvi being the chief varieties, and requiring no 
 special treatment. 
 
 Dermoid Cysts also form within or under the tongue, originating 
 usually in connection with the thyro-glossal duct (p. 823). 
 
 Cancer of the Tongue occurs in the form of squamous epithe- 
 lioma, and is both a frequent and a very fatal variety of this 
 disease. It is usually met w T ith in men, and may arise as a result 
 of the irritation caused by excessive smoking, especially of cigars, 
 cigarettes, or foul pipes. 
 
 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 probably due to the irritation caused by ragged and 
 irregular bicuspid or molar teeth ; (b) it may start in a crack, 
 fissure, or cicatrix on the dorsum, as a result of chronic superficial 
 glossitis, or of a preceding gumma; (r) it may commence as a 
 wart-like growth, 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 infiltra- 
 tion, starting as an ingrowth from the mucous membrane, with- 
 out 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 mani- 
 fested, viz., a new growth is noticed, hard in consistence, in- 
 definite in its extent, which may or may not be painful from the 
 first, and which ulcerates superficially, exposing a more or less 
 crateriform cavity, with a grey, sloughy, foul surface, readily 
 
AFFECTIONS OF THE MOUTH, THROAT, AND CESOPHAGUS 779 
 
 bleeding when touched, and discharging a foul secretion, which 
 causes extreme fcetor of the breath. The ulcer is surrounded by 
 an indurated mass, which gradually shelves off into the neigh- 
 bouring 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 very excessive, and usually extends along many of the 
 branches of the fifth nerve, especially to the ear, so that sleep 
 become impossible, and the patient's condition steadily and 
 rapidly deteriorates. The glands under the chin and at the 
 angle of the jaw early become involved in the disease, which 
 ultimately attacks the glandulae concatenatae. These secondary 
 growths are very frequently cystic in character, from the degenera- 
 tion of the masses of epithelium formed within them ; after a time 
 they approach the surface and burst, leaving ragged malignant 
 ulcers in the neck. The lower jaw, moreover, 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 
 putrefaction swallowed with the saliva, the excessive salivation, 
 the occasional haemorrhages, and the extent of the secondary 
 growths. The patient rarely lasts, apart from treatment, for more 
 than twelve months after the disease has been first noticed. 
 
 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-five years 
 of age, with the typical enlargement of the glands, profuse saliva- 
 tion, and impaired movements, there can be little doubt as to the 
 diagnosis. But when it is seen in the early stage, as an infiltration 
 of a syphilitic fissure or cicatrix, or as a small wart, it may be 
 exceedingly 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 infiltration of the 
 base of the ulcer, are important guiding marks ; but in doubtful 
 cases a small portion of the growth should be excised under 
 cocaine, and subjected to careful microscopic examination, and 
 thus its nature ascertained. Moreover, the administration of 
 steadily increasing doses cf iodide of potassium will generally 
 bring about rapid improvement in a syphilitic case, but will do 
 no good to an epithelioma, except perhaps temporarily when the 
 two diseases co-exist. 
 
 Treatment. —The only hope of curing the patient lies in thorough 
 and early removal of the growth, which it must be remembered, 
 has probably extended much further than one expects. Hence, 
 
7S0 A MANUAL OF SURGERY 
 
 no halt-measures should be adopted, but complete operations, 
 including also the lymphatic area, are desirable. 
 
 Ligature of the lingual artery and division of the gustatory 
 nerve have been performed in cases where the disease had pro- 
 gressed too far to attempt radical treatment, with the double object 
 of starving the growth and relieving the pain ; such, however, are 
 of little value. Dusting the surface of the tumour with pyoktanin 
 will perhaps give the most relief to the unfortunate patient. 
 
 Many operations for removal of the tongue have been suggested 
 and practised from time to time, the majority of which have, how- 
 ever, fallen into disuse, and will not even be noticed here. We 
 shall merely indicate the chief plans of treatment adopted at the 
 present day. For practical purposes, the cases may be divided 
 into two groups — those in which the disease is limited to one 
 portion of the tongue, and the muscular tissue is not extensively 
 invaded ; and those in which glands or other structures are also 
 obviously involved, or the tongue itself is widely infiltrated. In 
 the first class of cases an intrabuccal operation will often suffice, 
 combined with separate removal of the glands ; in the second, 
 more extensive extrabuccal procedures are required. 
 
 The Intrabuccal Method now adopted for partial removal of the 
 organ is that known as Whitehead's Operation. The lingual artery 
 should always be previously secured in the neck (p. 285), thus 
 giving the surgeon an opportunity of removing the submaxillary 
 gland, with its associated lymphatics, which are so often affected. 
 The mouth is then well opened with an efficient gag, and the 
 chloroform administered by means of Junker's apparatus. A 
 good assistant is necessary in order to prevent blood entering 
 the larynx, small pieces of sponge held in smooth-nosed, long- 
 handled forceps 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, and if portions of both sides are to be 
 removed, a silver wire or silk thread should in addition be passed 
 through the base not far from the epiglottis so as to command 
 the stump. The essential feature of the operation is to carefully 
 snip through the organ little by little by means of long-handled, 
 straight, blunt-pointed scissors, picking up all the vessels as they 
 are divided, and by this means the loss of blood is reduced to a 
 minimum. The modus operandi for partial removal of one-half is 
 as follows : The tongue, being drawn out of the mouth by the 
 two anterior loops of silk, is carefully divided down the middle line 
 into two segments, which are readily 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 line of 
 attachment of the mucous membrane to the alveolus, and then 
 along the middle line of the floor of the mouth to the tip of the 
 tongue, so that the sublingual salivary gland can be also taken 
 away — a most necessary step. The mucous lining of the dorsum 
 
AFFECTIONS OF THE MOUTH, THROAT, AND CESOPHAGUS 781 
 
 is now divided transversely behind the growth, and the muscular 
 structure of the organ slowly snipped through with scissors, and 
 during the process, by the aid of the finger or a director, the 
 vessels and nerves can be seen and recognised before division. 
 Removal of the diseased half with the sublingual gland is thus 
 easily accomplished by making the incisions meet, and dividing the 
 intervening tissues. 
 
 If the tip is alone 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 catgut sutures. 
 
 If the whole tongue is to be excised, or even when one side alone 
 needs removal as far back as the epiglottis or hyoid bone, special 
 precautions have to be taken in order to diminish the risk of 
 asphyxia from falling back of the stump of the organ after the 
 operation. Thus, a thick silver wire can be passed deeply through 
 the epiglottis, by means of which it is drawn forwards, and the wire 
 is then fixed to the upper lip by a strip of gauze and collodion. 
 The objection to this plan is the patent condition of the glottis, 
 into which septic exudations from the mouth are likely to run, 
 probably inducing septic pneumonia. A much better method is 
 that which has been introduced and largely adopted of late, viz., 
 the performance of a preliminary tracheotomy in order to allow the 
 pharynx to be plugged. A Hahn's trachea-tube (i.e., a large one 
 surrounded with compressed sponge infiltrated with iodoform, 
 which will expand and absolutely shut off the lower respiratory 
 tract from the mouth) is inserted, or a Trendelenburg's air- 
 tampon ; or an ordinary tube may be employed if the pharynx is 
 well packed with a sponge so as to prevent blood trickling down- 
 wards ; the anaesthetic can then be administered through the tube. 
 The advantages of this method of treatment are threefold : (a) The 
 patient can be kept in a condition of complete anaesthesia without 
 hindrance to the surgeon, so that the operation is more quickly 
 finished, the shock is less, and the removal of the disease can be 
 more thoroughly accomplished ; (b) the patient runs no danger of 
 asphyxia during the operation by blood trickling into the lungs, 
 or by fragments of tissue or sponge getting loose in the mouth 
 and being inhaled, whilst later on falling back of the root of the 
 tongue does no harm ; and (c) the chances of septic pneumonia 
 are reduced to a minimum. Of course, opening the trachea is 
 not entirely devoid of danger, and therefore this plan should not 
 be adopted except where extensive dissections are called for, and 
 then may be undertaken with advantage a few days previously. 
 At the time of operation the pharynx is firmly packed with a 
 sponge. 
 
 Where the jaw, floor of the mouth, or glands in the neck are 
 much implicated, or the tongue substance itself extensively 
 infiltrated, an Extrabuccal Operation is necessary ; and of the 
 
782 A MANUAL OF SURGERY 
 
 many plans that have been recommended, we consider Kochers 
 Operation, or some modification of it, by far the best. The 
 incision (Fig. 271 C), commencing close to the lobule of the ear, 
 runs 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. If part of the jaw also needs removal, the 
 incision may have to extend through the lower lip, and the flap is 
 then turned outwards and backwards so as to expose the bone. 
 All the lymphatic glands in the region — the submental, sub- 
 maxillary, 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. Any diseased portion of 
 the jaw is isolated by saw-cuts in front and behind, and may 
 be removed at once if desirable, or left in situ and taken away 
 with the disease ; but, as already mentioned, it is always well, if 
 possible, to leave a bridge of bone to maintain the continuity of 
 the mandible. 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, which are snipped through with scissors, any bleeding 
 points being secured as divided. If the whole organ is to be 
 removed, it is unnecssary to divide it in the middle line. If the 
 jaw is healthy, the reflection of mucous membrane is incised close 
 to the alveolus, so that, by detaching the mylo-hyoid from the 
 bone, a communication is made between the outside wound and 
 the mouth, and the tongue is then drawn through this lateral 
 opening, and removed close to the epiglottis behind, and close to 
 the hyoid bone below, the whole floor of the mouth being effectu- 
 ally dealt with in this way. 
 
 The raw surface is painted with Whitehead's varnish (which 
 consists of Friar's balsam, but with the rectified spirit replaced 
 by a saturated solution of iodoform in ether), and, where trache- 
 otomy has been performed, the mouth is plugged with aseptic 
 gauze. 
 
 The external incision is closed by a continuous suture, a large 
 drain-tube being inserted at the lowest point for a few days. No 
 attempt is made to keep the base of the tongue forwards, and, in 
 fact, it is better that it should fall back so as to close, the opening 
 of the glottis, and so prevent septic saliva from entering the air- 
 passages ; it will be subsequently drawn forwards again by the 
 process of cicatrization of the wound in the floor of the mouth. 
 The plug of gauze may be removed in twenty-four hours, and 
 replaced or not at the discretion of the surgeon. The mouth 
 must be freely and frequently washed out with some unirritating 
 antiseptic lotion, e.g., sanitas (1 in 10), boroglyceride (1 in 20), 
 
AFFECTIONS OF THE MOUTH, THROAT, AND CESOPHAGUS 783 
 
 boric acid (to grains to 1 ounce), or a weak solution of Condy's 
 fluid. If all goes well, a smaller size of Hahn's tracheotomy-tube 
 is inserted on the second day, an ordinary tube on the fifth or 
 sixth, and even this is removed in seven to ten 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. Where no tracheotomy has 
 been performed, the greatest care and watchfulness will be re- 
 quired to prevent the stump of the tongue falling back and produc- 
 ing asphyxia ; the mouth and pharynx must be constantly cleansed, 
 to diminish as far as possible the risk of septic pneumonia. 
 
 This operation is certainly the most successful of any for exten- 
 sive disease, and the immediate results are satisfactory ; but 
 necessarily where the disease is so widely diffused as to need 
 such a severe procedure, a considerable percentage of the cases 
 will suffer from recurrence. 
 
 The great danger of the operation — septic pneumonia — is best 
 combated by carefully cleansing the mouth and teeth previously 
 with antiseptics, by a preliminary tracheotomy, and efficient 
 plugging of the pharynx. Secondary haemorrhage is occasionally 
 met with, but probably only when the patient is very exhausted 
 at the time of the operation, and where the mouth is not well 
 irrigated subsequently ; the bleeding vessel should be again tied 
 on the face of the stump, or in the neck if such has not already 
 been undertaken ; failing this, one must depend on the application 
 of perchloride of iron or the actual cautery. Antistreptococcic 
 serum may also be utilized as a preliminary measure in order to 
 prevent the occurrence of septic troubles ; three or four injections 
 of 10 c.c. each are made on the day preceding the operation, and 
 perhaps one or two afterwards. The results obtained in this way 
 have been satisfactory. 
 
 Kocher's lines of incision may be modified according to circum- 
 stances, provided that the essential principles are kept in view, 
 viz., the complete removal of the primary disease and of the 
 infected glands, and the provision of effective drainage. 
 
 The removal of a part, or even the whole, of the tongue is not 
 such a mutilation physiologically as one might expect at first. 
 Deglutition is interfered with for a time, but the power is soon 
 regained, and even articulation may be in great measure restored. 
 
 Affections of the Floor of the Mouth. 
 
 Sublingual Abscess, when acute, is due to infection of the sub- 
 mucous tissue, as by puncture with a fishbone, or starts in a fol- 
 licle of the sublingual or in a submucous gland. The inflammation 
 
784 A MANUAL OF SURGERY 
 
 which follows results in the formation of a puffy swelling 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 
 oedematous laryngitis may also be induced. Considerable con- 
 stitutional disturbance generally accompanies 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 cavity being subsequently washed out 
 and drained. The more diffuse form of sublingual abscess is 
 usually associated with submaxillary cellulitis (p. 93). 
 
 The sublingual region is also a favourite site for Actinomycosis 
 (p. 148), which manifests itself as a diffuse brawny induration of 
 the tissues, progressing slowly, and not very tender. As it comes 
 to the surface, the skin becomes red and dusky, and sooner or 
 later a series of little pustules appear one after another with a 
 typical yellowish apex. These burst and discharge a glutinous 
 fluid containing the fungus, and if kept aseptic and allowed to 
 heal, are followed by depressed and puckered cicatrices. The 
 administration of gradually increasing doses of iodide of potassium 
 usually suffices to bring about a cure. 
 
 Cystic Swellings are not uncommon about the floor of the 
 mouth, and amongst them the following may be described : 
 
 (a) Mucous Cysts result from the distension of mucous glands ; 
 they form small translucent swellings, elastic and fluctuating. 
 All that is needed is to open them, and remove the anterior wall. 
 
 (h) Ranula is a very similar condition, but larger and unilateral, 
 containing a glairy mucoid fluid, and due to obstruction and dis- 
 tension 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. 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. 
 
 (c) Dermoid Cysts are frequently met with in the floor of the 
 mouth, occupying the middle line, and also projecting into the 
 neck beneath the chin. They are due to non-obliteration of 
 the upper end of the thyro-glossal canal (p. 823). The contents 
 are of the usual sebaceous type. Such tumours should never be 
 dealt with from the mouth, as they extend deeply, and need to be 
 carefully dissected out. A free opening must be made in the 
 middle line under the chin, and, if feasible, the whole cyst 
 removed unopened. If it gives way, the entire wall must be 
 dealt with, or recurrence will certainly ensue. 
 
AFFECTIONS OF THE MOUTH, THROAT, AND OESOPHAGUS 785 
 
 Affections of the 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, highly infectious in character, and 
 generally epidemic. The period of incubation is about three 
 weeks, and the attack itself consists in a slight febrile dis- 
 turbance, 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, sub- 
 lingual, and neighbouring lymphatic glands are sometimes, but 
 not frequently, enlarged. Suppuration is rare, but in adults 
 metastatic inflammation of the testes, mammae, or ovaries is not 
 uncommon. This complication is generally unilateral, and thus, 
 although atrophy of the testis commonly follows orchitis, sterility 
 is not produced. Treatment. — Keep the patient warm and quiet, 
 and administer salines. In the later stages friction with stimu- 
 lating 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 co'.d 
 or from injury, whilst the presence of a calculus in the duct leads 
 to a chronic sclerosing inflammation. The symptoms consist of 
 pain and swelling, together with a certain amount of constitutional 
 disturbance. An extremely interesting phenomenon is the paro- 
 titis which follows injuries or diseases of the abdominal or pelvic 
 viscera. This condition is not very unusual, as is evident by the 
 fact that Stephen Paget has been able to collect 101 such cases. 
 It was formerly attributed to pyaemia, but is now considered to 
 be due to infection of a mild type from the mouth, owing to a 
 septic state of the teeth induced by prolonged rectal feeding. In 
 confirmation of this view is the fact that it has been seen in not a 
 few cases of gastric ulcer, where the patient had to be fed per 
 rectum for some time. Treatment in these simple cases consists in 
 the application of fomentations, perhaps medicated with bella- 
 donna. 
 
 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., scarlet or typhoid fevers. If the inflammation spreads up 
 from the mouth, suppuration occurs primarily within the tubules ; 
 under other circumstances, pus forms in the interstitial tissues. 
 The gland becomes much enlarged, with congestion and oedema 
 of the overlying skin, and, owing to the tension of the fascia, 
 
 5° 
 
786 A MANUAL OF SURGERY 
 
 exceedingly painful. For the same reason, pus cannot readily 
 find its way to the surface, and hence is likely to burrow in various 
 directions, e.g., amongst the muscles of the neck, or even upwards 
 and inwards towards the base of the skull, or to the cavity of the 
 mouth, finding its way over the border of the superior constrictor 
 (the so-called ' sinus of Morgagni '). The constitutional symptoms 
 from toxic absorption are usually very severe. Owing to the 
 fact that large veins and arteries pass through the parotid gland, 
 pyaemic symptoms are not unlikely to supervene, and the prog- 
 nosis 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 precau- 
 tion should be taken to prevent mischief to the facial nerve, and 
 Hilton's method of operating maybe 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 freely 
 used regardless 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 gland to the neighbouring tissues, giving rise to what 
 has already been described as submaxillary cellulitis, or Ludwig's 
 angina (p. 93). 
 
 Obstruction to the Flow of Saliva results from various causes, 
 such as cicatricial contraction in the neighbourhood of the entrance 
 of the ducts into the mouth, or from the presence of a salivary 
 calculus, consisting of phosphate and carbonate of lime, and usually 
 fusiform in shape. 
 
 The chief Symptom of such obstruction is a painful enlargement 
 of the gland during and after meals, which slowly passes away as 
 the saliva finds its way past the block ; if it persists for long, the 
 gland becomes chronically enlarged, and its interstitial tissue 
 increased in bulk, whilst a certain amount of peri-adenitis also 
 follows. When a calculus is present, there is usually a consider- 
 able discharge of offensive muco-pus into the mouth. Where the 
 obstruction is complete, a cyst may form, and if this is opened, or 
 finds its way to the exterior and bursts, a salivary fistula results. 
 The formation of salivary calculi is not very common in con- 
 nection with the parotid gland, owing to the fact that the saliva 
 excreted is limpid in character, whereas that arising from the 
 submaxillary and sublingual glands is thick and mucoid. 
 
AFFECTIONS OF THE MOUTH, THROAT, AND (ESOPHAGUS 787 
 
 Treatment. — In cases of simple obstruction, an attempt must 
 be made to restore the natural exit, or to make an artificial one. 
 If a calculus is present, it can usually be seen or felt at intervals 
 projecting from the entrance of the duct ; in such a case the duct 
 must be incised, and the stone removed. Where, however, it is 
 located in the substance of the submaxillary, total removal of the 
 gland may be necessary. 
 
 Tumours of the Parotid Gland are of considerable interest, and 
 may be simple or malignant. 
 
 (a) The Simple parotid tumour consists of a growth starting 
 in the capsule or interstitial tissue of the superficial part of the 
 gland ; it contains nodules of cartilage mixed with fibrous and 
 mucous tissue, whilst some- 
 times glandular elements 
 similar to those met with 
 in the parotid are scattered 
 through the mass. It has 
 been already mentioned that 
 the cartilaginous elements 
 are probably due to the 
 persistence of remnants of 
 the embryonic Meckel's car- 
 tilage. The tumour feels 
 hard, firm, and nodular, but 
 where there is much myxo- 
 matous tissue, areas of 
 softening may be inter- 
 spersed amongst the harder 
 portions. The mass is 
 situated between the jaw 
 and the sterno-mastoid, ac- 
 cessory processes also ex- 
 tending over the masseter 
 in the region of the socia, 
 and later on burrowing 
 deeply between the mastoid 
 bone and the styloid pro- 
 cess, and beneath the ramus of the jaw (Fig. 282). In the early 
 stages the tumour is freely moveable on the deeper parts, as is 
 also the skin over it, but subsequently the mass becomes fixed 
 and adherent. The growth is usually slow, and at first quite 
 painless, 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 impor- 
 tance, owing to the fact that the growth is superficial to the gland, 
 and to the more important vessels and nerves. The simple 
 
 50—2 
 
 Fig. 
 
 282. — Parotid Tumour. 
 (Fergusson.) 
 
788 A MANUAL OF SURGERY 
 
 tumour, if allowed to persist, is not an uncommon precursor of 
 malignant disease. 
 
 (b) Malignant tumours of the parotid occur in the form of endo- 
 thelioma, sarcoma, or carcinoma, and are not unfrequently grafted 
 on to a simple tumour, the change of type being maiked by 
 increased rapidity of growth and greater pain. The mass be- 
 comes more fixed, and signs of pressure upon the vessels and 
 nerves develop ; the facial nerve is very likely to be implicated, 
 leading to paralysis of the face. Moreover, the skin becomes 
 hyperaemic and often adherent to the tumour, and finally ulcera- 
 tion and even fungation may obtain. Secondary deposits occur 
 in the neighbouring lymphatic glands or in the viscera, and the 
 patient soon passes into a state of malignant cachexia. Carcino- 
 matous tumours are less common than the sarcomata, but run a 
 similar course. The growth is an adenoid cancer, not unfre- 
 quently of the soft or encephaloid type, and neighbouring lym- 
 phatic 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 distinctly encapsuled, 
 and their removal, except in extreme cases, is not a matter of 
 special difficulty ; malignant disease is much more diffuse, render- 
 ing complete extirpation of the mass almost impracticable. The 
 distinction between the two forms is made by a consideration 
 of the signs and symptoms considered above, attention 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 intra- 
 buccal 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 dissemination. Simple 
 parotid tumours are dealt with either by making a vertical 
 incision over the most prominent part of the mass, or by turning 
 forwards a flap, exposing thereby the capsule, which is incised 
 transversely ; for although the facial nerve is generally beneath 
 the growth, it occasionally runs superficial to it, or in its sub- 
 stance. After this has been accomplished, the tumour is often 
 enucleated without much difficulty, but the surgeon must make 
 
AFFECTIONS OF THE MOUTH, THROAT, AND OESOPHAGUS 789 
 
 certain that no deeper processes are left, or recurrence will 
 inevitably follow. The haemorrhage from the transverse 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 undertaken. It is accomplished 
 through a vertical incision, or, if the skin is involved, by two 
 crescentic ones. The gland is then gradually freed from its 
 connections, care being taken, if possible, to keep outside its 
 capsule. It is best to deal with the lower part first, securing 
 with double ligatures the external carotid artery and temporo- 
 facial vein. The mass is then 
 drawn upwards 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 neces- 
 sarily resulting facial palsy. Re- 
 currence is almost certain to follow. 
 Removal of the angle of the jaw as 
 a preliminary step has been recom- 
 mended, since considerable space 
 is gained thereby, and a better 
 access to the field of operation. 
 
 Tumours of the Submaxillary 
 Gland are very similar in nature 
 to those of the parotid. Simple 
 tumours are represented by chon- 
 dromata, which in this position are 
 almost always pure and without 
 admixture of myxoma (Fig. 283). 
 
 Sarcoma and carcinoma are also met with ; if seen in the early 
 stages they are easily removed. 
 
 Salivary Fistula occurs almost solely in connection with the 
 parotid gland. It arises from penetrating wounds of the cheek 
 dividing Stenson's duct, or more frequently it follows operations 
 in its neighbourhood. It is a very troublesome condition, both 
 for the surgeon who is called upon to treat it, and for the patient 
 who suffers from the inconvenience of saliva flowing down the 
 cheek, the amount being, of course, increased at meal-times. 
 Stenson's duct extends forwards from the socia parotidis across 
 the masseter muscle for a distance of about 2 inches, and then 
 turns abruptly inwards to pierce the buccinator, and enter the 
 mouth opposite the second upper molar tooth. The buccal 
 and masseteric portions are almost at right angles, the latter 
 being represented by a line drawn from the lobule of the ear 
 to a point midway between the ala nasi and the angle of the 
 
 Fig. 283. — Submaxillary 
 
 (TlLLMAN.NS.) 
 
 Tumour. 
 
790 A MANUAL OF SURGERY 
 
 mouth. The diameter of the duct is about one-eighth of an inch, 
 its narrowest portion being at the orifice. 
 
 Treatment. — If the buccal portion is involved, a cure is often 
 attained by slitting up the duct within the mouth ; but when the 
 masseteric portion is wounded, and especially if near the socia 
 parotidis, treatment becomes more difficult. We have several 
 times found the following plan successful : A fine probe is passed 
 along the duct from the mouth as far as the lesion ; it is then 
 grasped by forceps inserted through the external aperture, and 
 drawn out on to the cheek, a proceeding sometimes facilitated by 
 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 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. 
 
 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 communication to exist between the nose and mouth. 
 The term does not include losses of substance, resulting from 
 injury, syphilis, or lupus. The cleft usually starts posteriorly, 
 and extends forwards for a variable distance, although it has 
 been known to be limited to the anterior portion of the palate 
 and bony alveolus, but only in exceedingly rare instances. 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 ; more or less of the hard palate may also be implicated, 
 the cleft reaching as far forwards as the site of the anterior palatine 
 canal (Fig. 284, B) ; whilst the severest type of the deformity 
 
AFFECTIONS OF THE MOUTH, THROAT, AND OESOPHAGUS 791 
 
 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 (Fig. 284, C). 
 
 On looking carefully at a cleft palate the defect usually appears 
 
 Fig. 284. — 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. 
 
 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 bony processes unite in the 
 middle line of the roof of the mouth, viz., the two palatal pro- 
 
 A B C 
 
 Fig. 285. — Diagram to Show the Modifications of Cleft Palath. 
 
 a, Ethmo-vomerine septum ; h, pa'atal segments; c, tongue ; d, cavity 
 of the nose ; e, buccal cavity. 
 
 cesses growing in horizontally from the maxillae, one on each side, 
 and the ethmo-vomerine septum projecting vertically downwards 
 from the under surface of the fronto- nasal process and base of the 
 skull. All these should amicably join together about the ninth 
 or tenth week of intra-uterine life. If, however, the palatal pro- 
 cesses fail to reach the middle line, a median defect appears 
 
792 A MANUAL OF SURGERY 
 
 (Fig. 285, A), unless the ethmo-vomerine septum be so hyper- 
 trophied as to project between them, when the appearance of a 
 double cleft is produced (Fig. 285, B). When one division of 
 the palate unites with the mesial septum, the other failing to 
 reach it, an apparently unilateral cleft results ; most commonly 
 the defect is on the left side, the vomer being attached to the 
 right free edge, a left-sided alveolar hare-lip also complicating 
 the case (Fig. 285, C). The reason why the anterior portion of 
 the palate is so rarely affected without the posterior part being 
 also involved is that the union of the various segments progresses 
 from before backwards. 
 
 The width of the cleft and the slope of the segments varies 
 greatly in different cases. The wider the cleft, the more un- 
 favourable 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. Remove it, they fall naturally together ; leave 
 it, and they are wedged permanently apart. As tc the slope of 
 the segments, the more vertical they are, the more favourable for 
 operation, since the flaps of muco-periosteum 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 
 apposition ; this involves much more traction on the stitches, and 
 hence less satisfactory results. 
 
 The effect of such a deformity upon the infant, from a physio- 
 logical point of view, is very serious. The process of nutrition is 
 considerably 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, otherwise they become emaciated and succumb to inanition 
 or intercurrent maladies. If they grow up, articulation becomes so 
 indistinct that it is often impossible to understand what they say, 
 the voice having a peculiar and characteristic intonation. All the 
 letters known as explosives, whether dentals, labials, or gutturals, 
 requiring a certain amount of air-pressure within the mouth for 
 their due pronunciation, are difficult to produce, particularly b, d, 
 p, t, g, f, etc. Moreover, the exposure of the nasal mucous mem- 
 brane to the air is so much greater than usual that it is liable to 
 catarrhal inflammation, resulting in the formation of scabs which 
 undergo putrefactive changes and lead to a sort of ozaena. Both 
 taste and smell are much diminished, partly from the unhealthy 
 state of the mucous membrane, and also from the absence of an 
 opposing surface against which the food can be triturated by the 
 tongue. The moral effect of this deformity, particularly when 
 associated with hare-lip, is such as to cause such patients to shun 
 publicity from a nervous feeling of self-consciousness. 
 
AFFECTIONS OF THE MOUTH, THROAT, AND (ESOPHAGUS 79;, 
 
 As to the best period at which to interfere by operation, con- 
 siderable divergence of opinion exists. Some surgeons advocate 
 its performance at as early a date as possible, and, in fact, it has 
 been undertaken when the child w y as but a few days old. The 
 success attending such practice has not been gratifying, since 
 infants have no moral control, and are much more likely to suck 
 at the stitches and interfere with them by the tongue, whilst the 
 buccal cavity is small, and the tissues so delicate and friable, 
 that the difficulty of the operation is much increased. On the 
 other hand, it should not 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. After an extended experience, it may be stated 
 that the operation is best undertaken between the second and the 
 third years, when a child can be easily kept under control. It is 
 most important that the general health be good, and the 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 under observation indoors for a few days before operating, 
 whilst for choice the spring or summer should be selected. If 
 the tonsils are enlarged, as is not uncommonly the case, it is by 
 no means necessary to remove them if no active inflammation is 
 present ; pharyngeal adenoids, moreover, may sometimes be left 
 with advantage, as they subsequently assist in shutting off the 
 nasal cavity during speech. 
 
 Operation. — The child should be placed on a suitable table 
 with a moveable headpiece, if possible, as it is often necessary to 
 alter the position of the head during the proceedings. The arms 
 are fixed to the sides by attaching them to a strap or bandage 
 passed round the thighs below the trochanters, but the patient 
 should not be tied down to the table, so that, although he cannot 
 raise the hands to the mouth during the partial anaesthesia which 
 is often present, yet he can be turned easily to either side so as 
 to allow blood to run from the mouth. Anaesthesia is induced in 
 the ordinary way by chloroform dropped upon the corner of a 
 towel. The greatest care must be taken not to drop chloroform 
 into the mouth, and for the same reason Junker's apparatus is 
 undesirable, on account of the chloroform vapour irritating the 
 edges of the cleft. The mouth is efficiently gagged open, and 
 preferably by means of a unilateral instrument, which can easily 
 be slipped in or out of position. 
 
 In a case involving both the soft and hard palate there is no 
 reason why the whole cleft should not be dealt with at one sitting. 
 When the inter-maxillary bone has been previously removed, and 
 a considerable gap left anteriorly, it is often only possible to 
 close the posterior two-thirds of the cleft, either dealing with the 
 anterior portion at a later date, or trusting to the application 
 of a suitable obturator, to which artificial incisors can also be 
 
794 
 
 A MANUAL OF SURGERY 
 
 attached. The proceeding usually employed is practically identical 
 with that introduced by Langenbeck, and known as uranoplasty. 
 For convenience it may be described in four stages : 
 
 Stage 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 incisor to preserve the vascular supply of the 
 front of the flap (Fig. 286). The muco-periosteum is divided 
 down to the bone, and by the use of a suitable raspatory the 
 
 Fig. 286. — Diagram to Indicate Extent of Incisions in Uranoplasty. 
 
 The thick black lines show the primary incision ; the thick dotted lines the 
 extension backwards of the same to relieve any 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 
 
 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 in dealing with the hinder part 
 to ensure its total detachment from the hamular process and 
 back of the bony palate, and yet not to damage it at this, its 
 weakest spot. This must be thoroughly carried out on either 
 side, the extent of the incisions being shown by the continuous 
 black lines in Fig. 286. Copious bleeding always accompanies 
 this stage of the operation, and the head should be turned on one 
 side and lowered, and the pharynx constantly sponged so as to 
 prevent the blood entering the air-passages. 
 
 Stage II. : Paring the Edges of the Cleft. — This is 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 
 
AFFECTIONS OF THE MOUTH, THROAT, AND OESOPHAGUS 795 
 
 removed, in one piece, if possible, on the side seized, and the same 
 process repeated on the other. The paring of the edges is pur- 
 posely 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 \V. 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. 287 A) ; as a rule, it is not necessary to hold the flap to effect 
 this. The loop of silk projecting from the cleft (Fig. 287 B) is now 
 grasped with smooth-nosed forceps and drawn out of the mouth, 
 
 Fig. 287. Fig. 288. Fig. 289. 
 
 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. 
 
 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. 287 C, D). One of these is loosely threaded through 
 the other (Fig. 288 E), and the latter gently withdrawn, carrying 
 with it the loop-end of the former (Fig. 288 F), and thus a double 
 thread is carried through both sides of the palate, a loop projecting 
 from one side, and the free ends from the other. This process is 
 commenced anteriorly and carried backwards until the base of 
 the uvula is reached, the stitches being inserted about half a 
 centimetre apart, so that nine or ten threads may be needed to 
 secure the whole palate. They are left loose, the ends being held 
 by the anaesthetist or assistant against the cheeks until all have 
 been inserted. A 6-inch length of fine well-annealed silver wire is 
 successively hooked over each loop (Fig. 289 G), drawn into posi- 
 
7y6 A MANUAL OF SURGERY 
 
 tion by the silk thread (Fig. 289 H), and tightened to a suitable 
 degree by a wire-twister, so that the pared edges of the cleft are 
 exactly apposed. This is best undertaken from before backwards. 
 Finally, the uvula is stitched with silk inserted by means of a 
 double-curved needle (Fig. 289 I); 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 to thoroughly 
 divide the levator palati (see the thick dotted lines in Fig. 286). 
 Occasionally the anterior and posterior pillars of the fauces, con- 
 taining respectively the palato-glossi and palato-pharyngei muscles, 
 will also need to be snipped across. 
 
 The child should now 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 given. 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. 
 
 In dealing with clefts of the soft palate alone, a modification of 
 the above operation may be performed, called staphylovraphy . 
 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 o f a voice- 
 trainer is absolutely 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. 
 
AFFECTIONS OF THE MOUTH, THROAT, AND CESOPHAGUS 797 
 
 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 apertures 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 sometimes 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 indiarubber bag filled with air, sewn 
 to the back of the obturator. They are complicated and difficult to keep in 
 order, and, to our minds, 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: (b) 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 destruction of tissue'; it is usually seen in children, 
 and often associated with a similar disease of the nose, from 
 which, indeed, it may have spread : (d) 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 epithelioma, 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 interferes with the closure of the naso- 
 pharynx by the velum during articulation. The treatment of these 
 conditions should follow the usual antisyphilitic course. Perfora- 
 tions are best remedied by the use of plate obturators. We have 
 seen out-patients make efficient 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 
 
798 A MANUAL OF SURGERY 
 
 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-periosteal 
 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 re- 
 moved. Caries is generally due to syphilis or tubercle. 
 
 The following tumours occur on the hard palate. Simple epulis 
 (p. 737) may extend from the alveolus, or an identical condition 
 may start in the middle line. An adenoma of the palatal glands 
 is occasionally 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 of 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 
 relaxed 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, resulting in a troublesome throat-cough and even vomit- 
 ing. 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-pointed 
 scissors, leaving about a third of an inch of the organ behind. 
 
 Affections of the Tonsils. 
 
 Acute Tonsillitis results either from cold, or from the inhalation 
 of impure air, especially when contaminated with 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 : 
 
 (a) Acute superficial tonsillitis, which consists of a slight super- 
 ficial inflammation, the result of cold, etc., in which the tonsil 
 participates with the pharynx and velum. There is but little 
 
AFFECTIONS OF THE MOUTH, THROAT, AND OESOPHAGUS 79; 
 
 swelling of the part, which, however, becomes red and painful, 
 rendering swallowing difficult. Ordinary anti-catarrhal remedies 
 are necessary, and a chlorate of potash gargle. 
 
 (b) Acute follicular tonsillitis is characterized by a general en- 
 largement of the organ, which is dusky red in colour and painful, 
 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 follicles, which may coagulate 
 on the surface and form a false membrane, distinguished from 
 that of diphtheria by its want of adhesion to the subjacent 
 tissue, being readily detached by a camel's-hair pencil. The 
 temperature is high, the glands below the angle of the jaw 
 enlarged and tender, the tongue covered with a thick whitish fur, 
 and the bowels confined. Such a condition may herald in an 
 attack of so-called blood-poisoning, or septicaemia. 
 
 (c) Acute parenchymatous tonsillitis, or quinsy, is a more diffuse 
 inflammation, which is not limited to the organ, but also involves 
 the soft palate and fauces. The swelling is more extensive, 
 the pain is greater, and suppuration frequently results. Other 
 symptoms are much the same as in the above. 
 
 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 tonsillitis. 
 From erysipelas of the fauces, it is known by the redness being 
 more concentrated, the oedema less marked and more limited, by 
 the glands at the angle of the jaw being less enlarged, and by the 
 absence of any external manifestation of the disease. 
 
 Treatment must always be commenced by a good calomel purge, 
 which mav be followed by the administration either of salicylate 
 of soda (20 grains, thrice daily), or of chlorate of potash and 
 sulphate of magnesia, to which a few drops of tincture of aconite 
 may be added if the constitutional symptoms are severe. The 
 patient will experience much relief by inhaling the steam from hot 
 water (150° F.), in which a little creasote or carbolic acid is dis- 
 solved, or the tonsils may be scarified. Suppuration is dealt with 
 by a free incision, the knife entering the most prominent part of the 
 swelling, and cutting backwards towards the middle line ; the close 
 proximity of the carotid should not, however, be forgotten. Hot 
 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. 
 
 Chronic Tonsillitis appears in two distinct forms : 
 
 (a) Chronic inflammatory tonsillitis occurs in children whose 
 tonsils, after one acute attack, remain enlarged, painful, con- 
 gested, and very liable to recurrence, which often runs on to 
 suppuration and ulceration. After a time the tonsils shrink back 
 and atrophy, becoming hard and fibroid. 
 
 (b) Chronic hypertrophic tonsillitis is met with in tuberculous 
 
Soo A MANUAL OF SURGERY 
 
 children, resulting from an overgrowth of the lymphoid tissue, 
 and is usually associated with the presence of adenoids in the 
 naso-pharynx. The tonsils are enlarged, pale in colour, and firm 
 in consistence ; the orifices of the crypts are very patent, and in 
 them are often seen plugs of mucous secretion, which may 
 become infiltrated with lime salts, forming concretions, which 
 however, are never of any great size. The patients are very 
 liaMe to recurrent attacks of inflammation, with or without 
 suppuration, and even cysts may form from the blocking of the 
 follicular ducts. When much enlarged, the tonsils may meet in 
 the middle line beneath the uvula, causing obstruction both to 
 swallowing and respiration. The patient usually breathes with 
 the mouth open, owing to the concurrent naso-pharyngeal obstruc- 
 tion, 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. 
 
 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. ferri per- 
 chloridi, or touched with the galvano-cautery, Failing this, ton- 
 sillotomy should be performed ; in children the organ may be cut 
 away as far back as possible, but in patients over the age of twenty 
 only a thin slice should be removed, and never the whole organ, 
 since there is much more risk of grave haemorrhage ; the galvano- 
 cautery is much better treatment in adults. It has also been 
 suggested that the voice is weakened by tonsillotomy, but this is 
 somewhat doubtful. 
 
 Tonsillotomy may be undertaken in two ways : 
 
 (a) By the guillotine. The fauces having been carefully and 
 repeatedly brushed 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. 
 The ring of the instrument is passed over the projecting organ, 
 external pressure behind the angle of the jaw assisting in this 
 manoeuvre. By the pressure of the thumb the projecting mass is 
 cut off by the sharp blade. In dealing with the right side, unless 
 the surgeon is ambidextrous, he had better stand behind the 
 patient's head, looking over into the mouth. 
 
 (b) By the bistoury. The tonsil is seized at its lowest point and 
 drawn well inwards by means of hooked forceps, and the pro- 
 jecting mass removed by a straight blunt-pointed 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 risk of wounding the internal carotid, which is in close 
 
AFFECTIONS OF THE MOUTH, THROAT, AND OESOPHAGUS Soi 
 
 contiguity to the outer surface of the gland. The surgeon must 
 stand behind the patient's head in dealing with the right side, and 
 in front when operating upon the left. 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. In children the 
 hypertrophic type of enlarged tonsil may be enucleated without 
 much difficulty by dividing the mucous membrane in front of it, 
 and shelling it out of its bed, the posterior reflexion of mucous 
 membrane being subsequently snipped through with bistoury or 
 scissors. 
 
 The haemorrhage, though brisk for the moment, soon ceases if 
 care is taken not to cut too deeply, or encroach upon the sur- 
 rounding mucous membrane. Should the bleeding continue, it 
 can generally be arrested by douching the face with iced water, 
 or by the local application of wool pledgets soaked in iced boric 
 acid lotion, or in tinct. ferri perchloridi ; possibly a gargle con- 
 taining hazeline may be efficacious in bad cases, or the galvano- 
 cautery may be applied. This is more likely to occur in adults 
 than in children. 
 
 Syphilitic Disease of the Tonsil is met with in various stages. 
 The primary chancre is seen occasionally, arising in one case we 
 know of through infection from a stick of caustic which had 
 been previously used to cauterize a syphilitic ulcer and insuf- 
 ficiently cleaned before being applied to the tonsil, the surface of 
 which was abraded. The glandular enlargement in the neck is 
 very marked in such cases, and the course of the disease usually 
 severe. Secondary ulcers of the ' snail-track ' type (plaques muqucuses) 
 are common in this region, being usually symmetrical. In the 
 tertiary period a diffuse gummatous infiltration occurs, involving also 
 the palate and fauces (p. 803), and leading to pharyngeal stenosis. 
 
 Tumours of the Tonsil are almost always malignant in type, but 
 are not very common. Epithelioma occurs as a firm indurated 
 infiltration rapidly spreading to adjacent parts, and involving the 
 lymphatic 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 runs 
 a rapidly fatal course if left to itself. Lymphosarcoma of the tonsil 
 arises in the organ itself, usually after middle life ; 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 infiltrates 
 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 
 
 5 1 
 
8o2 A MANUAL OF SURGERY 
 
 haemorrhage 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 some- 
 times with the utmost ease, and with very little haemorrhage. 
 Recurrence in the lymphatic glands is, however, almost certain 
 to follow, (b) From the neck. The best plan is to make an incision 
 along the anterior border of the sterno-mastoid, and carefully 
 dissect 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 surrounding structures and removed. A good many cases 
 have now been reported which were treated in this manner with 
 complete success, even when the tongue, palate, or pharynx were 
 invaded. It is occasionally necessary to make an incision from 
 the angle of the mouth backwards through the cheek ; the tonsil 
 is thus well exposed, and can be dealt with satisfactorily. The 
 patient should always be immunized to streptococcal infection 
 before the operation. 
 
 Affections of the Pharynx. 
 
 Acute Pharyngitis is usually associated with a similar inflam- 
 matory 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. 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 sneezing, 
 interference with nasal respiration, and great pain on swallowing, 
 are produced by this condition, and if it spreads to the Eustachian 
 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 relief is often given by 
 inhaling steam from water at 150 F. to which a little Friar's 
 balsam has been added. 
 
 Erysipelas of the Fauces and Palate has been already alluded to 
 
 (p. 96). 
 
 Chronic Pharyngitis is commonly met with in clergymen and 
 
AFFECTIONS OF THE MOUTH, THROAT, AND OESOPHAGUS 803 
 
 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 Luschhas tonsil (vide Adenoids, p. 767). The uvula 
 may be also elongated and hypertrophic in this condition. 
 
 2. Chronic Atrophic Pharyngitis is usually associated with the 
 atrophic form of rhinitis sicca (p. 759), and possibly with chronic 
 laryngitis. The mucous membrane is smooth, dry, and glazed, 
 and the exudation forms adherent scabs. The throat feels dry 
 and irritable, and the voice is often husky. 
 
 The Treatment of chronic pharyngitis varies with the condition 
 and character of the affection. If of a simple type (' relaxed 
 throat '), all sources of irritation — such as smoking, spirits, and 
 condiments — must be avoided, the bowels and digestion attended 
 to, and astringent sprays, gargles or applications made use of, care 
 being taken when necessary to apply these to the naso-pharynx 
 by passing the brush up behind the soft palate. The most useful 
 reagents to employ are the glycerine of tannic acid, equal parts 
 of glycerine and tinct. ferri perchloridi, whilst chloride of am- 
 monium inhalations are sometimes valuable, as also sprays of 
 menthol dissolved in paroleine. 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. In the 
 dry form of pharyngitis, inhalations of chloride of ammonium are 
 recommended, or chloride of ammonium lozenges ; the nasal con- 
 dition, however, is that which most needs treatment. 
 
 Syphilitic Affections of the Pharynx may be met with in the 
 secondary or tertiary stages. In the former they are of a super- 
 ficial character, such as mucous tubercles, snail-track ulcers, etc. ; 
 in the latter they appear in the shape of a dip/use gummatous 
 infiltration, which is often of considerable consequence, both at 
 the time an J subsequently. It manifests itself as a widespread 
 
 5 1 — 2 
 
8o 4 A MANUAL OF SURGERY 
 
 nodular thickening 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 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 septum, 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 un- 
 frequently 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 ; lym- 
 phatic glands become secondarily affected, and the tumour gradu- 
 ally invades surrounding tissues, although it is interesting to note 
 that for some time it is limited to the mucous membrane, extending 
 superficially 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 go to prove that if the operation 
 involves removal of portions of the upper or lower jaw, a fatal 
 issue is likely to follow. The same precautions as to cleansing 
 the teeth, immunization to streptococcal infection, 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, splitting 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 pharyngotomy is a useful means of approach 
 in some of these cases (p. 844). 
 
AFFECTIONS OF THE MOUTH, THROAT, AND OESOPHAGUS 805 
 
 Retro -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 chronic variety generally follows 
 tuberculous caries of the spine, or disease of the bones at the base 
 of the skull. 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 superven- 
 tion of oedema of the glottis. The abscess should be opened from 
 the neck in all cases, 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 posterior 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 
 vertebrae by the right hand. A drain-tube is then inserted, and 
 the case runs an ordinary aseptic course. 
 
 Affections of the (Esophagus. 
 
 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 conditions, and the children die shortly after birth. Con- 
 genital 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 
 development of the so-called Diverticula. Two forms have been 
 described by Zenker : (a) Pressure Diverticula, which are the more 
 common, and seem to be associated with some congenital weak- 
 ness 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. 
 
So6 A MANUAL OF SURGERY 
 
 They usually spring from the posterior wall, close to the junction 
 of the pharynx and oesophagus, constituting sometimes what is 
 known as a ' pharyngocoele ' ; the cavity extends downwards 
 between the oesophagus and vertebral column. The symptoms are 
 due to distension of the cavity with food which stagnates and 
 putrifies, 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. Treatment, where 
 possible, consists in exposing the diverticulum in the neck, 
 removing it, and stitching up the opening in the pharyngeal or 
 oesophageal wall, (b) 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. 
 
 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. Impaction lower down is likely to be 
 followed by ulceration, perforation, and death, either from haemor- 
 rhage owing to one of the large vessels being opened, or from 
 suppurative cellulitis. In some cases, however (Konig states 
 about 50 per cent.), the foreign body spontaneously passes either 
 into the mouth or stomach. 
 
 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. 290), being caught in the loops of 
 thick horsehair forming part of the apparatus. If a coin or small 
 hard 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 sometimes be pushed down into the stomach. A large bolus 
 of food may be removed by forceps from the upper part of the 
 oesophagus, and large foreign bodies— e.g., plates of teeth — may 
 be similarly extracted, though great care must be taken not to 
 tear the mucous membrane. Skiagraphy is now employed to 
 
AFFECTIONS OF THE MOUTH, THROAT, AND OESOPHAGUS 807 
 
 assist in the localization of metallic substances such as coins, as 
 also to determine whether or not they have been dislodged, whilst 
 removal may be much expedited by the use of the cryptoscope. 
 
 If impacted in the upper part, asophagotomy may be performed. 
 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 platysma and deep 
 fascia are divided, and the muscle drawn outwards ; the omo-hyoid 
 needs division, and the surgeon then carefully works 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 situation of 
 the tube, and this is carefully 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 stuffed with gauze plugs or drained. When 
 
 Fig. 290. — Expanding Probang for the Removal of Foreign Bodies 
 from the cesophagus. 
 
 located in the upper part of the thoracic portion of the oesophagus 
 the tube is opened as low as possible by cutting down on the point 
 of a bougie passed from the mouth, and then it is often possible to 
 extricate it. 
 
 When the foreign body is impacted 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, 
 purgatives 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 
 motions are carefully examined. Should, however, the foreign 
 body be large, and the gastric symptoms persist, it should be re- 
 moved by gastrotomy. 
 
 Inflammation of 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 and difficulty in deglutition, and the treatment consists 
 in the restriction of the diet to liquids, whilst in bad cases rectal 
 feeding may be necessary. Chronic catarrh results from the 
 
SoS 
 
 A MANUAL OF SURGERY 
 
 continual drinking of raw spirits, and stenosis from cicatricial 
 contraction may gradually follow. 
 
 Varix of the veins in the lower portion of the oesophagus is 
 occasionally 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 slight abrasion or ulceration of the mucous 
 membrane, perhaps originated by the impaction at an earlier 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 purga- 
 tives, valerian, etc.), whilst the 
 passage of a full-sized oeso- 
 phageal bougie is useful. 
 
 Organic Stricture of the (Eso- 
 phagus occurs in two forms — - 
 the fibrous and the malignant : 
 
 i. Fibrous Stricture of the 
 (Esophagus is usually located 
 near its commencement, just 
 behind the cricoid cartilage, 
 and is most frequently 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 increasing difficulty in the swal- 
 lowing, 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 
 
 Fig. 291. — Cancerous Growth of 
 the (Esophagus. (Treves' Sur- 
 gery.) 
 
AFFECTIONS OF THE MOUTH, THROAT, AND OESOPHAGUS 809 
 
 become dilated, and in this pouch or cesophagocoele 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 pro- 
 gresses, he becomes steadily emaciated from sheer starvation, and 
 may even die from this cause. 
 
 2. Malignant Stricture of the Oesophagus is usually epithelio- 
 matous 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. 291), 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 carci- 
 noma 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 glands, either 
 of the neck or posterior mediastinum, visceral complications 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 usually 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, 
 although the side-to-side movements of the larynx may be im- 
 peded. 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 be 
 involved in the mass, leading to interference with the action of the 
 heart, whilst implication of the recurrent laryngeal nerve causes 
 constant cough and uni- or bi-lateral paralysis of the larynx. 
 
 The Diagnosis of oesophageal stricture must be made on general 
 principles, and by a process of exclusion of the many other forms 
 of dysphagia detailed below. It is confirmed by examining the con- 
 dition of the tube with an oesophageal bougie. A conical-ended 
 instrument of medium size should be employed for diagnostic 
 purposes, and by this means the situation of the obstruction can 
 be ascertained. 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 forwards — if thrown backwards, the larynx is 
 pressed against the spine, and the difficulty of introducing the 
 instrument increased. The bougie is well warmed and smeared 
 with glycerine, and, having been suitably curved, is guided by the 
 surgeon's left index- finger over the 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 
 
A MANUAL OF SURGERY 
 
 the larynx, the bougie is pushed steadily onwards ; if there is no 
 stricture, the instrument will enter the stomach about 16 inches 
 from the teeth. If any obstruction is present, the large instru- 
 ment is withdrawn, and the passage of a smaller one attempted. 
 The greatest care must be taken, especially in suspected malignant 
 disease, as it is by no means difficult to perforate the walls and 
 open up the mediastinal tissues, even causing 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, and the history of the 
 case and general condition of the patient will need to be thoroughly 
 investigated; a hacking cough with no special pulmonary symptoms 
 is always a bad and suggestive sign. 
 
 Treatment of Fibrous Stricture of the (Esophagus. — (a) Dilatation 
 of the stricture by means of gradually increasing bougies ; for 
 this purpose it is better to use conical-ended instruments rather 
 than the usual type, which are of the same calibre throughout. 
 An interval of some days should elapse between the attempts 
 at 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 Symond's Tube may be inserted. It consists of 
 a gum-elastic, funnel-shaped tube, passed through the stricture 
 by a whalebone introducer, the funnel resting against the face 
 of the stricture. A thread attached to the upper end is brought 
 out of the mouth in order to remove and clean it, a proceeding 
 needed about once a fortnight, (c) Internal cesophagotomy by means 
 of a concealed knife has also been attempted, the stricture being 
 divided posteriorly ; it is a somewhat risky proceeding, and is only 
 feasible when the lesion is situated high up in the tube, (d) When 
 the contraction is at the pharyngeal extremity, it may be possible 
 to open the oesophagus below, and either divide and dilate the 
 stenosed portion, or ecsophagostomy may be performed by sewing 
 the mucous membrane to the skin, thus forming an entrance 
 to the alimentary canal in the neck. Under these circum- 
 stances, it is better practice to completely divide the oesophagus, 
 closing the upper end by sutures, and fixing the lower end to the 
 margin of the wound, (e) 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 dilata- 
 tion), a proceeding similar to Loreta's operation for stricture of 
 the pylorus. (/) Where none of these proceedings are possible, 
 or if tried have failed, the stomach may be opened, and division 
 of the sticture by Abbe's string saw 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 
 
AFFECTIONS OF THE MOUTH, THROAT, AND CESOPHAGUS Sn 
 
 is secured, and by its 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. 
 (g) Gastrostomy 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 prac- 
 ticable. In such a case the opening in the stomach may be 
 allowed to close. 
 
 Treatment of Malignant Disease of the (Esophagus. — Dilatation 
 by bougies should not be employed as a routine practice, for fear 
 of increasing the ulceration, causing severe haemorrhage, or per- 
 forating the walls of the tube. It may, however, be used as a 
 temporary measure in the earlier stages to enable the patient to 
 take an increased amount of food, and thus for a time improve his 
 general condition and render him more fitted to undergo further 
 treatment. Symonds' method of tubage may be utilized in malig- 
 nant 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. Unfortunately these tubes occa- 
 sionally slip through into the stomach, or the guiding string is 
 swallowed ; moreover, under the best circumstances the tube needs 
 changing every fortnight, and the ulceration may be increased 
 thereby. Hence gastrostomy, performed as soon as possible by one 
 of the modern methods, is a much more satisfactory plan of treat- 
 ment. Excision of the growth in the neck has been successfully 
 accomplished in a few cases when the disease was recognised early, 
 and very limited in extent. Tracheotomy is occasionally required 
 in the later stages, from implication of the glottis or trachea. 
 
 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 : 
 
 i. Pharyngeal — e.g., acute or chronic inflammation, whether simple, scarlatinal, 
 diphtheritic, etc. ; ulceration of syphilitic or malignant origin ; stenosis, as a 
 result of ulceration ; paralysis (eg., labio-glosso-laryngeal or bulbar) or spasm ; 
 impaction of foreign bodies ; naso-pharyngeal polypi projecting behind the 
 velum ; retro-pharyngeal abscess or tumour, etc. 
 
 ii. Laryngeal — eg., acute or chronic laryngitis; tuberculous, syphilitic, or 
 malignant disease. 
 
 iii. (Esophageal —e.g., acute or chronic inflammation, impaction of foreign 
 bodies, the presence of diverticula, cesophagospasm, and simple or malignant 
 stricture. 
 
 iv. Extrinsic. In the neck : goitie, 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 displace- 
 ment backwards of the sternal end of the clavicle. 
 
 To investigate a ease of dysphagia, note : (i.) the method of onset, whether acute 
 or chronic — if the former, it is probably due to a foreign body ; (ii.) the condition 
 of the pharynx as seen from the mouth and on digital exploration ; (iii.) 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 ; (iv. ) the 
 character of the voice, as indicative or not of larvngeal mischief — if the voice 
 
812 A MANUAL OF SURGERY 
 
 is husky, a laryngoscopic examination must be made; (v.) the chest must be 
 carefully examined for aneurisms, etc. ; (vi.) the oesophagus may be auscultated 
 along the vertebral groove whilst the patient drinks water to ascertain the 
 situation of the mischief; (vii.) it must be examined finally by bougies. 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 forgotton 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 in the material vomited, and the existence of enlarged glands in 
 the neck, will also assist in establishing a diagnosis. 
 
CHAPTER XXVIII. 
 
 AFFECTIONS OF THE EAR. 
 
 It is impossible to do more than deal with some of the more 
 important surgical aspects of diseases of the ear in this place, and 
 for a more detailed consideration of the subject we must refer our 
 readers to special text-books. 
 
 The External Ear is the site of various affections which may 
 come under the observation of the general surgeon. Thus, the 
 pinna may be congenitally absent, and even the external meatus 
 closed, a malformation often associated with macrostoma. 
 Nothing can be done for this want of development, and the 
 surgeon must never be tempted to try and dig out the concealed 
 membrana tympani. More frequently accessory auricles are pre- 
 sent, consisting merely of fibro-cartilage covered with fat and skin. 
 Large and prominent ears constitute a very unsightly deformity, 
 for 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 appearance results. Haematoma 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 traumatic cases 
 (Fig. 292) ; unless inflamed it should not be interfered with, as a 
 general rule, although, if the appearance of the patient is important, 
 it may be advisable to remove the blood, since its organization 
 and subsequent contraction may lead to considerable deformity. 
 Eczema, boils, and other inflammatory affections, are met with in 
 the external ear and pinna, but these call for no special mention. 
 
 Plugs of wax (cerumen), which become dark and indurated, not 
 unfrequently block the meatus, leading to more or less complete 
 deafness ; this may come on suddenly after bathing, owing to the 
 plug rapidly swelling up. If they encroach on the membrana 
 tympani, subjective symptoms of giddiness, vomiting, and rushing 
 noises in the ear may also be caused. On examination with an 
 
8i 4 
 
 A MAN (LI I, OF SURGERY 
 
 Fig. 292. — Hematoma Auris. 
 
 ear speculum, their presence is readily detected. Treatment con- 
 sists in washing them away, after previously softening with oil or 
 
 glycerine. A large syringe with a 
 fine nozzle should be used, and a 
 stream of warm water injected along 
 the roof of the meatus ; as it returns, 
 the softened masses of wax are 
 washed away. Foreign bodies in the 
 meatus, such as buttons or beads, 
 are similarly removed, if possible, 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 im- 
 patience 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. 
 
 The Surgical Complications of Chronic Otorrhcea are frequently 
 serious, and call for prompt treatment. The discharge usually 
 comes from the middle ear (otitis media) through a perforation in 
 the tympanic membrane. It must be noted that the tympanic 
 cavity is lined by a mucous membrane which is in direct communi- 
 cation through the Eustachian tube with that lining the nasal 
 fossae ; and since this membrane is adherent to the periosteal 
 lining of the cavity, every case of otitis media is likely to be 
 associated with an internal periostitis of the temporal bone. These 
 complications may be classified under three main headings — the 
 extracranial, the cranial, and the intracranial. 
 
 The extracranial complications of otorrhcea are comparatively 
 unimportant. 
 
 (a) Eczema of the meatus is frequently seen, and merely needs 
 the parts to be kept dry and clean, and possibly a little boric 
 acid powder insufflated ; it readily disappears when the discharge 
 ceases, but is not unfrequently associated with enlargement of the 
 cervical glands, which may suppurate, or in predisposed indi- 
 viduals may become the seat of tuberculous disease. 
 
 (b) Boils arise from infection of the sebaceous glands in the 
 meatus with pyogenic cocci from the discharge, and are exceed- 
 ingly painful owing to the denseness of the tissues involved. 
 They should be fomented, and opened when pus has formed. 
 
AFFECTIONS OF THE EAR Si 
 
 (c) Inflammation may occasionally spread from the meatus to 
 the tympanic plate of the temporal bone, leading to subperios- 
 teal abscess and necrosis ; or it may extend into the temporo- 
 maxillary articulation, giving rise to suppurative arthritis and 
 disorganization of that joint (p. 750). 
 
 The cranial complications of otitis media are often of a grave 
 nature, and may end in permanent deafness, or even endanger 
 the life of the individual. 
 
 (a) The ossicles frequently necrose, and are cast off in the 
 discharge, and thus hearing may be impaired, although not 
 necessarily destroyed ; ankylosis of the ossicles one to another 
 may also be determined, leading to considerable loss of function. 
 
 (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 
 associated with suppuration within the skull, and any of the 
 intracranial complications mentioned below. The roof of the 
 tympanic cavity (tegmen 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 prevented by the regular use of Politzer's bag. 
 
 (r) Polypi may also develop, consisting essentially of granulation 
 tissue protruding through the opening in the membrane ; they 
 lead to considerable obstruction, and may do harm by keeping 
 back the discharge. They should be removed by the curette, 
 and the bare bone, usually felt at their base, scraped ; the 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 nerve in that region. It must 
 be remembered that the bony canal lies immediately behind the 
 tympanic cavity, and to the inner side of the passage from the 
 attic to the mastoid antrum (iter ad antrum). All the muscles on 
 that side of the face are involved, and possibly also the palate and 
 uvula. No radical treatment is practicable, although the face 
 should be regularly faradized, so as to maintain as far as possible 
 the tone of the muscles. 
 
 (e) 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 rela- 
 tively of large size communicates with the posterior portion of 
 the tympanic cavity and represents the antrum ; but after puberty 
 the whole bone becomes hollowed out into a series of spongy 
 
8i6 A MANUAL OF SURGERY 
 
 cells, lined with mucous membrane, which open into the floor 
 of the antrum. When the inflammation in otitis media, which has 
 almost always become septic, extends into this bony process, 
 severe local and general symptoms are likely to result. The 
 patient complains of intense pain in the ear, with tenderness on 
 pressure, and perhaps redness and oedema over the mastoid 
 process. The discharge from the ear often ceases for a time at 
 the commencement of these symptoms, but reappears later on. 
 As the case progresses, febrile symptoms of an 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 an abscess has developed, the auricle is characteristically 
 displaced downwards and outwards. Any of the intracranial 
 complications mentioned below may occur as sequelae. Occa- 
 sionally the mastoid trouble is of a more chronic type, and even 
 tuberculous in nature, the cells being choked up with lymph and 
 inflammatory material of a cheesy nature, whilst the bone itself 
 becomes thickened and condensed. The process feels distinctly 
 enlarged, and a good deal of deep-seated pain of an aching 
 character is experienced, 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 is often 
 the cause of great distension of the antrum, which in a case 
 operated on by one of us measured quite i| inches across. The 
 symptoms, at first of a chronic type, are likely to be followed 
 sooner or later by an acute attack of septic 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 ; accu- 
 mulated discharge 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 palliative measures for too long, 
 but when the symptoms are well marked, even in the early stages, 
 and before suppuration has occurred, it is good practice to make 
 an incision (Wilde's incision) down to the bone, reaching from the 
 base to the apex of the process ; much relief is always obtained 
 by this procedure, and the inflammatory phenomena are some- 
 times completely checked. Should this not succeed, the mastoid 
 antrum must be laid open and its contents evacuated (Schwartze's 
 operation). Many instruments have been suggested in order to 
 
AFFECTIONS OF THE EAR Si 7 
 
 accomplish this ; thus, it has been recommended to use the brad- 
 awl, trephine, gouge, or gimlet ; the gouge is, however, probably 
 the best, if a burr worked by a surgical engine is not obtainable. 
 A curved incision is made immediately behind the ear, which is 
 drawn well forwards (Fig. 293), and the gouge applied on a level 
 with the roof of the external auditory meatus, and about -| inch 
 behind its centre (Fig. 294). A small dimple in the bone can 
 often be felt at the required spot, which can also be found by 
 taking the point of junction of two lines drawn as tangents to 
 the roof and posterior wall of the bony meatus respectively 
 (Fig. 295, 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 boring being made exactly parallel to this. In an 
 
 t'-^^ja^ 
 
 Fig. 293. — Incision for Mastoid Fig. 294 .—Site for Drilling Bone 
 Operations. in order to open the Mastoid 
 
 Antrum. 
 
 It is often well to apply the chisel as indicated here 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. 
 
 adult the mastoid antrum is reached about three-fifths of an inch 
 from the surface of the bone. The surgeon recognizes that he 
 has opened the cavity by the loss of resistance, and the escape 
 of exceedingly offensive pus. The opening is then freely enlarged 
 by the use of the gouge and cutting pliers, and the cavity syringed 
 out through the external meatus. Diseased bone in the mastoid 
 process or around the tympanic cavity may be scraped away, and 
 the wound plugged with antiseptic gauze ; it should be syringed 
 through from the external meatus daily. In the more chronic 
 cases it may be advisable to split off the whole of the outer 
 coating of bone from the mastoid process, so as to lay open all the 
 cells, which will often be found filled with inspissated pus. 
 
 In the more severe forms it is recommended to detach the 
 auricle posteriorly from the bony margins of the meatus, and 
 then to gouge away the whole of the osseous tissue intervening 
 
 52 
 
8i8 A MANUAL OF SURGERY 
 
 between the meatus and tympanic cavity in front and the mastoid 
 antrum behind. A metal guide is passed from the opening in the 
 antrum into the attic along the iter, and all the bone in front of 
 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 membrane and the ossicles are then removed, 
 and the whole cavity well curetted. The deep portion of the 
 posterior wall of the cartilaginous 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 cleaned 
 more efficiently (Stacke's operation). The results of this proceeding 
 have been very satisfactory, but the proximity of the facial nerve 
 must never be forgotten, and the anaesthetist should be instructed 
 to watch the face continuously for any twitching, which indicates 
 that the nerve is being touched, inasmuch as the surgeon is 
 working at the side, and cannot see. 
 
 The intracranial complications of otorrhcea are subcranial 
 abscess, localized or diffuse meningitis, thrombosis of the lateral 
 sinus, and abscess in the cerebrum or cerebellum. 
 
 (a) Subcranial Abscess. — When the roof of the tympanum or 
 any part of the lining of that cavity which encroaches on the 
 cranium becomes inflamed or carious, suppuration between the 
 skull and dura mater may ensue. The membranes are gradually 
 stripped from the bone by the increasing pressure of the exuda- 
 tion, and symptoms of cerebral compression and irritation are 
 thereby induced. Accumulations of pus occur most commonly 
 along the summit of the petrous portion of the temporal bone, 
 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 usually raised, but rigors, even if 
 present at first, are by no means a constant feature of the case. 
 The pulse is of the usual febrile type, viz., full and 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 symptom. Optic neuritis may be 
 observed in consequence of the inflammation extending to the 
 membranes at the base of the brain. There may be some tender- 
 ness on pressure over the temporal region, and even 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 (See also p. 690.) 
 
 The Diagnosis from cerebral abscess is sometimes a matter of 
 considerable difficulty. The symptoms, however, set in some- 
 what more acutely, whilst the temperature is raised, and the signs 
 of irritation of the membranes, such as retraction of the neck, all 
 
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820 A MANUAL OF SURGERY 
 
 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. 
 
 The 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 days. 
 
 (b) Meningitis may 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 
 disappears when the originating disease has been cured. The 
 diffuse variety is generally septic in nature, and secondary to some 
 suppurative affection in the neighbourhood, or to thrombosis of 
 the lateral sinus. For symptoms, see p. 691. Occasionally a 
 simple serous effusion occurs within the meninges, leading to 
 increased pressure and consequent drowsiness, but disappearing 
 entirely when the cause has been removed. 
 
 (c) Thrombosis of the Lateral Sinus arises from direct extension 
 of the inflammatory process from the middle ear through the 
 mastoid bone, or it may be set up by a septic thrombosis of the 
 mastoid emissary vein spreading to the sinus. A clot forms 
 within it, which, gradually increasing in size, leads finally to 
 occlusion of its lumen. Infection with pyogenic organisms deter- 
 mines disintegration of the clot, septic emboli are detached, and 
 thus pyaemic symptoms originated. In well-marked cases the 
 thrombus extends as far back as the Torcular Herophili, and 
 downwards along the jugular vein into the neck. 
 
 The most marked Symptom of the case is the sudden appear- 
 ance 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 
 slow and easily compressible, and in the later stages the patient 
 is drowsy and dull, probably from serous exudation within the 
 meninges. The discharge from the ear, which may have been 
 previously offensive, usually ceases. Optic neuritis may or may 
 not exist, being often preceded by photophobia. If the 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. Stiffness of 
 the muscles at the back of the neck is an evidence of a certain 
 amount 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 cedematous. 
 
 In well-marked cases the Diagnosis is easily made, but in the 
 early stages, and especially in children, it is often a matter of 
 some difficulty. The abrupt onset, the oscillating temperature, 
 the recurrent rigors, the pain in the neck, and the deep tenderness 
 
AFFECTIONS OF THE EAtf 821 
 
 on pressure over the course of the lateral sinus or jugular vein, 
 are the most trustworthy signs of this affection. 
 
 Treatment, to be successful, should be undertaken early. The 
 skull is trephined at a spot about j inch above Reid's base line, 
 and about 1 inch behind the centre of the external auditory meatus 
 (Fig. 295, A or B). The outer wall of the sinus is thereby 
 exposed, and a puncture with a fine needle readily determines 
 whether it 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. The 
 lateral sinus is now freely opened, and the septic thrombus partly 
 scraped, partly washed away, additional bone being removed if 
 necessary. It is desirable, but not essential, to completely remove 
 the lower part of the thrombus ; if such is attempted, the jugular 
 must be opened above the ligature, and the clot syringed away. 
 Bleeding occurs from the posterior part of the upper opening as 
 soon as all the coagulum is removed, but it is easily controlled by 
 plugging the sinus with a small piece of aseptic sponge or gauze. 
 The wound in the neck should be lightly stuffed and not closed, 
 since septic infection is 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 complication not 
 unfrequently met with, has been already discussed (p. 718). 
 
CHAPTER XXIX. 
 
 SURGERY OF THE NECK. 
 
 Affections of the Neck. 
 
 Affections connected with the Branchial Clefts. — In the second or third week 
 of intra-uterine life a series of branchial 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 bene 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 tracts 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. 
 
 Branchial Cysts arise from incomplete closure of a branchial cleft, the 
 unobliterated portion being distended with secretion. They usually appear in 
 adolescents, often between the ages of ten and twenty, and are frequently 
 attributed to a blow, which, it may be presumed, brings into activity struc- 
 tures which would otherwise have remained passive. They grow slowly and 
 painlessly, forming rounded swellings, 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 
 
SURGERY OF THE NECK 823 
 
 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 epithelium, 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 tending to spread up towards 
 the styloid process ; it may even reach from the mastoid process to the hyoid 
 bone, running parallel to the posterior border of the jaw, and fluctuation may 
 be detected through the mouth. Treatment consists in extirpation when the 
 condition has attained sufficient size to be troublesome. 
 
 Branchial Carcinoma. — Considerable doubt has been expressed as to whether 
 it is possible for carcinoma to originate in the 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 
 tc 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 experi- 
 enced, and lymphatic glands become secondarily enlarged. The disease runs 
 its ordinary course, but may destroy life through haemorrhage from the main 
 vessels, which are invaded by the tumour. The cyst sometimes gives way 
 into the pharynx, and a malignant ulcer of the pharyngeal wall is thus 
 induced. Pathologically, the condition is an interesting one, since the tumour 
 does not always possess the characters of an epithelioma. Its embryonic origin 
 is sometimes indicated by the fact that myxomatous and cartilaginous tissue is 
 included in its substance.* Treatment is usually impracticable owing to the 
 deep connections of the growth. 
 
 Various other congenital conditions may be met with in the neck. Con- 
 genital induration of the sterno-mastoid in all probability arises from injury 
 during parturition, and usually occurs in head presentations, probably from 
 bruising of the side of the neck against the under surface of the symphysis ; 
 it is said to be more common on the left side than on the right. In cases 
 that have been examined microscopically, the indurated mass has been found 
 to consist of fibrous tissue. It disappears spontaneously after a time, but 
 may lead to torticollis at a later date. The congenital form of torticollis 
 (P- 378)i cysts in connection with the thyro-glossal duct, and cystic hygroma, 
 may also be mentioned. 
 
 Cysts of the Neck. 
 
 1. Cysts of Congenital Origin. — (a) Dermoids occur here as in 
 any other region where congenital remains are found. As already 
 mentioned, they may develop from the branchial clefts, but may 
 also be found in the middle line, or in connection with the thyro- 
 glossal duct, (b) The thyro-glossal duct (Fig. 296) consists of a 
 tubular outgrowth from the embryonic 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 subsequently developed from it, and unites with the lateral 
 lobes, which in turn spring from the deeper parts of the branchial 
 * For pathological report of a case see Veau, Revue tie Chirurgie, March, 1900. 
 
824 A MANUAL OF SURGERY 
 
 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 represented by the pyramid of the thyroid 
 isthmus. The whole of this tube disappears under ordinary 
 circumstances ; if, however, the upper part remains unobliterated 
 a dermoid cyst may originate from it, placed either in the sub- 
 stance of the tongue or immediately below it (see p. 784). If the 
 lower portion remains patent, a cyst develops containing mucoid 
 
 Fig. 296. — Median Section of Tongue, Larynx, and Trachea, showing 
 Thyro-glossal Duct extending from the Foramen C/ecum of the 
 Tongue downwards behind the Hyoid Bone, and in Front of the 
 Trachea to the Isthmus of the Thyroid Body. (Semi-diagram- 
 matic, from College of Surgeons' Museum.) 
 
 A small dermoid cyst in the centre of the tongue is also represented. 
 
 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 adenomatous 
 nature may develop from any part of the duct, but especially from 
 the lower end ; they are quite innocent in nature, and unless 
 troublesome may be left alone, (c) Cystic hygroma is sometimes 
 congenital, but may also be acquired. It consists of a multi- 
 locular swelling, the spaces composing it being due to dilatation 
 of lymphatic spaces, and filled with serum. The tumour is often 
 
SURGERY OF THE NECK 825 
 
 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. 
 
 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 pomura Adami, and this may become enlarged and 
 distended with fluid. A bursa also exists between the back of 
 the hyoid bone and the thyroid cartilage, which might easily be 
 mistaken for one of thyro-glossal origin. In doubtful cases a 
 microscopical examination of the lining wall will quickly settle 
 the diagnosis, since if it is bursal in origin it is lined with endo- 
 thelium, whilst if it is thyro-glossal it is lined with epithelium. 
 In the former case incision and drainage usually suffice to bring 
 about a cure, although excision is preferable ; in the latter case 
 the lining wall must be entirely removed, (c) Unilocular serous 
 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 (see p. 187). (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. 
 In the former case they may be treated by excision, securing the 
 vessels with which they communicate above and below ; in the 
 latter tapping and injection of perchloride of iron may suffice, 
 or they may be opened and stuffed. (/) Cysts are also occa- 
 sionally met with in connection with the salivary glands and the 
 thyroid body, (g) Malignant cysts arise, as already mentioned, 
 from the remains of the branchial clefts, or from a degeneration 
 of epitheliomatous lymphatic glands. They are often of large 
 size, and their removal is impracticable owing to the adhesions 
 which they contract to the deeper structures. 
 
 Cut Throat. 
 
 Injuries of the neck are commonly met with in cases of attempted 
 homicide or suicide, and vary much in severity according to the 
 extent and position of the wound. A right-handed suicide usually 
 cuts his throat from left to right, and therefore the incision is bold 
 
826 A MANUAL OF SURGERY 
 
 and clean on the left side, tailing off towards the right ; in a left- 
 handed suicide the incision runs in the opposite direction. A 
 homicidal cut throat varies in its direction according to whether 
 it is done from behind or in front, and also with the hand 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 
 haemorrhage is very liable to ensue. The course and treatment 
 of the latter class of case require no particular notice, since the 
 general principles relating to all wounds must be adhered to. 
 Where, however, the air-passages have been opened, special 
 complications arise, requiring suitably modified treatment. 
 
 Wounds involving the Air-passages, the result of cut throat, may 
 be situated at four different levels : (a) above the hyoid bone, 
 encroaching on the base of the tongue ; (b) through the thyro- 
 hyoid space, the most common situation; (c) in the larynx; and 
 (d) opening or dividing the trachea. 
 
 The immediate effects of such lesions are due to shock, haemor- 
 rhage, asphyxia, or the entrance of air into veins. When above the 
 hyoid bone, the root of the tongue and submaxillary region are 
 involved, and haemorrhage from the lingual or facial arteries or 
 their branches follows ; if the wound extends far enough, the 
 main vessels are divided, and death results. In the less severe 
 cases the patient runs considerable risk of being suffocated by the 
 epiglottis and base of the tongue falling back over the larynx. 
 Much difficulty will be subsequently experienced in feeding the 
 patient, owing to impairment of the movements of the tongue. 
 When the thyvo-hyoid space is opened, the origins of the facial and 
 lingual arteries are again in danger, as also the upper part of the 
 superior thyroid. The base of the epiglottis is divided, and 
 portions of mucous membrane around the entrance of the larynx 
 may be detached, and cause obstruction to respiration. Blood 
 may also trickle down the larynx into the trachea, and lead to 
 asphyxia. Wounds of the larynx are usually transverse, and not 
 very extensive, owing to the resistance offered to the knife by the 
 cartilage. The thyroid body may be wounded and bleed freely, 
 otherwise there is but little haemorrhage. Blood may find its 
 way into the trachea or lungs, and asphyxiate the patient. W T hen 
 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 displace- 
 ment 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 inflam- 
 matory in origin, (a) Any form of septic inflammation may occur 
 
SURGERY OF THE NECK 827 
 
 in the wound, possibly giving rise to cellulitis, which may spread 
 downwards to the mediastinum. Where it involves the tissues 
 above the entrance to the larynx, oedema of the glottis may be 
 produced. Secondary haemorrhage also arises from this cause, 
 and even general pyaemia, (b) Inflammation of the air-passages, 
 tracheitis, bronchitis, or broncho-pheumonia, frequently follows, 
 partly as a result of the entrance of cold air, partly from the 
 admission of septic material, such as food, decomposing blood- 
 clot or discharges. The patient may become cyanosed from these 
 causes, and in consequence of this partial asphyxia, the sensibility 
 of the mucous membrane of the glottis is diminished, allowing of 
 the passage into it of food which appears at the mouth of the 
 wound ; in some cases this may have arisen from division of the 
 superior laryngeal nerve, but the depth at which this structure is 
 situated in the neck makes it difficult to conceive how it could be 
 divided without injury to the main vessels, (c) Surgical emphysema, 
 or the entrance of 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, (d) Septic traumatic fever is almost always present 
 in these cases, the temperature varying with the extent of the 
 inflammation in the cellular tissue or in the lungs. 
 
 The Treatment consists in securing all bleeding-points, if pos- 
 sible, but occasionally they are placed so deeply that it is neces- 
 sary to tie the external carotid. General oozing from the surface 
 must be attended to, for fear of blood being sucked into the air- 
 passages ; if it persists after thoroughly opening the wound and 
 exposing it to the cold air, it must be checked by sponge pressure. 
 Every attempt should be made to render the wound aseptic, and 
 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 ; in some cases where 
 cleanly cut, total closure without the use of a tube can be safely 
 effected. When the wound involves the larynx, it is desirable to 
 close the opening at once, since the larynx does not readily 
 tolerate the presence of a tube ; if it is necessary to introduce one, 
 it is better to perform a high tracheotomy. When the wound 
 involves 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, 
 
8?8 A MANUAL OF SURGERY 
 
 and then a more thorough purification of the wound can be under- 
 taken ; if the epiglottis is divided, it must be accurately sutured. 
 If there is any doubt as to the advisability of this proceeding, a 
 high tracheotomy is first performed, and then the wound closed 
 as far as possible. 
 
 In every instance the head should be flexed on the chest, and 
 in suicidal cases a careful watch maintained to prevent the patient 
 tearing the wound open. Extreme shock from loss of blood is 
 dealt with by the infusion of saline solution, and the patient's 
 general health attended to. Feeding should always be under- 
 taken through a tube passed into the oesophagus, whether that 
 structure is wounded or not, and such should be continued until 
 the patient's natural powers of 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 
 being continuous 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 separat- 
 ing the skin from the mucous membrane, and in order to accom- 
 plish this, the external wound must be enlarged vertically. The 
 edges of the mucous membrane are then pared, and stitched 
 together horizontally. The external wound is either left open to 
 allow of the escape of air and discharge, or may be partially closed, 
 and a drainage-tube or gauze stuffing inserted, (b) Laryngeal or 
 tracheal stenosis, due to the cicatrization of wounds in these regions, 
 may be remedied by wearing an O'Dwyer's tube (p. 853) for a 
 time, or may necessitate the constant use of a tracheotomy-tube. 
 (c) Aphonia may arise from division of the recurrent laryngeal 
 nerve, and is then usually persistent, (d) Oesophageal or pharyngeal 
 fistula may also in rare instances complicate the healing of an 
 extensive wound in the throat, but tend to close of themselves, 
 and require no special treatment. 
 
 Diseases of the Thyroid Body. 
 
 Goitre. — Enlargement of the thyroid body, or, as it is termed, 
 bronchocele or goitre, is a condition frequently seen in this 
 country, and to which much attention has been directed of recent 
 years, owing to the discovery that the thyroid body exercises 
 considerable influence over the metabolism and nutrition of the 
 body. Total absence or removal of the gland or its complete de- 
 generation leads to accumulation of mucin in the body, producing 
 myxcedema or tetany ; whilst recently it has been suggested that 
 
 * For fuller information than can be given here, see Berry, ' Diseases of the 
 Thyroid Gland and their Surgical Treatment.' J. and A. Churchill. 1901. 
 
SURGERY OF THE NECK 829 
 
 the symptoms of Graves' disease are due to the excessive absorp- 
 tion of normal or vitiated thyroid secretion. 
 
 The Causes of bronchocele are still enshrouded in a good 
 deal of uncertainty. It occurs endemically in this and some 
 other countries, being especially frequent in the hilly parts of 
 Derbyshire and Gloucestershire (and known, in fact, as Derby- 
 shire neck), whilst it is also exceedingly common in Switzerland. 
 The old idea that it occurs more frequently in places located on 
 chalk or magnesian limestone is not true, it being more common, 
 perhaps, in regions where the green sandstone and carboniferous 
 limestone crop up. Possibly the disease is due to the presence 
 or absence of some mineral constituent of the drinking water, 
 and the discovery made by Baumann, of Friburg, suggests that 
 an absence of iodine is the cause of the trouble. At any rate, 
 iodine is to be found in the normal thyroid secretion in close 
 combination with albumen, whilst it is absent in cases of goitre, 
 the enlargement of the gland being looked on in the light of 
 a compensatory hyperplasia. Other causes which have been 
 suggested are want of sunshine and air, as in the case of individuals 
 who live in valleys into which the air does not readily penetrate, 
 or in the underground kitchens and cellars of large towns, defective 
 sanitary conditions and the habit of carrying weights upon the 
 head also possibly assisting. In the form ordinarily met with, it 
 is not hereditary to any great extent, and is not influenced by 
 intermarriage ; but it may be congenital, and if associated with 
 skeletal changes, defective growth, and intellectual weakness, 
 constituting the condition known as cretinism, and in reality a 
 manifestation of myxcedema, it certainly runs in families. Cre- 
 tinism is, however, more frequently due to total absence of the 
 gland than to degeneration of a goitrous tumour. The ordinary 
 type of goitre seen in this country is much more common in women 
 than in men. 
 
 Varieties and Clinical Features. — Four chief forms of goitre are 
 described, viz. : The parenchymatous or simple, the cystic, the 
 fibro-adenomatous, and the exophthalmic ; but the thyroid body 
 may become enlarged in other ways, giving rise to the conditions 
 known as malignant goitre and acute goitre, whilst acute inflam- 
 mation 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 possibly the isthmus alone. Its consistence varies 
 with the nature of the growth, but it always moves with the 
 larynx on deglutition. In every form there is probably a certain 
 amount of anaemia, whilst some of the symptoms characteristic 
 of the exophthalmic variety are often produced even in simple 
 cases, possibly from the excessive absorption of thyroid secretion. 
 Pressure on surrounding structures leads to dyspnoea or dysphagia, 
 and cerebral symptoms may arise from interference with the main 
 
830 
 
 A MANUAL OF SURGERY 
 
 vessels, which are displaced outwards. The trachea is especially 
 liable to changes of situation and shape from its compression ; it 
 is usually flattened from side to side, and is sometimes pushed an 
 inch or more from the middle line (Fig. 300) ; atrophy of the 
 cartilaginous rings may also be induced. Pressure on the re- 
 current laryngeal nerve leads to harshness in speaking or aphonia, 
 and to spasmodic attacks of dyspncea, which may even prove fatal. 
 Simple or Parenchymatous Goitre (Fig. 297) 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 
 
 Fig. 
 
 297.- 
 
 -Large Simple or Parenchymatous Goitre involving 
 the whole gland. 
 
 amount of fibrous stroma is usually present. The whole gland is 
 generally involved, but possibly one lobe is larger than the other. 
 It is soft and elastic to the touch, quite painless, and unless large 
 gives rise to but little inconvenience. Some amount of lobulation 
 is occasionally present. Not uncommonly it is associated with 
 some cystic development or new formation of an adenomatous 
 type and malignant disease is always preceded by this condition. 
 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 is then termed a. fibrous goitre, and 
 if the sclerosis is very marked, myxoedema may supervene. 
 
 The Fibro-adenomatous Goitre (Fig. 298) consists in the develop- 
 ment of one or more encapsuled adenomatous nodules in the sub- 
 stance of the thyroid body, which is itself concurrently enlarged. 
 
SURGERY OF THE NECK 
 
 831 
 
 These nodules are perhaps most common in the isthmus, but may 
 occupy one or other lobe, or, when multiple, be scattered through 
 the substance of the organ. If situated near the surface, their 
 limitation and free mobility in the gland can be easily detected, 
 but when placed deeply their special features cannot be recognised. 
 Two varieties have been described : (a) The foetal, in which the 
 growth is solid and homogeneous, consisting under the microscope 
 of closely apposed alveoli in which there is no colloid develop- 
 ment, 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, (b) 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 of separation between this 
 
 Fig. 
 
 298. — Fibroadenoma of Isthmus of Thyroid Body in a Woman, 
 aged Twenty-three Years. 
 
 latter condition and the simple hypertrophy, 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 in a 
 localized adenoma, the inter-alveolar walls being absorbed. They 
 may be single or multiple, and contain either a thin fluid or a 
 thick grumous colloid material, somewhat like furniture polish. 
 Intracystic growths of a papillary nature are not unfrequent. 
 The lining membrane of these cysts is epithelial in nature, the 
 individual cells being cuboidal when the cyst is small, and 
 flattened out or squamous when large. It is sometimes intensely 
 vascular, and haemorrhage into the cysts is by no means un- 
 common, causing the contents to be brown or blood-stained. 
 
832 
 
 A MANUAL OF SURGERY 
 
 Secondary changes occur in any of these varieties, chiefly 
 affecting the interstitial tissue, which may develop into cartilage 
 or bone, or may calcify, but only in very chronic cases. Haemor- 
 rhage into the alveolar spaces or cysts is not uncommon ; acute 
 infective inflammation may also involve the mass, and malignant 
 disease, usually of a cancerous nature, sometimes supervenes. 
 
 The Treatment of the three preceding forms of goitre may 
 be considered together, as they are very different in nature to 
 those which follow. In the early stages palliative measures can 
 be employed, consisting in 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 
 iodide of potassium may be administered internally, and iodine 
 
 Fig. 299. — Diffuse Fibro-adeno- 
 mata of Thyroid Body with a 
 tendency to become cystic. 
 
 Fig. 300. — Large Unilateral 
 Goitre displacing the Trachea 
 to the Right, and Compressing 
 it Laterally to a Serious Ex- 
 tent. (Tillmanns.) 
 
 paint or iodide of potassium ointment applied locally. In India 
 cures are often produced by inunction of iodide of mercury 
 ointment, the part being subsequently exposed to the rays of the 
 mid-day sun ; such treatment is generally impracticable in this 
 country. The deficient amount of iodine present in the gland in 
 these cases explains why this drug is so pre-eminently useful, and 
 it has been found that the active principle of the gland isolated by 
 Baumann and called ' thyro-iodine ' is the best form in which it 
 can be administered. The exhibition of thyroid extract is some- 
 times followed by a diminution of a simple goitre, and the same 
 explanation of its value probably holds good. 
 
 In cases where, in spite of such treatment, the growth persists 
 or increases in size, other measures must necessarily be employed, 
 
SURGERY OF THE NECK 833 
 
 and there is no doubt that removal of the tumour or of a part 
 of the gland is the best practice to adopt. Total extirpation, 
 as already mentioned, results in myxcedema ; but as long as a 
 sufficient portion of the secreting substance is left, whether it is 
 derived from the isthmus or from one of the lobes, no such 
 accident need be feared. The operation necessitates a somewhat 
 deep dissection, and will encroach on important structures; but 
 with due care and the maintenance of efficient asepsis, the most 
 satisfactory results are obtained, except when the growth is of 
 very great dimensions. We would particularly emphasize the 
 fact that goitres should be treated in the same way as other new 
 growths, viz., by removal when small. There is still unfor- 
 tunately 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. Other plans of treat- 
 ment have been utilized in the past, e.g., ligature of the thyroid 
 vessels, division of the isthmus, curetting the mass with a large 
 Yolkmann's spoon, passage of a seton, or intraglandular injection 
 of irritants, such as tincture of iodine ; but they should be entirely 
 discarded in favour of more radical measures. 
 
 Partial thyroidectomy (or Kocher's operation) is conducted as 
 follows : An incision is made over the most prominent part of the 
 tumour, preferably along the lower third of the anterior border 
 of the sterno-mastoid. Kocher recommends a transverse or 
 angular incision in order that the scar may be less visible, and 
 this may be employed in suitable cases. The platysma and deep 
 fascia are divided, the sterno-mastoid drawn outwards, and the 
 sterno-hyoid, sterno-thyroid, and omo-hyoid displaced inwards, 
 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 of 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 the isthmus from the trachea. In detaching 
 the latter, the surgeon must not forget that the cartilaginous rings 
 may have been absorbed, and that the walls of the trachea, being 
 then merely fibrous in nature, are easily wounded. The isthmus 
 should be transfixed and tied in two halves with a silk ligature, so 
 as to prevent haemorrhage. The growth can now be removed, 
 the bleeding points secured, and the wound closed, the muscles 
 and fascia being drawn together by buried catgut stitches. A 
 drainage-tube is best inserted for twenty-four or forty eight hours, 
 as it is difficult to employ much pressure on the neck, but this 
 
 53 
 
834 A MANUAL OF SURGERY 
 
 precaution may sometimes be omitted. Healing by first intention 
 should be the invariable result. 
 
 Fibro '-adenomata, when multiple or deeply placed, are treated by 
 extirpation of the affected lobe ; but if the new growth is single 
 and superficial, its enucleation should be undertaken by the pro- 
 ceeding known as Socin's operation, which has been mainly popu- 
 larized in this country by Mr. C. J. Symonds, of Guy's Hospital. 
 The skin and muscles are divided as before, and the gland 
 substance and capsule incised down to the growth, which is 
 readily shelled out. 
 
 A single cyst is treated in the same way as a fibro-adenoma, 
 viz., by enucleation ; if several cysts are present, removal of the 
 affected lobe may be necessary. The old line of practice, which 
 is still occasionally utilized, consisted in tapping with a full- 
 sized trocar and cannula, and injecting with tr. ferri perchlor. or 
 iodine. Good results sometimes followed these measures, but 
 occasionally the sudden relief of tension within the cyst gave 
 rise to severe haemorrhage from its walls, which threatened the 
 patient's life. In such cases the cyst was laid freely open, and 
 the cavity plugged with sponges or gauze soaked in some strong 
 haemostatic ; or it was sometimes feasible to rapidly enucleate the 
 whole cyst, and then command the haemorrhage by ligaturing the 
 supplying vessels. 
 
 Myxaedema (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 still have much to learn of the duties of this 
 organ, yet we do know that the elimination, if not the development, of mucin 
 in the body is controlled by it, and that its absence leads to an accumulation 
 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 symptoms soon disappear, and the 
 change from the dull, heavy condition of myxoedema to one of normal health 
 of mind and body is almost miraculous. 
 
 Similar treatment should be employed for myxoedematous cretins, who often 
 start growing rapidly as soon as treatment commences. 
 
 Tetany is another condition which sometimes obtains after complete removal 
 or disorganization of the thyroid body. It consists in a peculiar irritability of 
 the gray matter of the spinal cord, resulting in the development of tonic con- 
 traction of groups of muscles which may last for minutes, hours, or even a day 
 or two ; the irritability of the facial nerve is especially noticeable. The condition 
 may prove fatal from spasm of the respiratory muscles, but is more usually 
 chronic, lasting perhaps for years, and running its course concurrently with 
 myxcedema. It is supposed to be due to actual poisoning with mucin, and 
 the treatment required is the same as for myxcedema. 
 
SURGERY OF THE NECK 835 
 
 Exophthalmic Goitre, or, as it is often termed, Graves' or 
 Basedow's disease, 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 nature of the disease has long 
 been a topic of discussion, one of the earliest ideas being that 
 it results from some derangement of the sympathetic nervous 
 system, or possibly of the medulla. Lately, however, owing to 
 the fact that in cases where thyroid extract has been given to 
 excess symptoms somewhat akin to those seen in this condition 
 have arisen, it has been suggested that the disease is due to the 
 excessive absorption of thyroid secretion, although why it occurs 
 in some cases of enlargement, and not in others, has not been 
 explained. In all probability the truth lies half-way between 
 the two theories, the enlarged thyroid and some of the symptoms 
 being alike due to some central disturbance in the upper part 
 of the medulla, whilst others are due to excessive absorption of 
 thyroid secretion. 
 
 The patients usually affected are females, about the middle 
 period of life, whose menstrual functions are often impaired. 
 Overwork, worry, and severe mental strain, are apparently re- 
 sponsible for the onset of the symptoms in many instances, and 
 a sudden shock or fright accounts for others. The protrusion of 
 the eyeball is a marked feature of the case, and 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 lid and the cornea (von 
 Graefe's sign). A fine fibrillary tremor of the limbs is also 
 commonly observed in these cases. The patient is always ex- 
 tremely nervous, and the pulse-rate high ; any exertion or 
 excitement increases the irritability of the heart's action, and 
 may induce considerable respiratory distress. Leit to itself, 
 the disease in some cases tends to improve, but in others it 
 may progress to a fatal issue from asthenia or cardiac compli- 
 cations. 
 
 Treatment consists in freeing the patient, if possible, from all 
 sources of worry, whilst bromides, iron, and perhaps iodide of 
 potassium, are administered internally, attention being aiso 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. Phosphate of soda has lately 
 been much commended in this disease, and Kocher speaks favour 
 
 53— 2 
 
836 A MANUAL OF SURGERY 
 
 ably of it when conjoined with suitable hygienic measures. 
 Thymus extract has also proved beneficial. 
 
 Since the introduction of the theory that the derangement is 
 mainly thyroidal in origin, surgical treatment by removal of a 
 portion of the gland has been suggested, and the results gained 
 so far have been encouraging, although the proceeding is not 
 devoid of serious risk, and should not be lightly 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. The patients never take an anaes- 
 thetic well, and several fatal results have ensued from this cause. 
 They are also very liable to syncope after the operation, and occa- 
 sionally a curious train of symptoms supervenes within a few 
 hours. The temperature rises suddenly to 104 or 105 , the pulse- 
 rate is greatly accelerated, and the patient becomes delirious 
 and finally comatose, dying in that state in about forty-eight hours. 
 It is supposed that excessive thyroid toxaemia is responsible for 
 these phenomena. 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 aseptic wool. 
 
 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. It is a little doubtful whether the improvement is really 
 to be ascribed to the operation, or to the altered environment 
 necessitated by it. The symptoms sometimes recur at a later 
 date, and such cases have been treated by removing another 
 portion of the gland. 
 
 Excision or division of the cervical chain of sympathetic 
 ganglia has also been employed in this condition, and apparently 
 with good effects ; but no final statement as to its value can yet 
 be hazarded. 
 
 Malignant Disease of the Thyroid Body is more frequently 
 cancerous in nature than sarcomatous, usually taking the form 
 of an adenoid cancer, and always preceded by simple enlarge- 
 ment. The tumour grows rapidly, infiltrating the surrounding 
 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 by the growth. 
 The secondary deposits frequently affect osseous tissues, con- 
 stituting pulsating tumours exactly simulating thyroid tissue in 
 nature. Myxoedema may ensue as a complication, owing to the 
 total destruction of the glandular substance. Treatment by 
 extirpation can only be undertaken in the early stages. 
 
 Acute Goitre is but rarely met with, consisting of a rapid 
 
SURGERY OF THE NECK 837 
 
 enlargement 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. Comparatively little can be 
 done for such cases ; incisions into the fascia, division of the 
 isthmus, and tracheotomy, have been suggested. In the latter 
 case it will be necessary to have a specially long tube, which can 
 be passed for some distance down the trachea. 
 
 Inflammation of the Thyroid Body, or acute thyroiditis, occa- 
 sionally supervenes as a complication of an ordinary goitre. It 
 is almost always infective in nature, the cocci reaching it from 
 without, as in a punctured wound, or from within the body on a 
 pyaemic embolus, suppuration being usually induced ; it some- 
 times follows a blow, and may then be simple. The gland 
 becomes enlarged, hot and tender, fever and rigors follow, and 
 the presence of pus is indicated by superficial cedema and fluctua- 
 tion. The early treatment consists in the application of fomenta- 
 tions and perhaps leeches, or in the use of an ice compress. The 
 patient is kept in bed, purged, and carefully dieted. Under such 
 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 closely attached to one of the lateral lobes. They 
 are recognised by their connection with the thyroid body, moving 
 up and down with it on deglutition, and if troublesome should be 
 removed. They may also occur in any part of the thyro-glossal 
 duct, and even in the base of the tongue, in that situation 
 resembling a dermoid cyst. 
 
CHAPTER XXX. 
 SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST. 
 
 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 intruding substance, 
 i. In the Nasal Passages, see p. 757. 
 
 2. Obstruction occurring at the Rima Glottidis, or pharyngeal 
 entrance to the larynx, is usually due to attempts to bolt large 
 masses of food, which, becoming impacted, may cause immediate 
 death. A person, eating a meal voraciously, turns black in the 
 face and falls off his chair, dead. A similar result has followed 
 such a foolish act as attempting to swallow a billiard ball. If 
 the obstruction is not complete, as when a plate of false teeth 
 becomes impacted, great dyspncea is caused, and absolute inability 
 to swallow, the symptoms rapidly increasing owing to oedema of 
 the submucous tissue of the glottis. Accidents of a similar nature 
 may occur during chloroform narcosis, an epileptic fit, or drunken- 
 ness, some such substance as a plate of teeth being dislodged from 
 the mouth, or a mass of food being vomited, and blocking the 
 entrance to the larynx. The Treatment must be very prompt, 
 since there is no time to lose. The mouth should be forced open 
 by the handle of a fork or anything suitable that happens to be 
 near, and the finger rapidly swept round the pharynx so as to 
 dislodge the foreign body. Failing this, laryngotomy must be 
 performed at once, and artificial respiration, if necessary, instituted. 
 In less urgent cases there is time to remove the substance from 
 the mouth with the assistance of a frontal mirror. 
 
 3. In the Larynx. — A foreign body enters the larynx by inhala- 
 tion 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 bodies we find 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 
 
SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST 839 
 
 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 to have 'gone down the wrong way.' The 
 voice becomes croupy and hoarse, respirations stridulous, and any 
 movement of the patient may for some time bring on a spasmodic 
 fit of dyspnoea. After a while the obstruction, which is at first 
 partial, may become complete from oedema of the glottis, whilst 
 perichondritis and ulceration or necrosis of the cartilages may be 
 induced. Laryngoscopic examination should reveal the situation 
 of the intruding body. The Treatment consists in attempting to 
 remove it through the mouth with suitably curved forceps guided 
 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. 845) must 
 be undertaken. 
 
 4. In the Trachea. — To lodge in this situation a foreign body 
 must be small enough to pass through the glottis, and not too 
 heavy, otherwise it drops into one of the bronchi ; it may become 
 impacted, if it has jagged edges, but is not uncommonly free. It 
 may remain in one spot, only moving when the patient alters his 
 position or coughs, and then the longer it stays, the less moveable 
 it is, owing to its becoming embedded in mucus. 
 
 The Symptoms may be described as those of obstruction, irrita- 
 tion, and inflammation. During the passage of the body through 
 the larynx, the patient suffers from a severe attack of spasmodic 
 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 performing a low tracheotomy with 
 a good-sized opening, and if possible removing the intruding body 
 at once ; or the patient may be inverted and the back well 
 concussed in order to dislodge it. Failing this, the wound in 
 the trachea must be left widely open, by inserting a wire stitch 
 through each side of the incision and tying the ends behind the 
 neck ; very probably the body will be expelled through it during 
 an attack of coughing. 
 
 5. To become 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, an O'Dwyer's tube, or the inner cannula of a tracheotomy- 
 tube. The right bronchus usually becomes obstructed, the reason 
 
840 A MANUAL OF SURGERY 
 
 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 
 symptoms similar to those described above manifests itself, viz., 
 obstruction, irritation, and inflammation. The obstruction is 
 twofold : immediate, as a result of the passage of the body 
 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 at first the obstruction is 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, re- 
 sulting in bronchitis, the formation of a bronchiectasis, and peri- 
 bronchial pneumonia ; suppuration ensues, and the foreign body 
 may be expelled sooner or later with a sudden gush of pus during 
 a fit of coughing. Thus, in a case treated by the late Mr. William 
 Rose (grandfather to one of the authors*), a beech-mast was 
 inhaled in November, 1812, and was not extruded till May, 1822, 
 the patient having in the meantime developed all the symptoms 
 of a bronchiectasis. Sometimes the abscess may extend through 
 the lung substance to the pleura, setting up a localized empyema, 
 through which, when opened, the article is expelled. In other 
 cases the lung becomes riddled with abscesses, and the patient 
 dies of exhaustion. 
 
 Treatment. — The position of the foreign body must be, if 
 possible, ascertained by careful examination of the lungs, which 
 may reveal a certain amount of collapse, whilst skiagraphy 
 may also be useful. A low and extensive tracheotomy is then 
 performed, and the bronchi 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. 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. 
 
 Injuries of the Larynx. 
 
 Several conditions arising from traumatism of the upper air- 
 passages have been already described, e.g., fracture of the hyoid 
 bone (p. 443), and incised wounds, as in cut throat (p. 825). 
 
 Occasionally the thyroid or other cartilages may be injured or 
 fractured by direct violence, as in garrotting, causing local pain 
 and haemorrhage, and possibly some obstruction to the respira- 
 
 * Lancet, August, 1843. 
 
SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST 841 
 
 tion. 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. 
 
 Before the student can understand the subject, 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 ele- ..■ > 
 
 vates, 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 "J 
 
 is seen in the mirror. Con- 
 siderable practice is needed in 
 order to attain any facility in 
 the use of this instrument, as 
 also to be able to recognise 
 normal from abnormal struc- 
 tures. The use -of cocaine to 
 anaesthetize the fauces is in 
 many 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. 
 
 Acute and Chronic Laryngitis 
 are conditions of but slight 
 surgical interest. The acute 
 affection arises from cold or 
 over-exertion of the vocal ap- 
 paratus, and is characterized 
 by aphonia (loss of voice) and 
 cough. Locally, the vocal cords 
 
 ({■>» 
 
 Fig. 301. — CEdema of Glottis and Tongue 
 from Behind. (College of Surgeons' 
 Museum.) 
 are seen to be hyperaemic and The tongue is seen to be enlarged and swollen, 
 swollen. The Treatment is rather and the aryteno-epiglottidean folds are 
 medical than surgical, although cedematous, so that the entrance to the 
 in children intubation or trache- larynx is represented by a mere chink, 
 otomy may be sometimes re- 
 quired. 
 
 Diphtheritic Inflammation of the Larynx is usually met with as an extension 
 of a similar affection of the fauces. It gives rise to severe dyspnoea from 
 obstruction in the rima glottidis, and, if the condition does not yield to the 
 injection of the diphtheritic antitoxin, will probably require intubation or 
 tracheotomy. 
 
842 A MANUAL OF SURGERY 
 
 Acute (Edematous Laryngitis, or oedema of the glottis, is a condition of con- 
 siderable surgical importance. Causes. — (a) It is either secondary to some 
 other laryngeal affection, such as acute catarrhal laryngitis, or acute peri- 
 chondritis ; or (b) 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 un frequently 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. 
 Characters. — The folds cf mucous membrane extending on either side of the 
 epiglottis both to the root of the tongue and backwards to the arytenoid car- 
 tilages become swollen and cedematous from a serous infusion into the sub- 
 mucous tissue (Fig. 301). The same condition also involves the inter-arytenoid 
 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, 
 merely covered with a layer or two of squamous epithelium. The epiglottis 
 becomes folded laterally upon itself as a leaf, merely leaving a valve-like chink 
 which permits of expiration, although considerably 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 amount 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 examination, when the slit-like opening of the 
 glottis, bounded below and behind by thickened cedematous 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, either by the finger-nail or with a suitable 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. Fomentations or ice com- 
 presses 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, laryngotomy sufficing in adults, 
 but a high tracheotomy being needed in children. 
 
 Syphilitic Disease 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. It is very 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 gummatous infiltration or localized 
 gummata may develop, giving rise to destructive ulceration, which especially 
 affects the epiglottis and aryteno-epiglottidean folds, and may spread back- 
 wards and involve the whole glottis (Fig. 302). Inflammation of the peri- 
 chondrium is likely to follow, leading to necrosis of the cartilages. Hoarseness 
 and dyspnoea are the chief symptoms of this affection, whilst considerable 
 obstruction may be subsequently caused by cicatrization and laryngeal stenosis. 
 Treatment consists in the administration 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. 
 
 Tuberculous Laryngitis (Fig. 303) is occasionally a primary manifestation, 
 but is much more frequently secondary to phthisis, arising from infection 
 of the mucous membrane owing to the constant passage over it of the 
 sputum. It usually commences at the posterior part of the larynx in tha 
 
SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST 843 
 
 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. 359). Considerable destruction of tissue ensues, involving 
 the whole circumference of the larynx, and even leading to necrosis and 
 destruction of the cartilages. Hoarseness, cough, and perhaps a certain 
 amount of dyspnoea, in a patient suffering from phthisis, are the chief symp- 
 toms arising from this affection, the prognosis of which is always of a grave 
 nature. Treatment .—In phthisical patients local treatment is of but little avail, 
 but where the disease is primary an attempt should be made to deal with it ; 
 such, however, can only be undertaken by the skilled laryngologist, as it 
 consists in the topical application of caustics and antiseptics. Thyrotomy or 
 subhyoid pharyngotomy has sometimes been practised, in order to attain this 
 object more thoroughly. 
 
 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, 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 neighbourhood, 
 e.g., cancer of the oesophagus, the factual "pressure in the latter case being 
 
 Fig. 302. — Gummatous Disease of 
 the Larynx. (Tillmanns.) 
 
 Small gummata are seen invading 
 the mucous membrane of the 
 epiglottis and front of the larynx. 
 
 Fig. 303. — Tuberculous Disease 
 of the Larynx, with Extensive 
 Ulceration in Front and Behind. 
 (Tillmanns.) 
 
 a, b, c, Remains of the epiglottis. 
 
 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 paralysis 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 uncommonly the 
 paralysis is incomplete, and then merely affects the abductor muscle (the 
 crico-arytenoideus posticus). The Symptoms arising from unilateral 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 are 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. 304) 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 laryngo- 
 scopy examination, and may be removed successfully by laryngeal forceps, 
 after the parts have been efficiently cocainized. It is recommended by some 
 authorities to destroy the growth with a galvano-cautery. 
 
 Epithelioma Laryngis occurs in patients over forty, originating as a papillary 
 overgrowth, usually near the base of the epiglottis, or from the true or false 
 cords (Fig. 305). The tumour gradually spreads, both superficially and deeply, 
 
844 
 
 A MANUAL OF SURGERY 
 
 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, destroy- 
 ing life by dyspnoea and exhaustion. Pain is often a most distressing symptom, 
 being referred either to the larynx or pharynx, or, according to Ziemssen, not 
 unfrequently to the ear. Treatment. — In the early stages it is possible that 
 thyrotomy and efficient curetting and cauterization may suffice to bring about 
 a cure. Later on, removal of one or both halves of the larynx will be 
 required, and the operation may even include parts of the tongue and 
 
 Fig. 304. — Papillomata of the 
 Larynx, springing from the 
 Right Vocal Cord. (Till- 
 
 MANNS.) 
 
 Fig. 305. — Epithelioma of the Larynx, 
 involving the Right Vocal Cord 
 and Base of the Epiglottis. (Till- 
 
 MANNS.) 
 
 pharyngeal wall. Where, however, the disease has spread extensively, its 
 total extirpation is rarely practicable, and all that can be done is to treat 
 symptoms as they arise, and perform tracheotomy when necessary. 
 
 Operations upon the Air-passages. 
 
 1 . Subhyoid Pharyngotomy was devised by Malgaigne, in order 
 to provide access to the upper parts of the larynx in the treat- 
 ment of foreign bodies or tuberculous disease. A transverse 
 incision is made through the thyro-hyoid space, the pharynx is 
 opened, and the epiglottis detached from the base of the tongue 
 (Fig. 306, 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 
 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 utilised 
 
 * See Revue de Chirurgie, May, 1900. 
 
SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST 845 
 
 this operation both for the removal of an epithelioma of the epi- 
 glottis and back of the tongue, and for enucleating a sarcoma of 
 the posterior pharyngeal wall, and were much pleased with the 
 approach given to these parts. 
 
 2. Thyrotomy (Fig. 306, II.) consists in a partial or complete 
 vertical section of the thyroid cartilage, and may be required 
 for the removal of foreign bodies or 
 tumours, or for the radical treatment 
 of laryngeal tuberculosis or cancer. 
 Tracheotomy is performed as a pre- 
 liminary measure, and the trachea 
 plugged around the tube. An in- 
 
 A.. 
 
 J\ 
 
 \ 
 
 II 
 
 111 
 
 %Zi 
 
 Sch 
 
 H 
 
 Th 
 
 Th 
 
 cision 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 de- 
 fined and severed transversely, and 
 the thyroid cartilage accurately 
 divided by a knife, cutting-pliers, or 
 fine saw. The lateral halves are 
 separated, and the intra-laryngeal 
 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 phonation 
 will be considerably impaired. This 
 is best ensured by making a hori- 
 zontal cut across the front of the 
 cartilage before dividing it. 
 
 3. Extirpation of the Larynx 
 (Laryngectomy) is always a serious 
 operation, which is never under- 
 taken except for malignant disease. 
 According to the site of the tumour 
 the removal may be partial or com- 
 plete ; for a growth strictly limited 
 
 to one side, extirpation of that half will suffice, and admirable re- 
 sults 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 without mechanical assist- 
 ance, whilst if the disease has extended beyond the limits of the 
 larynx, operative interference is very unsatisfactory. 
 
 Operation for Complete Extirpation. — A low tracheotomy should 
 be performed, as a preliminary measure, and preferably a few days 
 before ; the trachea is plugged with a Halm's tube or a Trendelen- 
 burg's air tampon at the commencement of the operation. An 
 
 V 
 
 \1 
 
 Fig. 306. — Operations on the 
 
 Air-passages. (Tilmanns.) 
 
 I., Subhyoid pharyngotomy ; II., 
 thyrotomy: III., laryngotomy ; 
 IV.,cricotomy; V., high trache- 
 otomy ; VI., low tracheotomy ; 
 Z, hyoid bone; Sch, thyroid 
 cartilage ; R, cricoid ; Th, 
 thyroid body. 
 
846 A MANUAL OF SURGERY 
 
 incision is made in the middle line of the neck from the hyoid 
 bone to below the cricoid cartilage, at the upper end of which a 
 transverse cut is made, extending as far as the sterno-mastoid 
 muscle on either side. The soft parts are then stripped from the 
 lateral borders of the thyroid cartilage with raspatories, the sterno- 
 hyoid, sterno-thyroid, and thyro-hyoid muscles being divided at 
 their insertions. Both the superior and inferior laryngeal vessels 
 are tied and divided. Having thus freed the larynx anteriorly, 
 the subsequent steps of the operation may be undertaken either 
 from below upwards or from above downwards ; the former pro- 
 ceeding is, to our minds, the better. The crico-tracheal mem- 
 brane is divided, and the larynx drawn forwards, so as to enable 
 the posterior attachments, i.e., the connections of the constrictor 
 muscles to the cricoid and thyroid cartilages, to be severed by 
 scissors, the larynx being thus separated from the anterior 
 pharyngeal wall, which must be left intact, if possible. The 
 thyro- hyoid membrane and the 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 ligaments. The operation is not particularly difficult or 
 dangerous, provided that the surgeon keeps close to the larynx, 
 and that the disease does not spread beyond its limits. When 
 other structures, such as the base of the tongue, have been 
 invaded by the growth, these steps must be modified so as to 
 secure, if possible, complete removal of the disease. Finally, the 
 transverse incision is sutured, but no stitches are inserted in the 
 median wound, which is plugged, and allowed to heal by granula- 
 tion. The upper end of the trachea should be secured to the skin 
 at the lower angle of the wound, so as to prevent its retraction. 
 The patient is fed per rectum for a few days, or by the passage of 
 an oesophageal tube. At the end of a week the tracheotomy tube 
 is removed from its original situation, and inserted into the upper 
 end of the trachea, the lower opening being allowed to close. 
 When the wound has healed sufficiently, an artificial larynx can 
 be inserted, by means of which the patient is able to speak in a 
 somewhat reedy monotone, but it is seldom satisfactory. 
 
 Dr. H. Lambert Lack advocates the total closure of all com- 
 munication between the pharynx and the air-passages after 
 laryngectomy. The upper end of the trachea is securely stitched 
 all round in the lower angle of the incision and flush with the 
 surface. The rent in the mucous membrane of the pharynx is 
 then carefully closed ; the wound is thoroughly disinfected, and 
 the various layers of muscles are sutured together, as also the 
 skin. Union by first intention can thus be attained, and the 
 results have been most gratifying. Phonation is of course lost 
 absolutely, but the patient can whisper, the necessary air-pressure 
 being obtained in the dilated pharynx or upper end of the 
 oesophagus. 
 
SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST 847 
 
 If the disease is limited to one half of the larynx, the thyroid 
 cartilage is cleft in the middle line, and the operation confined to 
 the affected side. 
 
 4. Laryngotomy is always undertaken for the relief of dysp- 
 noea arising from some sudden obstruction to the respiration, 
 and is thus to be looked on as an operation of urgency. It is 
 required in cases where the entrance to the larynx is obstructed 
 by a foreign body, for spasm of the glottis, or for accumulations 
 of blood in the neighbourhood of the larynx during an operation. 
 It is readily performed by making a vertical incision over the 
 situation of the crico-thyroid membrane, which is then divided 
 transversely along the upper border of the cricoid cartilage, the 
 sterno hyoid muscles being, if necessary, drawn aside, and a 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 pen- 
 knife, and the larynx opened, the margins of the wound being 
 held aside by a hairpin, or by the handle of a scalpel turned edge- 
 ways, 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 considerable irritation, and the voice 
 may be subsequently impaired by the contraction of the cicatrix. 
 A special laryngotomy tube is required, the lumen of which is oval 
 and flattened from above downwards, not circular. 
 
 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 lavyngotvacheotomy (Fig. 306, IV.). 
 
 5. Tracheotomy. — The trachea usually consists of from sixteen 
 to twenty rings, of which six or seven are situated above the 
 sternum. The isthmus of the thyroid body usually 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 is serious obstruction to the respiration, e.g., 
 various forms of laryngitis, and especially that due to diphtheria ; 
 for stenosis, tumours, and some forms of paralysis of the larynx ; 
 for the removal of foreign bodies, either in the larynx, trachea, 
 or one of the bronchi; or for compression of the larynx or trachea 
 by external tumours, such as an enlarged thyroid body. It is 
 also undertaken as a preliminary measure in operations on the 
 mouth, tongue, pharynx, or larynx, in which there is any likeli- 
 hood of asphyxia or secondary septic pneumonia, owing to the 
 entrance of blood or septic discharges into the air-passages. As 
 a general rule, the high operation (that is, above the isthmus of 
 the thyroid body) is to be preferred, but under special circum- 
 stances it may be advisable to open the trachea lower down. 
 
8 4 S 
 
 A MANUAL OF SURGERY 
 
 The risk attaching to the high operation is considerably less than 
 to the low, but the opening is made nearer to any disease which 
 may exist in the larynx. For the removal of foreign bodies from the 
 bronchi or trachea, the low operation should always be employed. 
 The high operation (Fig. 306, V.) is performed as follows : The 
 patient is placed on the back, with a sandbag or pillow beneath 
 the neck, so as to throw the head backwards and put the struc- 
 tures on the stretch, and with the shoulders somewhat raised. 
 Anaesthesia may be induced by chloroform, but it is unnecessary, 
 and indeed unwise, to push the anaesthetic, since it is only needed 
 for the division of the skin ; where the dyspnoea is considerable, it 
 is better to employ cocaine. The head is held exactly in the 
 middle line, and the surgeon feels for, and identifies, the cricoid 
 cartilage. The incision extends from this structure downwards 
 for about 1^ inches. The superficial fascia is divided, and the 
 interval between the sterno-hyoid muscles made out, so as to 
 
 Fig. 307. — Durham's Tracheotomy-tube. (Down Brothers. 
 A, Outer-tube with introducer; B, lobster-tailed inner-tube. 
 
 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. 
 
 The isthmus of the thyroid body may now be seen, and, if pro- 
 jecting unduly upwards, should be pushed down after the fascia 
 along its upper border has been transversely incised. The trachea 
 is next clearly exposed by using the handle of a scalpel and dis- 
 secting forceps, and should be fixed and steadied by 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 upwards. A deep inspiration is usually taken at 
 once, followed by a severe fit of coughing, and if the operation is 
 undertaken for diphtheria the surgeon must be careful not to let 
 any membrane which may then be expelled enter his eyes, nose, 
 or mouth. The insertion of the tube is in many cases easy, in 
 
SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST 849 
 
 others a matter of some difficulty ; a good deal depends upon the 
 age of the patient, the urgency of the symptoms, and the depth 
 from the surface at which the trachea lies. Anything which 
 suffices to separate the lips of the tracheal incision, 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 breath- 
 ing 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. 306, VI.) is performed in almost precisely 
 the same way, except that the in- 
 cision extends farther downwards, 
 even reaching to the episternal 
 notch, although the deeper part of 
 the wound should never pass be- 
 yond 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 wound- 
 ing the left innominate vein. The 
 superficial layers of fascia are 
 divided, and the sterno-hyoid and 
 sterno-thyroid muscles drawn to 
 either side by retractors. The 
 inferior thyroid veins then come 
 into view, and may cause trouble 
 if they are distended with blood , 
 as is so frequently the case in 
 patients suffering from dyspncea. 
 They must be held aside by 
 hooks, or divided between liga- 
 tures, and the deep layer of fascia 
 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 that most generally employed consists of 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 of mucus being left within the outer tube on 
 removal of the inner. A face-plate, or some similar contrivance, 
 is attached to the outer cannula, in order to fix and study it. One 
 of the best is that known as Durham's lobster -tailed tracheotomy -tube 
 (Fig. 307, A and B) ; the rigid outer tube of this instrument is 
 introduced by means of a flexible guide set on a handle, and passed 
 
 54 
 
 Fig. 308. — Parker's Tracheotomy- 
 tube and Introducer. (Down 
 Brothers.) 
 
850 A MAM UAL OF SURGERY 
 
 within it. The guide is then withdrawn, and replaced by the inner 
 flexible cannula (B). Parker's tube (Fig. 308) also has a handy 
 introducer, and is perhaps of a better shape than most of the 
 others, following more closely the direction 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 surgeon must see that 
 both limbs enter the trachea, as trouble has arisen from one limb 
 passing outside, and the other inside, thus hindering the intro- 
 duction of the inner tube. In cases of preliminary tracheotomy 
 (p. 781), undertaken to prevent the entrance of blood during opera- 
 tions, Halm'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. Trendelenburg'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 following are the chief conditions 
 which may lead to mistakes and accidents : 
 
 (1) The administration of any general anaesthetic is often 
 inadvisable in semi-asphyxiated patients, since complete cessa- 
 tion of respiration may be caused thereby, possibly from spasm 
 of the glottis. In such the cutaneous incision may be made 
 under the influence of some local anaesthetic, whilst for the 
 deeper parts of the operation nothing is required. 
 
 (2) It is not always easy to find the trachea, especially in the necks 
 of 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 line by some external growth, and can 
 then only be found by careful exploration with the finger. 
 
 (3) Hemorrhage is generally troublesome. It is usually venous 
 in character, arising either from the anterior jugular vein or from 
 the inferior thyroid plexus. If possible, it should be controlled 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 
 
SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST 851 
 
 must not be forgotten, although it but rarely reaches above the 
 sternum. In about 8 per cent, of all subjects an arterial twig 
 (the thyroidal una) 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 occurrence of septic pneumonia at 
 a later date. 
 
 (4) The possibility of the entrance of air into veins must not be 
 overlooked, although it is an uncommon accident, since the intra- 
 venous pressure is so great. 
 
 (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. 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 anaesthetic, the difficulty is 
 manifestly increased. Many accidents have happened from this 
 cause, e.g., wounds of the large veins or arteries of the neck, or 
 even of the oesophagus or bodies of the vertebrae ! 
 
 (6) As soon as the trachea is opened, a severe fit of coughing is 
 induced, which is sometimes so prolonged as to interfere with the 
 introduction of the tube. Under such circumstances the incision 
 in the trachea may be opened up 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 
 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 
 altogether and passed into the fascial interspace in front, as also 
 to one or other side ; as before mentioned, the outer portion of 
 a bivalve tube has often been passed with one limb within the 
 trachea and the other outside. A very dense diphtheritic mem- 
 brane has also been a cause of difficulty, in that, although the 
 tube has been really passed into the trachea, it has not penetrated 
 the membrane, and thus has hindered rather than helped the 
 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 warm temperature (75 F.), the air being moistened 
 by the steam issuing from one or more bronchitis kettles, so 
 as to make up for the absence of nasal and oral respiration. 
 Draughts are excluded by curtains, and nothing should be placed 
 
 54— 2 
 
852 A MANUAL OF SURGERY 
 
 over the entrance to the tube, so that respiration may not be 
 hindered, nor the expectoration of mucus, false membrane, etc., 
 prevented. One of the most frequent sources of extension of diph- 
 theria to the lungs, or of septic pneumonia, is the re-inspiration of 
 material which has been coughed out upon a portion of muslin or 
 gauze, placed with excellent intentions over the mouth of the 
 tube. A nurse should be in constant attendance on the patient, 
 in order to wipe away all such material as it is expelled. 
 
 The inner portion of the tube is removed by the nurse, and 
 cleaned two or three times a day, any inspissated mucus upon it 
 being readily removed by the use of a solution of bicarbonate of 
 soda (20 grains to 1 ounce). The outer tube is also removed once 
 a day for cleansing purposes, but only by the medical attendant. 
 Should the respiration become impeded by a collection of mucus 
 in the trachea, a fine feather may be passed down the tube in 
 order to clear it, but never in diphtheritic cases ; for such a con- 
 tingency special suction-tubes have been devised. Attempts have 
 been made to clear the passages by applying the lips to the tube, 
 and removing the block by suction ; such is, however, quite un- 
 justifiable, 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 impair- 
 ment of the voice. In order to prevent this, the inner cannula is 
 made with a hole in the upper end, so that part of the air may 
 pass through the larynx. If the patient can then breathe com- 
 fortably when the finger is placed over the entrance to the tube, 
 its presence is no longer necessary. 
 
 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 may be advisable to make use of indiarubber tubes. 
 
 (b) Various forms of septic trouble may arise in the wound, 
 leading to cellulitis, and even secondary haemorrhage ; this is 
 especially dangerous in the low operation, since the inflammation 
 may extend to the mediastinal tissues. In cases of diphtheria 
 the wound may also become affected with the disease. 
 
 (c) Inflammation of the trachea, bronchi, and lungs may result 
 either from the entrance of cold, or unmoistened air, or from the 
 inspiration of septic or diphtheritic material. 
 
 (d) Difficulty is sometimes experienced in leaving off the tube, 
 owing to the presence of granulations obstructing the lumen of the 
 trachea, or to stenosis of the larynx from contractions or adhesions 
 
SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST S53 
 
 of the vocal cords, or even to paralysis of the abductor muscles, 
 especially in diphtheritic cases. The trachea may also be kinked, 
 and its calibre thus diminished, by cicatricial union of the skin 
 and mucous membrane. The diagnosis of the cause at work in 
 any particular case can only be made by laryngoscopy, or careful 
 examination of the wound and upper portion of the trachea. 
 Granulations may be scraped away under an anaesthetic or 
 destroyed by caustics, stenosis of the larynx is overcome by dilata- 
 tion with an O'Dwyer's tube, whilst laryngeal paralysis must be 
 treated by the use of electricity. 
 
 Fig. 309. — O'Dwyer's Intubation Apparatus. (Down Brothers. 
 
 The cannulae are seen below on the right ; a hinged inner tube passes 
 throughout the length of each, and the upper end of this is screwed 
 to the extremity of the introducer seen in the middle ; when it has been 
 inserted into the larynx, the trigger of the introducer is drawn, and by this 
 means the inner tube is loosened and can be easily removed, leaving the 
 cannula in position. To extract the tube, the rectangular forceps repre- 
 sented at the top is utilized ; the point of the forceps is inserted into the 
 top of the cannula, and then by opening the blades the cannula is fixed 
 and can be withdrawn. A useful type of unilateral gag is also represented, 
 and a small gauge to indicate the size of cannula required at different ages. 
 
 6. Intubation of the Larynx is a means of treating laryngeal 
 obstruction which has been introduced in order to obviate the 
 risk always present in tracheotomy. It consists in the passage 
 through the mouth of a suitably curved tube into the larynx, by 
 means of a specially contrived introducer. The best patterns 
 to employ for the purpose are those known as O'Dwyer's tubes 
 (Fig. 309). The lower end of the cannula is oval, and not 
 circular, and passes between the cords into the larynx, whilst the 
 
854 A MANUAL OF SURGERY 
 
 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 success in cases of oedema of 
 the glottis and laryngeal stenosis, but is scarcely to be recom- 
 mended for diphtheria, owing to the risk of carrying the false 
 membrane down with it. 
 
 Surgical Affections of the Lungs. 
 
 Wounds of the Lungs result from violence applied to the chest, 
 with or without fractures of the ribs, or in consequence of pene- 
 trating injuries. 
 
 Non-penetrating Wounds consist either of laceration or contusion. 
 
 Contusion of the king often follows some injury which is not 
 sufficiently severe to fracture the ribs. The symptoms produced 
 are severe pain in the side, with perhaps temporary shock and 
 slight haemoptysis. Some traumatic inflammation follows, both of 
 the lung and of the pleura, as indicated by loss of resonance and 
 possibly friction sounds. The treatment consists in keeping the 
 patient quiet in a warm room, at the same time carefully regulating 
 the bodily functions. Possibly pain may be relieved by strapping 
 the side of the chest. 
 
 Laceration of the lung is usually secondary to fracture of the ribs, 
 especially from direct violence. The severity of the symptoms 
 necessarily varies with the character and extent of the injury. 
 The patient suffers from marked shock in severe cases, associated 
 with pain in the side and dyspnoea. Evidences of hemorrhage 
 soon follow, either in the form of haemoptysis or haemothorax. 
 If the wound is a small one, the patient complains of an irritating 
 cough, and brings up a good deal of blood-stained frothy mucus ; 
 but if the laceration is extensive, involving some of the larger 
 pulmonary trunks, a quantity of pure blood may be ejected, even 
 leading to death from syncope, or from asphyxia, owing to the 
 blood filling the larger bronchial tubes. Hemothorax may also be 
 so excessive as to cause the patient's death from compression of 
 the lung. It results in a gradually increasing area of dulness ex- 
 tending from below upwards, together with loss of breath sounds 
 and vocal fremitus, coming on soon after the injury without signs 
 of inflammation. 
 
 Owing to the laceration of the pulmonary vesicles, air tends to 
 escape either into the pleural cavity, giving rise to the condition 
 known as pneumothorax, or into the cellular tissue of the body, 
 constituting surgical emphysema. Pneumothorax is always asso- 
 ciated with more or less collapse of the lung, and is almost 
 certain to lead to considerable interference with respiration, and 
 possibly to severe dyspnoea, or even orthopneea. The air which 
 finds its way into the pleura, having been filtered through the 
 lungs, is free from organisms, and hence does not cause 
 
SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST S5; 
 
 suppuration or putrefaction of the blood-clot present, unless 
 bronchitis or some other suppurative condition has existed pre- 
 viously. The physical signs of pneumothorax consists in a high- 
 pitched tympanitic note on percussion, and on auscultation 
 amphoric breathing and possibly metallic 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 haemopneumothorax 
 is produced, recognised by a splashing or succussion sound heard 
 on shaking the patient. Surgical Emphysema almost always indi- 
 cates a wound of both pulmonary and parietal layers of the pleura, 
 which are slightly separated by air, constituting a localized 
 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 expiration, being forced perhaps to a con- 
 siderable distance from the spot where it commences, or even 
 spreading over the whole body. It is of no serious significance, 
 disappearing rapidly after the wound in the lung has commenced 
 to heal, thus occluding the opened pulmonary alveoli. It is 
 recognised by the parts becoming swollen and puffy, and giving a 
 sensation of fine crackling crepitus when the hand is pressed over 
 them. Occasionally emphysema may arise as an interstitial con- 
 dition, when the parietal pleura has not been injured, the air 
 escaping from the alveoli along the the inter-alveolar connective 
 tissue into the root of the lung, and then appearing first at the 
 lower part of the neck. 
 
 Such are the ordinary phenomena observed in the early stages 
 of a ruptured lung. The effects subsequently produced consist 
 in a localized traumatic pleuro-pneumonia, associated with slight 
 elevation of the temperature, possibly rusty sputum, and often 
 severe dyspnoea. In the worst cases death may result from 
 asphyxia. 
 
 Penetrating Wounds of the Lung are followed by very similar 
 effects, modified, however, by the fact that the external wound 
 in the chest wall allows of the exit of blood, arising either from 
 an intercostal artery or from the wounded lung, whilst it also 
 permits the entrance of septic organisms with the air into the 
 pleural cavity, and thus may change the character of the result- 
 ing pleuro-pneumonia from a simple to an infective imflammation. 
 Empyema is consequently a frequent sequela, whilst the inflam- 
 mation of the lung may be of a spreading nature, possibly termi- 
 nating in suppuration or gangrene. Surgical emphysema is also 
 induced by air being sucked into the wound during inspiration, 
 and failing to escape during expiration, owing to the lips of the 
 wound falling together. This condition may ensue even when 
 the lung itself has not been damaged. 
 
 Treatment. — When the rupture of the lung is due to a sub- 
 
S56 A MANUAL OF SURGERY 
 
 cutaneous injury, the patient should be kept quiet in a warm 
 room, and the side strapped. The compression of the chest wall 
 must sometimes be omitted in patients where the irregular ends 
 of fractured ribs, broken by direct violence, are driven inwards, 
 for fear of increasing the mischief in the lung. 
 
 Persistent haemoptysis must be treated by keeping the patient 
 absolutely quiet, and allowing him to suck ice continually. 
 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. Stimu- 
 lants 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 compress the lung and lead to dyspnoea, 
 and under these circumstances it may be necessary to open up 
 the pleural cavity and remove it. Such must never be under- 
 taken 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 lacerated 
 bronchi ; the suppuration and fever thereby induced necessitate 
 the opening and drainage of the pleural sac. 
 
 Simple pneumothorax seldom requires surgical treatment, since 
 the imprisoned air is quickly absorbed, and the lung re-expands ; 
 but should it give rise to severe dyspnoea, it may be advisable to 
 remove the air by aspiration. 
 
 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-pressure, and thus decrease the amount of 
 blood carried to the uninjured lung, so as to enable it to cope with 
 the work of blood-aeration. This may be accomplished by ad- 
 ministering antimonial wine (10 to 15 minims every four or six 
 hours) combined with full doses of liquor ammoniae 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 with a purified finger or 
 probe is permissible, so as to determine whether portions of the 
 clothing have been carried in, or a rib comminuted ; all such loose 
 fragments must be removed, as also any penetrating foreign body, 
 such as a bullet, if accessible. The greatest gentleness must, 
 
SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST 857 
 
 however, be employed, since it is easy to dislodge clots lying in 
 the pulmonary tissues, and thereby restart the bleeding. As a 
 general rule, it is unnecessary to syringe out the deeper parts with 
 an antiseptic, since if one of the main bronchi has been opened, 
 the lotion might then find its way into the air-passages. The 
 insertion of a drainage-tube is scarcely called for as a routine 
 procedure, but it is advisable to lightly plug the wound with 
 gauze. 
 
 The chief danger arises from the loss of blood, and, as already 
 stated, this may come from division of an intercostal artery, or 
 from the lung. If of intercostal origin, it should be treated as 
 described at p. 244. Pulmonary hemorrhage is, unfortunately, not 
 so readily controlled ; and much difference of opinion has been 
 expressed as to the most satisfactory means to adopt in these 
 cases. Probably the best method consists in keeping the patient 
 absolutely quiet, and trusting to the application of cold to the 
 side, and to the administration of haemostatics, as indicated above 
 for non-penetrating wounds. In bad cases the haemorrhage may 
 only cease when the patient is in a condition of profound collapse 
 or syncope ; intravenous infusion of saline solution may then 
 suffice to tide him over the period of danger, and lead to a 
 successful result. 
 
 Two other plans of treating pulmonary haemorrhage which 
 have been recommended may be noted, viz., venesection from 
 the systemic circulation so as to reduce blood-pressure, and thus 
 obtain thrombosis ; and plugging the wound in the parietes so 
 as to cause the blood to accumulate in the pleural cavity, and 
 thus by its pressure lead to a similar result. Neither of these 
 methods commends itself to us, although both are occasionally 
 successful, and possibly would be the only plans practicable in 
 dealing with a large number of wounded. The latter of the two 
 has an additional objection in that it is almost certain to be 
 followed by suppuration and septic fever, necessitating the opening 
 and washing out of the pleural cavity at a later date. 
 
 The question of opening the thorax by resecting a considerable 
 portion of rib, so as to deal directly with the injured lung, has 
 been raised of recent years, and several cases in which it has 
 been undertaken have been recorded. Whether or not such 
 practice is justifiable is a question that further experience can 
 alone decide ; at present all w T e can say is that a surgeon should 
 be prepared to do this operation, although only resorting to it in 
 exceptional circumstances. 
 
 The later treatment of these cases is much the same as for 
 simple non-penetrating injuries. Should symptoms of septic 
 pleurisy follow, the wound must be freely opened, a portion of 
 rib being excised, if necessary, and the cavity washed out and 
 drained, as for empyema. 
 
 Hernia of the Lung, or pneumocele, is a rare condition in which 
 
858 A MANUAL OF SURGERY 
 
 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 auscultation 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. 
 If left unreduced, 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, results not 
 only from traumatism, but also as a sequela of a simple pleurisy, 
 or as a complication of various affections of the lungs, whilst a 
 basal empyema is not an uncommon result of intra-abdominal 
 suppuration. A description of the physical signs and symptoms 
 belongs rather to the physician than to the surgeon. It will suffice 
 to mention here that the affected side of the chest does not move 
 on inspiration, whilst there may be some bulging of the inter- 
 costal spaces ; on percussion the side is dull, except perhaps 
 immediately below the clavicle, where tympanitic resonance 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 dyspnoea is usually present in cases of 
 empyema, whilst the other thoracic viscera may be displaced. 
 Left to itself, an empyema usually finds its way to the surface, 
 and perhaps most commonly bursts through the fifth or sixth 
 costal interspace, though sometimes through the second in front, 
 owing to the perforating vessels being larger here than elsewhere. 
 Occasionally a localized empyema is met with, giving rise to 
 similar effects, but on a smaller scale. When situated on the left 
 side in close proximity 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, 
 
SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST 859 
 
 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 expan- 
 sion, 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) The opposite lung undergoes 
 expansion and hypertrophy, and together with the heart projects 
 over to the opposite side ; (b) the abdominal viscera and dia- 
 phragm are displaced upwards ; (c) the chest wall falls in, and the 
 spine becomes laterally curved, with its convexity to the sound 
 side ; and (d) there is an exuberant growth of granulation tissue 
 from the surface of the pleura. In a certain proportion of cases 
 these structural changes suffice to determine a cure, but in others 
 a cavity still remains, lined with thickened pyogenic membrane, 
 and discharging pus or serum, according to whether or not sepsis 
 is present. Under these circumstances extensive operative inter- 
 ference is necessary. 
 
 The Diagnosis of empyema is readily made by attention to the 
 physical signs, and confirmation of such an opinion can be obtained 
 by puncture with a sterilized hypodermic syringe. A medium- 
 sized needle should always be employed for this purpose, and it is 
 well to insert it along the top of a rib after drawing the skin up 
 or down, so that on removal a valvular puncture results. The 
 character of the organisms contained in the sample of pus thus 
 withdrawn should, if possible, be ascertained, since it has been 
 proved that the Prognosis depends much on this point. Thus, 
 an empyema due to the presence of pneumococci, presumably 
 following a pneumonia, runs a mild course, and is readily cured, 
 even by aspiration alone ; one due to the ordinary pyogenic cocci 
 is more acute, and requires drainage with or without resection 
 of a piece of rib. The presence of tubercle bacilli renders the 
 outlook much more serious, whilst the addition of septic organisms 
 to any of the above aggravates the process and much impedes 
 a cure. The chronicity or not of the affection is also a most 
 important element in the prognosis, since the later the treatment 
 commences, the denser are the adhesions which bind down the 
 lung, and the less the chance of its re-expansion. 
 
 Treatment therefore should never be delayed ; the earlier it is 
 undertaken, the better the results. 
 
 Aspiration may be adopted in the first instance, but is generally 
 to be regarded as of an exploratory nature, though a cure will 
 
860 A MANUAL OF SURGERY 
 
 occasionally follow when the empyema is of pneumonic origin. 
 It is, however, sometimes of value in order to relieve for a time 
 the pressure on the other lung and the resulting dyspnoea, and 
 thus allow of the administration of an anaesthetic for the more 
 serious subsequent operation. 
 
 Drainage of the pleural cavity through an external incision is 
 the treatment almost invariably necessary, and the opening is 
 best made either in the mid-axillary line or a little in front of it, 
 through the fifth costal interspace. Under special circumstances 
 it may be necessary to open the pleural cavity at a lower level, 
 and then the ninth or tenth interspace in the scapular line is 
 selected. Whether a portion of rib need be removed or not, is 
 merely a question of mechanical convenience; if the drainage-tube 
 can be efficiently retained between the ribs without resection, well 
 and good ; but if, as in children, the space is narrow, then a 
 portion of rib must be removed. 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 curved raspatory to be passed beneath it ; at 
 least i inch of the rib is then cut away with bone pliers. The 
 parietal pleura is opened sufficiently to enable the finger to be 
 introduced and the cavity explored. A large drainage-tube is 
 inserted, just long enough to project into the pleural cavity, and 
 the wound immediately covered, so as to prevent as far as possible 
 the entrance of unfiltered air. 
 
 Formerly it was considered desirable to thoroughly wash out 
 the pus ; but it has now been demonstrated that such is unneces- 
 sary, and occasionally dangerous. Several cases of sudden death 
 have followed this practice, probably due to reflex irritation of the 
 vagus. In chronic cases, where sepsis has been admitted, irriga- 
 tion is often beneficial, but the following points must be attended 
 to : (i.) The fluid employed must be unirritating, though sterile ; 
 (ii.) it must be at the temperature of the body, neither too hot nor 
 too cold ; (iii.) it must not be injected with such force as to impinge 
 against the pleura or against the upper surface of the diaphragm ; 
 and (iv.) free exit must be given to it, so as to prevent tension 
 from accumulation within the pleural cavity. 
 
 If such treatment is undertaken sufficiently early, the lung may 
 be expected to expand, the discharge steadily diminishing, and the 
 wound ultimately healing; but, as we have already explained, such 
 does not always occur, and then a fistula persists, leading into a 
 cavity lined with a thick pyogenic membrane, discharging a variable 
 amount of pus. The best means of obtaining a cure in these cases 
 consists in removal of the rigid external wall, as by Estlander's 
 operation, which is characterized 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 
 
SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST 86 1 
 
 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 Schedes operation, in which not 
 only are the ribs removed, but also the intervening 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 introduced and practised with success is 
 the stripping of the thickened pleura away from the collapsed 
 lung, so as to enable it to expand once more (pulmonary decortica- 
 tion). Further experience is needed before any final opinion as 
 to the merits of these operations can be given. 
 
 Various operative proceedings have been directed to the lung 
 substance itself, concerning which, however, we can but suggest 
 a few points. 
 
 Pueumotomy, 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 in cavities located 
 in the lower half of the lung, which drain badly, and the difficulty 
 of diagnosing such a condition is considerable. 2. For bronchiectases 
 pneumotomy, though prima facie desirable, has given but little 
 benefit, since it is uncommon for only one dilatation of the bronchus 
 to exist. In suitable cases, however, where there is a good deal of 
 foetid secretion, which is with difficulty expelled, it may be useful. 
 3. In gangrene of the lung much benefit may be derived. 4. The 
 same is true as regards pulmonary abscess following pneumonia. 
 5. In hydatid disease of the lung, incision and drainage have so 
 considerably reduced the mortality that this method of 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 
 
862 A MANUAL OF SURGERY 
 
 removed. If the lung is adherent to the thoracic walls, and shows 
 no signs of retracting, the operation may be continued ; but if no 
 adhesions are present, it may be well to stuff the wound with gauze 
 for a day or two, so as to determine their formation and thus shut 
 off the pleural cavity. The lung itself may be punctured with sinus 
 forceps introduced along an exploring needle, and then opened, or 
 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 the 
 physician, whilst if it is more diffuse it cannot be extirpated. 
 Primary malignant tumours of the lung, moreover, are usually 
 central, and the diagnosis can rarely be made early enough to 
 warrant an attempt at removal. The only conditions under v/hich 
 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. 
 
 Wounds of the Heart. 
 
 Wounds of the Heart and great vessels are so usually fatal 
 either immediately or within a few hours, that it is unnecessary 
 to discuss them here in any detail. If the patient does not die 
 at once, he suffers from intense shock and prostration, combined 
 with a weak and turbulent action of the heart, great pain in 
 the chest and dyspnoea, whilst the pulse is scarcely to be felt. 
 Free haemorrhage occurs if there is an external wound, but if 
 the opening in the pericardium is small and valvular, the heart's 
 action may be brought to a standstill by the pressure of the blood 
 within. Should the patient survive, pericarditis generally super- 
 venes, and is often of a purulent type. As to Treatment, the great 
 essential is to keep the individual absolutely quiet, and with the 
 head low. The external wound should be purified, but during 
 the stage of primary shock no attempt should be made to explore 
 it, either by finger or probe, for fear of dislodging a clot. Later 
 on the question of exploration may be raised, and more than one 
 case has now been published in which the surgeon has success- 
 fully sutured a stab-wound in the ventricle. To expose the heart 
 for this purpose it is usual to turn up a trap-door flap of the 
 chest wall, including portions of the fourth and fifth costal 
 
surgery of the air-passages, lungs, and chest 863 
 
 cartilages and ribs. Other cases are reported in which a wound 
 of the heart has healed spontaneously, and the patient survived 
 for many years. 
 
 Effusion into the Pericardium, whether serous or purulent, may 
 occasionally require surgical treatment in order to relieve symp- 
 toms of cardiac failure, due to the pressure of the exudation. 
 For serous pericarditis all that is needed is to aspirate the cavity. 
 This is usually undertaken close to the 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 a finger's 
 breadth from the border. 
 
 For suppurative pericarditis an incision may be made in the 
 
 Fig. 310. — Artificial Respiration by Sylvester's Method (First Stage). 
 
 The arms are grasped just above the elbows, and raised well above the head 
 so as to expand the thorax. 
 
 same situation after removing the fourth or fifth costal cartilage, 
 the cavity washed out, and even a drainage-tube inserted. Care 
 must be taken to prevent infection of the mediastinal tissues, and 
 this can sometimes be accomplished by stitching the pericardium 
 to the parietes before opening it. 
 
 Asphyxia. 
 
 Asphyxia, or Apncea, 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 
 obstruction is so marked that the patient is obliged to maintain the upright 
 sitting position, the term Orthopnea is applied to it. 
 
 The Causes of asphyxia may be classified as follows : 
 
 1. Conditions arising from the presence of abnormal contents within the 
 
864 
 
 A MANUAL OF SURGERY 
 
 air-passages, e.g. , foreign bodies, blood-clot, or pus from the bursting of an 
 abscess or aneurism ; 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.g., 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 respiratory 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 in 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.g., in the 
 neck : strangling, hanging, garrotting, etc. ; the presence of tumours, such as 
 
 Fig. 311. 
 
 -Sylvester's Method of Artificial Respiration 
 (Second Stage). 
 
 The arms are brought down to the side, and pressed firmly inwards against the 
 thoracic parietes so as to expel the air. These two stages are alternately 
 repeated about fifteen times in the minute. 
 
 goitres or aneurisms ; a retro-pharyngeal abscess or tumour, and, under 
 exceptional circumstances, displacement backwards of the sternal end of the 
 clavicle. Within the thorax gradually increasing obstruction to the respiration 
 may be caused by the presence of tumours, aneurisms, or effusion into the 
 pericardium or pleura. 
 
 4. Nervous causes, e.g. , paralysis or spasm of the larynx, and paralysis of the 
 diaphragm, either from peripheral lesions, such as the pressure of aneurisms 
 or tumours on the nerve trunks, or from central causes, such as a lesion in the 
 upper part of the spinal cord or medulla. It may also arise from paralysis of 
 the respiratory centre, as from an overdose of chloroform. 
 
 5. In many forms of cardiac disease the lungs may become engorged with 
 stagnant blood, leading gradually to dyspnoea, orthopnoea, and finally asphyxia, 
 owing to the increasing difficulty in eliminating the excessive accumulation of 
 carbonic acid. 
 
SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST 865 
 
 The Treatment of the different conditions giving rise to asphyxia cannot here 
 be dealt with in extenso. We can only indicate the general plan of treatment 
 to be adopted. A rapid examination is at once made, to ascertain, if possible, 
 the cause of the mischief, and whether its onset has been gradual or sudden. 
 If it has been gradually 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 any 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 arti- 
 ficial 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 electrode being 
 placed over the neck, and the other on the epigastrium. The administra- 
 tion of oxygen instead of air is useful during the earlier stages, whilst if the 
 condition is due to cardiac disease with distension of the right side of the 
 heart, venesection holds out the best hope of relief. Obstruction within the 
 larynx needs tracheotomy or intubation, as also other conditions associated 
 with pressure on the trachea. 
 
 In cases of threatened death from drowning, the first care must be directed 
 to clearing the air-passages and mouth of water, weeds, etc., by rapid inver- 
 sion, drawing the tongue well forwards, and swabbing out the pharynx ; or the 
 patient is turned on his face, with a firm pillow, or coat rolled up, placed 
 beneath the thorax ; and the chest is compressed so as to help in the evacua- 
 tion of the water, which runs out of the mouth. Artificial respiration can 
 then be commenced. 
 
 Artificial Respiration is required in a variety of surgical conditions, and is 
 best 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 (Fig. 310). This position is main- 
 tained for about two seconds, and then the arms are lowered to the side, and 
 pressed firmly against the ribs, so as to determine a forcible expiratory act 
 (Fig. 311). 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 unnecessarily hurry over it, as harm rather than good thereby results. 
 
 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 supply 
 
 55 
 
CHAPTER XXXI. 
 
 DISEASES OF THE BREAST. 
 
 Congenital Malformations of the breast are much more common 
 than is usually supposed. One or more accessory breasts or 
 nipples are found either below the normal one or just above it, 
 but sometimes they have been found in the axilla, on the outer 
 side of the thigh, or other curious situations. They are often of 
 a most rudimentary nature, but in a few cases they have secreted 
 milk. The existence of these structures probably explains the 
 occasional origin of cancer in unusual situations, such as the 
 axilla. Very rarely the breasts are entirely absent. 
 
 Affections of the Nipple. 
 
 Fissures of the Nipple (cracked nipples) seldom occur apart from 
 lactation, and may usually be traced to a want of care and cleanli- 
 ness on the part of the mother, associated with a tender condition 
 of the skin, which might have been prevented by bathing the 
 parts during the later weeks of pregnancy with spirit, so as to 
 harden them. The actual lesion is brought about by leaving the 
 nipples wet after nursing. The superficial layers of epithelium 
 become macerated, and are easily rubbed off, thus exposing the 
 more delicate and sensitive deeper parts, which are irritated and 
 inflamed by the repeated acts of suction. As a result, nursing 
 becomes painful, and if persisted in, the wound may be infected, 
 the inflammation spreading to the breast substance along the 
 duct or lymphatics, 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 
 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 formed, 
 it should be dressed with cooling or antiseptic lotions — e.g., lotio 
 plumbi or lotio acidi borici. Sometimes more stimulating appli- 
 cations are required, such as a solution of sulphate of copper, 
 
DISEASES OF THE BREAST 867 
 
 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 by 
 some supposed to be due to the presence and action of psorosperms. 
 It presents a smooth, red, raw surface, discharging an abundant 
 yellowish viscid fluid, and may occasionally spread widely beyond 
 the areola. It is almost invariably a precursor of cancer, and, 
 indeed, some authorities maintain that from the first the disease is 
 malignant, and not eczematous, in nature. The cancerous tumour 
 is usually located beneath the nipple, and may resemble either a 
 duct cancer, or an ordinary scirrhus. No local treatment is of any 
 avail, and the disease, when once recognised with certainty, is best 
 treated by 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 is rarely seen in the mothers of syphilitic 
 children (Colles's law, p. 136), but much more commonly in wet 
 nurses. 
 
 Primary Tumours of the Nipple are met with, such as papilloma, 
 sebaceous cysts, and occasionally epithelioma. 
 
 Inflammatory Affections of the Breast. 
 
 Acub3 Mastitis is naturally most often observed is 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 results most commonly from a sore or 
 cracked nipple, through which pyogenic organisms find their 
 way into the breast substance, either along the lymphatics or 
 the gland ducts. In the former case the inflammation is mainly 
 interstitial in character, the pus diffusing itself widely between 
 the lobules ; in the latter the pus forms primarily within the 
 alveoli of the glandular substance, but subsequently spreads 
 beyond it. Simple obstruction to one or more of the ducts from 
 inflammation of the nipple, without any external wound, also 
 determines inflammation, which is frequently non-suppurative in 
 character. In non-puerperal women acute mastitis may result from 
 injury, or may be pyaemic in origin. Occasionally a metastatic 
 inflammation of the breast occurs after the disappearance of the 
 parotid swelling in mumps ; whilst in girls about the age of 
 puberty a subacute inflammation, involving both the breast and 
 areola, and even terminating in suppuration, has been observed. 
 In newly-born infants a similar inflammation, occasionally running 
 on to suppuration, has been seen, possibly resulting from an 
 infection of the gland ducts during birth with cocci from the 
 maternal passages. A slight enlargement, with congestion of the 
 
 55—2 
 
868 A MANUAL OF SURGERY 
 
 breasts, often occurs after birth, and may be due to, or is certainly 
 aggravated by, the foolish habit followed by ignorant midwives of 
 pulling or forcibly squeezing them in order ' to break the nipple- 
 strings.' 
 
 Signs and Symptoms. — An inflamed breast is characterized by the 
 organ becoming swollen, acutely painful, and tender. The gland 
 lobules are felt to be enlarged and indurated, whilst if lactation is 
 progressing, the secretion is to some extent impaired ; but owing 
 to the inability of the mother to allow the child to relieve the 
 organ, on account of the pain produced thereby, considerable ten- 
 sion results from accumulation of milk. If suppuration follows, 
 the skin over the breast becomes red and cedematous, 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 sub- 
 cutaneous tissue ; it is often entirely unconnected with the organ, 
 or may originate in the superficial lobules. It is strictly limited, 
 and does not burrow deeply, coming readily to the surface. 
 (b) An intvamammavy abscess is that most commonly met with, 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 is one forming in the cellular tissue beneath 
 the breast. It may spread from the deep lobules, but more 
 frequently arises in connection with disease of some of the 
 adjacent ribs or cartilages, or as a cellulitis. In these cases the 
 breast is pushed forwards, and becomes prominent, floating, as 
 it were, on a bed of pus. The abscess usually points at the 
 periphery of the organ, perhaps in several places, but most com- 
 monly at the lower and outer quadrant. 
 
 Inflammation of the breast occurs in women who are anaemic 
 and weakly. Even the simple forms are associated with some 
 fever and malaise, and this becomes greatly exaggerated if 
 suppuration ensues, owing partly to the severe pain thereby 
 induced, and partly to the absorption of toxins. 
 
 The Treatment of simple acute mastitis consists, in the first 
 place, in supporting the inflamed gland by means of a sling or 
 bandage, and in binding the arm to the side, so as to keep at 
 rest the pectoral muscle, on which it lies. Fomentations are 
 then applied, and any tension due to retained secretion is relieved 
 by the breast-pump. The bowels are opened, and the patient 
 placed on a light and nourishing diet, whilst stimulants and 
 tonics, such as iron and quinine, may be judiciously administered. 
 
 As soon as the acute stage has passed, friction with warm 
 oil, or the inunction of a belladonna ointment, is advisable. 
 
DISEASES OF THE BREAST 869 
 
 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 little in 
 which direction the cat is made, since the pus is always superficial 
 to the breast tissue. In the true intvamammary abscess, the incisions 
 should radiate from the nipple. One or more may be needed, 
 and these should be made with a free hand, so as to allow of the 
 insertion of the finger, and the opening up of any pockets or 
 lobules which are distended with matter. A drainage-tube is 
 inserted for a time, and gradually shortened day by day, until 
 its entire removal is permissible. When the chief incisions are 
 needed above the nipple, it is often wise to make a counter-opening 
 in the lower half of the breast, and generally on the outer side, 
 to permit of more efficient drainage. With such treatment the 
 best of results may be attained, and it is interesting to note how 
 quickly the contour of the breast is restored, and how slight is the 
 permanent injury inflicted on the parts. The submammary abscess 
 is best opened towards the lower and outer side, but also at any 
 spot where pus points. 
 
 If septic sinuses persist after an abscess has burst, their orifices 
 should be enlarged, and their walls thoroughly scraped and dis- 
 infected ; deep cavities should be efficiently drained and stuffed 
 with gauze, so as to ensure the wounds healing by granulation. 
 
 Chronic Mastitis occurs in two forms — one, a localized affection 
 of one segment of the breast (chronic lobar mastitis), the other 
 involving the smaller lobules and interstitial tissue (chronic lobular 
 or interstitial mastitis). 
 
 1. Chronic Lobar Mastitis is by no means unfrequent as a 
 result of imperfect involution of the organs at the cessation of 
 lactation, but may arise from blows or squeezes, and especially 
 in young women ; it may also follow a subacute or acute attack, 
 which has not ended in suppuration. It is characterized by 
 an enlargement of one or more lobes of the organ, which are 
 usually tender, and often excessively painful, the pain being of 
 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. All 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 of 
 much interest, which occurs most frequently in women with small 
 or atrophic breasts, who have passed, or are near to, the climacteric, 
 
870 A MANUAL OF SURGERY 
 
 being then merely an exaggeration of the sclerosis which occurs 
 normally at that epoch. It is, however, sometimes met with at 
 an earlier age. Pathologically, it is characterized by diffuse over- 
 growth and infiltration of the connective tissue, which becomes 
 sclerosed and thickened. 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 by liquefaction of this proliferated epithelium, partly 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 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 give the patient 
 the impression of a tumour. 
 
 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 dis- 
 charge from the nipple is sometimes noticed. The skin seldom 
 becomes adherent to the swelling, whilst the lymphatic glands in 
 the axilla may be enlarged and tender owing to sympathetic 
 irritation. On careful examination of the breast, the affection is 
 rarely limited to one particular region, for although a distinct 
 enlargement of one portion may be present, yet the whole 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 on careful palpation, 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 disappear ; 
 but more frequently it slowly progresses, and then results in 
 one of three conditions : (a) General atrophy, the breast becoming 
 shrunken, hard, and nodular, (b) More frequently general cystic 
 disease follows, a condition in which the organ becomes trans- 
 formed 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 ; but there is abundant evidence to prove 
 that any continued source of irritation in an organ like the breast 
 
DISEASES OF THE BREAST S71 
 
 renders an individual with a cancerous tendency more liable to 
 its development. 
 
 The Diagnosis is sometimes easy, but the condition often 
 simulates somewhat closely a scirrhous tumour. The chief 
 points of distinction, 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 ; (hi.) that enlargement of the 
 axillary glands is less common than in scirrhus, and even if en- 
 larged 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 hard- 
 ness of a scirrhus; and (vi.) that it is often more disseminated 
 and less defined than a cancerous growth. (vii.) Moreover, 
 on careful palpation with the flat of the hand, it is often impos- 
 sible 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 in- 
 flammatory mass. Of course it is possible for the two conditions 
 to co-exist, and in doubtful cases an exploratory incision, and 
 microscopic examination of a portion of the tissue, can alone be 
 depended on. 
 
 Treatment. — In the early stages friction with some sedative 
 application may be used at the same time that the breast is 
 supported, and freed from the irritation of badly-fitting stays. 
 Firm and equable pressure, as by strapping, is also useful in some 
 cases, whilst iodide of potassium may be administered. If a definite 
 tumour is present, or if many cysts 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 may be 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 mistaken 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. Some few of these chronic 
 abscesses of the breast are of a tuberculous nature. 
 
$Ji A MANUAL OF SURGERY 
 
 Treatment consists in opening the abscess cavity, scraping out 
 its interior, disinfecting with pure carbolic acid, if tuberculous, and 
 draining or stuffing it. 
 
 Diffuse Tuberculous Disease of the breast is 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 
 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 different forms of cystic changes are 
 associated therewith. The following are the more important : 
 
 i. Acinous or Retention Cysts arise, as the name suggests, from 
 some obstruction to the ducts or lobules, whereby the secretion of 
 the organ is unable to escape. They are met with most frequently 
 in women during or after the puerperal period, a milk cyst, or 
 galactocele, being then produced. It usually results from compres- 
 sion of one or more of the ducts, connected with a sore nipple, and 
 contains inspissated milk ; it forms a rounded swelling, and is 
 located near the nipple. The wall is lined with cuboidal 01 
 columnar epithelium, according to whether a portion of the lobule 
 or the duct itself is implicated ; if, however, it attains any great 
 size, the epithelium may become flat and squamous. This is sur- 
 rounded by a fibro-cicatricial layer, the thickness of which increases 
 with the chronicity of the case. It is treated by laying the part 
 open, removing the contents, and stuffing or draining the cavity. 
 
DISEASES OF THE BREAST 873 
 
 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 supervene. 
 
 Retention cysts have also been described as resulting from 
 irritation of the nipple, as, for instance, when a young non- 
 pregnant woman constantly puts a baby to her breast ; the 
 organ becomes enlarged, the epithelium proliferates, and a thin 
 serous fluid is secreted, which does not entirely escape and by 
 its distension of the lobules gives rise to what may be termed 
 irritation cysts. They may in time undergo spontaneous absorp- 
 tion, but Erichsen describes a case of this nature in which the 
 swellings did not disappear until the patient subsequently became 
 pregnant. 
 
 Again, one 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 C/sbs originate, it is supposed, from a dilatation of 
 lymph spaces. They may be uni- or multi-locular, perhaps more 
 frequently the latter. They are lined by a smooth, shiny layer of 
 endothelium, and contain serum, perhaps blood-stained, and in 
 old-standing cases cholesterine ; being separate from the gland- 
 substance, they never give rise to a discharge from the nipple, and 
 intracystic growths are unknown. They are usually surrounded 
 by a wall of connective tissue which may become exceedingly 
 thick and dense. Occasionally, however, they project under the 
 skin, and if the walls remain thin, fluctuation, and even trans- 
 lucency, 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 
 enlargement 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 by inserting a grooved needle, or by an 
 exploratory incision, which should be made of sufficient depth to 
 
874 A MANUAL OF SURGERY 
 
 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. 
 
 (b) True Hydatid Cysts are occasionally met with, manifesting 
 the general characteristics described at p. 189. 
 
 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. 
 
 Tumours of the Breast. 
 
 In investigating any case of tumour of the breast, the surgeon 
 must never arrive at a hasty conclusion, but only give an opinion 
 as to its nature after a careful and detailed examination. Thus, 
 the age and previous history of the patient should be considered, 
 as also the family history. Simple tumours generally arise at an 
 earlier date than the malignant, whilst the sarcomata usually 
 affect younger individuals than the carcinomata. There can be 
 little doubt, moreover, as to the occasional tendency of tumours 
 to run in families. The length of time for which the swelling 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 limited if 
 the tumour has invaded the muscle, or even if the overlying fascia 
 
DISEASES OF THE BREAST 875 
 
 is seriously involved. Finally, the lymphatic glands in the axilla 
 must be carefully examined, as also, in suspicious cases, the 
 supraclavicular 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. — Four different varieties of 
 tumour are included in this group, viz., the adenoma, adeno- 
 fibroma, the so-called adeno-sarcoma, and the cysto-adenoma. 
 Each of these is characterized pathologically by the following 
 conditions : (a) Spaces lined by cuboidal epithelium are present in 
 all ; they may be tubular or slit-like in nature, simulating normal 
 gland tissue, or they may become distended and cystic, (b) The 
 epithelium lining their walls is in one or more layers, but scarcely 
 ever arranged so methodically or evenly as in the normal structure. 
 It is always limited by the basement membrane, and has no 
 tendency to extend beyond it. (c) The spaces usually contain 
 fluid, more or less abundant according to the amount of dilatation 
 present, and generally serous in character, though perhaps brown 
 or reddish in colour from admixture with blood, (d) Not un- 
 frequently intracystic growths are present, and in one form, the 
 cysto-adenoma, these are a specially prominent feature of the 
 case, (e) The alveolar spaces are surrounded by interstitial tissue, 
 which may vary considerably in amount, and be either simple or 
 complex in structure. 
 
 Pure Adenoma Mammae is said to exist when the proportion of 
 interstitial tissue to gland substance is similar to that which obtains 
 elsewhere in the breast. It is very uncommon and requires no 
 special notice, the clinical characters not differing from those of 
 fibro-adenoma, and its pathological nature being only specifically 
 recognised on microscopic examination. 
 
 Fibro-adenoma (or Adeno-fibroma) is the most common mam- 
 mary 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. 312) ; if situated deeply, 
 it still appears freely moveable, but its definition is less evident. 
 Sometimes several such growths are found in the same breast. 
 A fibro-adenoma is usually firm, and more or less elastic in con- 
 sistency, of slow growth, whilst it may be either painless, or in 
 anaemic and neurotic women exceedingly painful, the pain often 
 increasing at the menstrual 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, whilst the skin over it does not dimple. The general 
 
S76 
 
 A MANUAL OF SURGERY 
 
 health is unimpaired unless the patient is suffering from an 
 associated anaemia. On section after removal the tumour is of 
 a greyish-white colour, becoming pink on exposure to the air. 
 It is more or less foliated in texture, being compared by Virchow 
 to the section of a cabbage ; no juice can be obtained on scraping 
 the cut surface with a scalpel, although on pressure some fluid 
 of a thick glutinous or mucoid nature may escape. Microscopi- 
 cally, the tumour consists of imperfectly developed glandular 
 elemenis, surrounded by a considerable amount of firm interstitial 
 tissue, 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 con- 
 
 Fig. 31: 
 
 -flbro- adenoma mamm.e. (from mltseum of roval 
 College of Surgeons.) 
 
 verted 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 malig- 
 nant 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 effected 
 by cutting down upon the tumour in a direction radiating from 
 the nipple, until the capsule is reached, when the mass is enu- 
 cleated from its surroundings with a few touches of the knife. 
 
 Diffuse Hypertrophy of the breast (Fig. 313) is usually fibro- 
 adenomatous in nature, and consists of a general enlargement of 
 the organ, both gland substance and interstitial tissue participating 
 
DISEASES OE THE BREAST 
 
 877 
 
 in the process, and hence the breast becomes firm and indurated. 
 It may be uni- or bi-lateral, perhaps more frequently the latter, 
 and generally occurs in adolescents. The size varies considerably, 
 but the breasts may become enormous, hanging down by their 
 weight, and perhaps to such an extent as to rest on the knees of 
 the patient when sitting. They are usually painless, although 
 sometimes neuralgia is noticed. Functionally they are useless, as 
 even if the patient becomes pregnant, secretion of milk but rarely 
 occurs. The only treatment is amputation. 
 
 Fig. 313. — 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 gh lbs., the right breast 9 lbs. 
 
 The so-called Adeno-sarcoma is very similar in type to the 
 adenoma, differing from it mainly in the increased rate of growth, 
 in its soft consistency, and in the fact that the interstitial tissue is 
 of a more embryonic character, and, indeed, is often of a mucoid 
 nature. It is really a soft fibro-adenoma, and usually occurs in 
 women at a somewhat earlier period of life than sarcoma or 
 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 simple hard or 
 chronic fibro-adenoma, which, after remaining quiet for a time, 
 takes on a more active development. It remains, however, 
 
8 7 8 
 
 A MANUAL OF SURGERY 
 
 throughout its course strictly encapsuled, and when large may 
 lead to pressure atrophy of the true gland substance. It is soft 
 and elastic in consistency, usually painless, and freely moveable 
 on the surrounding breast tissue. The skin over it remains 
 healthy, although distended and atrophic when the tumour is of 
 large size ; the nipple shows no sign of retraction ; the axillary 
 glands are not involved, and there is no systemic invasion. On 
 removal the section is similar to that of a fibro-adenoma, but cysts 
 are often present, as also areas of mucoid softening, somewhat 
 resembling sago. It can be readily removed in its entirety, and 
 does not tend to recur. 
 
 Cysto-adenoma (Syn. : Cysto- sarcoma, Adenocele, etc.) is a con- 
 dition characterized by a marked development of intracystic 
 growths, fibro-papillomatous in nature, within the dilated acini 
 
 Fig. 314. — Cysto-adenoma Mamm.t.. (Museum of Royal College of 
 
 Surgeons.) 
 
 The fibro-papillomatous growths are seen projecting from a large cyst, into 
 which a bristle, passed down the nipple, enters. A glass rod has been 
 passed through a perforation in the skin into the cyst. 
 
 of a newly-formed mass of adenomatous tissue, or within the 
 smaller ducts (Fig. 314). 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 intracystic growths also varying in amount. These 
 latter consist of branched processes something like a cauliflower 
 in appearance, covered with cuboidal or columnar epithelium ; 
 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 
 
DISEASES OF THE BREAST 879 
 
 before it. The tumour produced is irregular in outline, owing to 
 the projection of the cysts ; it is usually painless, and unaccom- 
 panied by enlargement of the axillary glands ; if of large size, blue 
 veins are seen coursing over it. In the later stages the capsule 
 becomes adherent to the integument, and, finally, owing to the 
 pressure of the tumour, the skin may give way, allowing the 
 growth to protrude. Such will be followed by the development 
 of a fungating mass, which bleeds readily, and becomes extremely 
 offensive. With care a probe can be passed between the intra- 
 cystic 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 fun- 
 gating 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 
 consequence 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 pro- 
 minent. It is often the precursor of a duct cancer. Amputation 
 of the breast will in many cases be needed, although it may be 
 feasible in some to deal with the tumour alone. 
 
 Sarcoma of the Breast is not a common disease. It originates 
 in the connective tissue of the organ, being deeply placed in its 
 substance, or perhaps more frequently developing in the outer 
 and upper quadrant. It is of two chief types : (a) The round- 
 celled sarcoma forms a soft, somewhat elastic swelling, which 
 grows rapidly, and although often limited at first by a fibrous 
 membrane, the capsule tends sooner or later to give way, allowing 
 the growth to become diffused through the organ. It sometimes 
 gives rise to secondary growths in the axillary glands, or becomes 
 disseminated throughout the body by means of the bloodvessels. 
 Cysts often occur in its substance, resulting either from haemor- 
 rhage or occasionally from the dilatation of an incorporated 
 glandular alveolus ; in the latter case the cavity will be lined 
 with epithelium. Myxomatous changes are also not ^infrequently 
 observed, and in the more rapidly growing recurrent tumours 
 the mass is often a true myxo-sarcoma. It usually occurs in 
 women between the ages of thirty and forty, i.e., somewhat earlier 
 than scirrhus, whilst its rapid growth and the absence of 
 retraction of the nipple or dimpling of the skin are useful 
 diagnostic features. Should pregnancy follow, the tumour may 
 
880 A MANUAL OF SURGERY 
 
 increase in size at an alarming rate. In the infiltrating forms it 
 is almost impossible to distinguish it from encephaloid cancer, 
 except on microscopic examination, (b) A spindle-celled sarcoma, 
 or fibro-sarcoma, is also met with, forming a rounded or oval 
 tumour, more limited than the above, and growing somewhat less 
 rapidly. It somewhat simulates an adenoma, but is more closely 
 connected with the breast substance. The axillary glands are 
 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. 
 
 etiology. — The breast is an organ subject to great changes 
 in functional activity, richly supplied with blood, and closely 
 associated by nervous connections with other organs of the body, 
 especially the uterus. At the climacteric its functions are at an 
 end, and as it always undergoes a certain amount of fibrosis or 
 degeneration, it can be readily understood that changes are 
 very likely to ensue which may result in the formation of a 
 cancerous tumour. Such is usually met with after the age of 
 forty, although the disease may prove fatal at a much earlier 
 date. It equally affects women who have borne children and 
 nulliparae, and the question whether or not the woman has nursed 
 her children seems to have but little influence. The left breast 
 is more often affected than the right. It is frequently attributed 
 to some injury, such as a blow or squeeze ; whilst there is little 
 doubt that badly-fitting stays are responsible for a certain per- 
 centage of the cases. It not uncommonly follows eczema 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 
 difficult 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 influence. 
 
 Two distinct types of cancer are met with in the breast — viz., 
 acinous or glandular cancer (including scirrhus and encephaloid), 
 
DISEASES OF THE BREAST 
 
 and duct cancer. Colloid degeneration of either of the former 
 varieties has been observed, but is very uncommon. 
 
 i. Acinous Cancer is the form almost invariably seen; the 
 division into scirrhus and encephaloid is entirely artificial, 
 depending 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 outer half of the organ. It is 
 closely united to, if not absolutely incorporated with, the breast 
 substance, and on careful digital examination its margin is not 
 so accurately defined as at first appears. In the early stages it 
 is entirely distinct from the skin, which moves freely over its 
 surface ; but as growth proceeds, the stroma contracts, and, by 
 dragging on the suspensory ligaments passing from the mamma 
 to the skin, the latter structure becomes more or less fixed, and 
 hence, on attempting to move it upon the tumour, an appearance 
 of dimpling results. At the same time, the whole breast is acted 
 upon in a similar manner, so that the affected organ often seems 
 to be smaller than the other ; and, since the upper half of the 
 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 
 tractionof the growth on the galactophorous ducts (Fig. 315). The 
 tumour itself is rarely one 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 
 type, extending to the shoulder, and perhaps only elicited on mani- 
 pulation. As the growth increases in size, it becomes adherent to 
 the pectoral fascia, and may even infiltrate the underlying muscular 
 substance, so that, on examination, with the arm extended and 
 abducted, it is found that, although moveable across the fibres of 
 the muscle, the breast cannot be moved with them. 
 
 The lymphatic glands in the axilla soon become enlarged, the 
 disease rarely lasting many months without this complication. 
 Those running with the long thoracic vessels under cover of the 
 pectoralis major are first involved, and, as the case progresses, 
 the remaining axillary and subscapular sets become similarly 
 affected, and even after a time the supraclavicular. When the 
 deeper part of the breast is attacked, the disease may spread to 
 the mediastinal glands along the lymphatics, which accompany 
 the nutrient vessels arising from the internal mammary trunk ; 
 and thus intrathoracic deposits develop, which even extend along 
 the subpleural connective tissue, and affect the pleural cavity and 
 lungs. In those cases where the primary growth is situated near 
 the inner border of the breast, the free lymphatic anastomosis 
 across the middle line allows of the transmission of the disease to 
 the glands in the opposite axilla, and sometimes a similar affection 
 of the opposite breast arises from this cause. 
 
 The skin may be implicated in many ways, (a) We have already 
 
 56 
 
S82 
 
 A MANUAL OF SURGERY 
 
 mentioned the dimpling which is met with over the tumour in the 
 early stages. As the case proceeds, the cancer extends outwards 
 along the suspensory bands of fascia, so that the skin itself becomes 
 invaded, feeling firm and brawny, and looking congested and 
 purplish in colour, whilst a branny desquamation is usually present. 
 A crack or fissure at length forms, giving exit to a little serous 
 discharge, which at first scabs over, but finally leaves an ulcerated 
 surface, which slowly extends, and may attain considerable dimen- 
 
 Fig. 315. — Scirrhus Mammae. (From a Photograph.) 
 
 The patient had allowed the tumour to grow for two years. The whole of the 
 left breast was infiltrated and raised above the level of the other organ ; 
 the nipple was retracted. 
 
 sions. A typical scirrhous ulcer is hollowed out and excavated ; its 
 surface, if kept clean, is covered with smooth granulations, dis- 
 charging a considerable amount of sanious fluid, but if neglected, 
 it becomes sloughy and offensive ; it is surrounded by a projecting 
 elevation of the tumour substance, forming a sort of rampart around 
 it. (b) Less commonly the disease becomes disseminated through 
 the skin, giving rise to a series of dusky-red, button-like masses of 
 cancer, surrounded by skin which is often apparently unaffected ; 
 
DISEASES OF THE BREAST 
 
 or the whole cutaneous surface of the organ may become infiltrated 
 and thickened, constituting the condition known as cancer en 
 cuirasse. In the earlier stages the skin is thickened and firmer than 
 usual ; but 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 (pcau cT orange of French authors). Later the 
 colour becomes dusky, and the skin so contracted and indurated 
 that it is impossible to wrinkle it ; the sebaceous glands may 
 
 Fig. 316. — Side View of the same Breast as in Fig. 315. 
 The retracted nipple is well seen, as also the commencing infiltration of the 
 skin towards the axilla, whilst the lineae albicantes are also infiltrated 
 and swollen. 
 
 exude an abundant secretion, which becomes inspissated on the 
 surface into crusts or scabs, which are independent of any ulcera- 
 tion. This process often extends widely beyond the limits of 
 the breast, invading the whole thoracic wall, and even running 
 over the shoulder to the back of the head or neck ; it is due to a 
 diffuse extension of the disease along the cutaneous lymphatics, 
 and in its most typical form is slow in its development, the patient 
 perhaps living for many years. Localized buttons or nodules of 
 
 56—2 
 
A MANUAL OF SURGERY 
 
 cancer are often found scattered through the affected area. 
 (c) Occasionally one meets with a much more rapid form of 
 cancerous lymphangitis, in which the skin becomes similarly 
 affected, but the growth is not unfrequently associated with what 
 is supposed to be a ' weeping ' eczema, due in reality to the 
 yielding of dilated lymphatics, that can be easily seen on 
 examining with a lens. The process spreads widely and rapidly, 
 and cancerous nodules appear here and there in the infiltrated 
 area ; the prognosis is of course very grave. 
 
 In the later stages, the patient passes into a state of cachexia, 
 becoming emaciated and exhausted. Ulcerated surfaces of con- 
 siderable size may exist, and the tumour is fixed to the thoracic 
 wall, even invading the ribs. The arm on the affected side is 
 swollen and brawny, owing to the pressure of the enlarged glands 
 on the main lymphatics and veins of the limb, constituting a 
 condition of lymphatic or solid oedema. Secondary deposits also 
 develop in the viscera, and may lead to various symptoms, 
 according to the situations in which they are placed. Finally, 
 death from exhaustion ends the scene. 
 
 Encephaloid or Acute Cancer occurs less frequently 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 tend 
 to 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 
 gradually invaded by the tumour, ulceration follows, and a foul 
 fungating mass sooner or later sprouts up through the opening. 
 The cancer that attacks young women is often of this type, and 
 the prognosis necessarily very grave. 
 
 Finally, in elderly women, a chronic form of cancer is met 
 with, known as Atrophic Scirrhus, in which the disease lasts for 
 many years without much definite extension. Cases have been 
 known to persist for fifteen or twenty years, the patient at 
 length dying of some intercurrent malady, although in the great 
 majority dissemination has ultimately occurred. The special 
 characters are due to the excessive contraction of the stroma, 
 as a result of which the cellular elements become crushed and 
 practically destroyed. The nipple is deeply retracted, and the 
 tumour and breast substance in the most marked cases are 
 scarcely discernible. 
 
 2. Duct Cancer is a somewhat rare form of the disease, the 
 exact nature of which is still under discussion, and there is very 
 little doubt that several distinct types have been described under 
 this name. It is sometimes characterized by the development of 
 one or more nodules of a malignant papillomatous nature within 
 the dilated ducts, and usually situated not far from the nipple. 
 These growths are covered with columnar epithelium, and may, 
 
DISEASES OF THE BREAST 885 
 
 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 pro- 
 liferated epithelial cells of a spheroidal type, which arrange 
 themselves into more or less definite papillomatous 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. 
 
 The duration of cancer varies considerably in the different forms. 
 The encephaloid type runs a rapid course, and will probably 
 destroy the patient's life in six to twelve months. Duct cancer 
 is very slightly malignant, whilst atrophic scirrhus is similarly 
 slow in growth, and in both death may be postponed for a con- 
 siderable period, or is often due to some intercurrent malady. 
 Cancer en cuirasse is variable in its course, being sometimes 
 tolerably rapid, and at others chronic ; it cannot be cured by 
 operation, on account of its early and extensive dissemination. 
 A circumscribed scirrhous tumour is stated to end fatally, on an 
 average, in two or three years if no operative treatment is under- 
 taken, whilst removal of the mass will probably add another 
 year or eighteen months to the patient's life. These figures 
 are, however, derived from statistics of operations performed 
 before the general adoption of the more exact and extensive 
 measures which are now usually undertaken, and it is likely that 
 they considerably under-estimate the benefits derived from such 
 interference. 
 
 The Pathological Anatomy of cancer is discussed in Chapter VII. 
 
 The Diagnosis of scirrhus from chronic interstitial mastitis and 
 chronic abscess or cyst has been already considered (p. 871). From 
 tumours of the adenoid type it is easily distinguished. The stony 
 hardness of a scirrhus, its union with the breast substance, its 
 limited mobility, the dimpling of the skin, retraction of the nipple, 
 and enlargement of the axillary glands, are the chief local charac- 
 teristics to be noted. Non-malignant tumours are more elastic 
 to the touch, more moveable, and usually quite circumscribed in 
 outline, whilst the skin, though expanded, does not become 
 adherent ; the nipple is rarely retracted, and the axillary glands 
 remain of normal size. It is often impossible to distinguish a 
 cancerous from a sarcomatous tumour, except on microscopic examina- 
 tion ; a round-celled sarcoma closely resembles an encephaloid 
 cancer, although it is usually more circumscribed — at any rate, 
 in the early stages. The fibro-sarcoma may sometimes be mis- 
 taken for scirrhus, but it is more defined in outline, does not cause 
 retraction of the nipple or dimpling of the skin, whilst lymphatic 
 
SSf, A MANUAL OF SURGERY 
 
 enlargement is not a constant accompaniment. A cysto -adenoma 
 presents no difficulty in diagnosis if the skin is entire, and the cysts 
 prominent ; but when ulceration has taken place, and a fungating 
 bleeding mass protrudes, it is not unlike the later stage of an 
 encephaloid cancer or fungating round-celled sarcoma. It can 
 be distinguished, however, by the fact that a probe can some- 
 times be passed under the skin for some distance into the cavity 
 of the cyst, whilst lymphatic enlargement is rare. 
 
 Treatment. — This necessarily consists in the removal of the 
 tumour by operation ; but in order to give the patient as good a 
 chance as possible of a permanent cure, the excision must include 
 the whole of the breast, the greater portion of the overlying 
 integument, the subjacent pectoral fascia, possibly a part of the 
 pectoral muscle, and the whole of the lymphatic and connective 
 tissues of the axilla. A full description of the operation is given 
 below, but we desire here to emphasize the fact that the pro- 
 ceeding should be very radical if the patient is to derive any real 
 benefit from it. In the old days, only the more prominent portion 
 of the breast was removed with the tumour, and consequently 
 recurrence was so exceedingly common that if 5 or 10 per cent, 
 of the patients were really cured, it was thought to be as much as 
 any surgeon could reasonably expect. Since we have learnt more 
 of the anatomy of the organ and of the pathogenesis of the disease 
 (for which we are mainly indebted to Heidenhain and Stiles), 
 more extensive proceedings have been undertaken, with a gradual 
 amelioration in the results, so that several surgeons have been 
 able to report 50 to 60 per cent, of their cases as free from recur- 
 rence at the end of three years. It was suggested by Volkmann 
 that any case that remains free from recurrence for three years 
 may be claimed as a cure, but this is generally considered too 
 short a period on which to base such an assumption, since experi- 
 ence tells us that the disease often reappears at a much later date 
 (even nine or ten years). 
 
 It has been proved that the breast is a much more extensive 
 organ than was formerly supposed, and if merely the projecting 
 portion is removed, many deep lobules are left, which may lead 
 to recurrence. Moreover, it has been shown that the deeper 
 lymphatics pass into the fascia covering the pectoralis major, and 
 so to the axilla ; hence, this structure should always be taken 
 away, as well as a thin layer of the muscular fibres in certain 
 cases. Again, lymphatics travel along the fibrous bands reach- 
 ing from the breast tissue to the overlying skin, and thus this 
 latter must never be dissected back from over, the tumour. The 
 nipple should under no circumstances be left behind, since all 
 the interlobular lymphatics converge to a plexus around it, and 
 reach the axilla by three or four main trunks. The axilla itself 
 should be opened in every case, and entirely cleared of its lym- 
 phatic contents, since deposits in the glands are often found on 
 
DISEASES OF THE BREAST 887 
 
 microscopic examination, where no clinical evidence of their 
 presence had been previously noted. It is also important to 
 remove the breast and axillary tissues in one piece, so as to avoid 
 division of the lymphatics and possible infection of the wound 
 with their cancerous contents. 
 
 Of late years Halsted of Baltimore has been urging the neces- 
 sity of removing the pectoral muscles with the breast in all cases 
 of cancer, in order to gain better access to the axilla, and also to 
 ensure the extirpation of the lymphatics which pass between or 
 through them. This is often termed the complete operation, and 
 is being largely employed. The clavicular portion of the great 
 pectoral is left, the sternal portion being removed from within 
 outwards, and the tendon divided close to the humerus. Whilst 
 admitting that this practice is good and desirable in cases where 
 the muscle is involved, or where there is much axillary infection, 
 we scarcely consider it necessary as a routine procedure. 
 
 As to the cases in which operation should or should not be 
 undertaken, the following facts must be noted : Cancer en cuivassc 
 should never be touched, since it is impossible to eradicate the 
 disease, owing to its wide dissemination through the cutaneous 
 lymphatics. Atrophic scirrhus also is often left alone, on 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. Apart from these, all cases in 
 which there is a reasonable prospect of eradicating the disease 
 may be subjected to operation. The following grave conditions, 
 however, require the most serious consideration : (i.) Where the 
 supraclavicular glands are enlarged, it seems hopeless to expect 
 that the whole disease can be eliminated, and yet one likes to give 
 the patient her only chance. The operation must then include the 
 supraclavicular fossa in its scope, as recommended by Halsted ; 
 he indeed goes so far as to maintain that the posterior triangle 
 should be cleared of its lymphatic contents in all cases, whether 
 or not enlarged glands can be detected beforehand, and states that 
 in a considerable percentage of cases cancerous invasion will have 
 already occurred. The cervical incision is a curved one, extend- 
 ing along the posterior border of the sterno-mastoid, and outwards 
 along the clavicle. This flap is dissected up, and all the fat and 
 glands are removed from before backwards, the internal jugular 
 vein being the starting-point. Of course, the greatest care is 
 taken to avoid the thoracic duct or right lymphatic trunk, 
 (ii.) If the tumour is adherent to the thoracic parietes, no opera- 
 tive interference is advisable, (iii.) Evidence of pressure on, or 
 implication of, the axillary nerves also precludes such treatment ; 
 slight oedema of the arm due to pressure on the main vein need 
 not deter the surgeon from proceeding, since the whole vein has 
 been successfully excised ; in such cases the collateral circulation 
 
888 
 
 A MANUAL OF SURGERY 
 
 has evidently been opened up previously, (iv.) Profound cachexia 
 and evidence of visceral deposits also contra-indicate operation, 
 except to give relief to the local pain, (v.) Extensive ulceration 
 and fungation, and general diffusion of the tumour through the 
 breast, are, as a rule, prohibitory signs, (vi.) Disease of both 
 breasts, although rendering the prognosis more grave, is, ceteris 
 paribus, no hindrance, since both organs have been removed suc- 
 cessfully, even at one operation. Speaking generally, rapidly- 
 growing tumours in vigorous patients are exceedingly unfavourable 
 cases to deal with, whilst slow growth of the tumour, and definite 
 limitation of its outline, are favourable signs. 
 
 Amputation of the Breast is an operation which is performed 
 not only for the removal of cancerous or sarcomatous growths, 
 
 Fig. 317. — Incisions for Amputation of the Breast in Cancer. 
 
 but also for diffuse hypertrophy, for diffuse septic or tuberculous 
 disease when the organ is riddled with sinuses, and occasionally 
 for interstitial mastitis. The proceeding is a very simple one in 
 non-malignant cases. The incisions usually employed are semi- 
 lunar, and placed obliquely, as on the right side in Fig. 317; in 
 simple cases, however, there is no need to include so much of 
 the integument. The skin is dissected up on either side from the 
 glandular tissue, and the organ freed from its attachments to the 
 pectoral fascia ; the axilla need not be opened. 
 
 Operation for Cancer. — The patient lies on the back, with the 
 head directed towards the opposite side, and the arm raised, so as 
 to put the pectoralis on the stretch. An aseptic towel should be 
 wrapped round the head, so as to keep the hair out of the way, 
 and a similar carbolized towel may be placed below the chin, to 
 
DISEASES OF THE BREAST 
 
 form a barrier between the anaesthetist with his apparatus and the 
 field of operation. The axilla should be previously shaved, and 
 the skin carefully purified. The incisions employed vary with the 
 size and position of the tumour, one great essential being that no 
 portion of skin which lies immediately over the tumour should be 
 left ; where it is located in the outer and upper quadrant, as is so 
 commonly the case, incisions somewhat similar to those repre- 
 sented in Fig. 317 (right side) will do very well. In other cases 
 the incisions may be placed horizontally, extending backwards as 
 far as the posterior axillary fold, and then the axilla is dealt with 
 through a vertical incision running up along its anterior border 
 (Fig. 317, left breast). It is the usual custom to make the lower 
 incision first, so that the view of the surgeon may not be inter- 
 fered with by the blood trickling from the upper wound, but this 
 is by no means essential or always convenient. The skin is dis- 
 sected back on either side from the glandular substance, keeping 
 well clear of breast tissue. The inner side is then dealt with first, 
 the wound being carried down until the pectoral is exposed, and 
 the gland, together with the deep fascia, dissected off the muscle 
 from within outwards until its outer border is reached. It is 
 always wise to remove the superficial layer of muscle fibres, even 
 if one does not go further. Attachment to or infiltration of the 
 muscle, of course, involves the removal of a considerable portion 
 of its substance. During this stage of the operation all bleeding- 
 points are secured temporarily by Spencer-Wells' forceps. The 
 breast, together with the fascia, and perhaps part of the muscle, 
 is now lying turned outwards, merely connected to the trunk by 
 its axillary attachments. The surgeon then carries on the dis- 
 section along the under surface of the pectoral muscles, opening 
 up freely the axillary cavity, and if need be increasing the cutane- 
 ous incision for this purpose. The axillary vessels are first cleaned, 
 the vein often coming prominently into view. The apex of the 
 space is then dealt with, all lymphoid tissue and fat being removed, 
 and finally the inner and posterior walls are similarly treated, until 
 when the dissection is complete nothing remains within the cavity 
 but the main vessels and nerves ; whenever possible, the sub- 
 scapular branches should be spared. 
 
 When the complete operation is undertaken, the skin is dis- 
 sected back from the incisions beyond the extreme limits of the 
 breast. The division between the sternal and clavicular por- 
 tions of the pectoralis major is then opened up along its whole 
 length, and its insertion divided about an inch from the humerus; 
 the finger is then passed under its sternal origin from above down- 
 wards, so as to raise it from the underlying structures and allow 
 of its division with the knife. The pectoralis minor next comes 
 into view, and is divided at its costal attachments, and also close 
 to the coracoid process. The finger next sweeps down the outer 
 surface of the serratus magnus (sparing the nerve of Bell), detach- 
 
890 A MANUAL OF SURGERY 
 
 ing the axillary fat from it, and then the main axillary vessels and 
 nerves are dissected out. Finally, the subscapularis is cleared 
 from above downwards, and the whole mass, including breast, 
 pectoralis, and axillary contents, is freed from its attachments to 
 skin and muscles on the outer side. 
 
 Having thus, it is hoped, eliminated the disease, all bleeding- 
 points are ligatured, the wound is closed by a continuous suture, 
 aided by one or two deep tension stitches, and a drainage-tube is 
 usually inserted for a day or two ; it may be placed with advantage 
 through a special opening made in the posterior axillary wall. 
 Where much skin has been removed, there will be some difficulty 
 in bringing the edges of the incision together, but by judicious 
 undercutting and sliding an open wound can usually be avoided. 
 If, however, it cannot be closed, skin-grafting by Thiersch's 
 method must be resorted to. 
 
 The immediate results of this operation are exceedingly satis"- 
 factory, the mortality being slight, probably not 5 per cent. 
 Patients often used to complain of impairment in the movements 
 of the arm when the axilla had been opened and the wound allowed 
 to heal with the arm fixed to the side ; this is entirely obviated 
 by keeping the arm away from the side at right angles to the 
 body. Healing is assisted by this position, since drainage is 
 facilitated and better pressure can be exerted upon the wound, 
 and there is consequently less oozing. Even when the pectorals 
 have been sacrificed, the patient is still able to lift the arm to the 
 back of the head, and the movements of the limb seem but little 
 impaired. The final results necessarily vary with the period at 
 which operation was undertaken, and with the care and skill of 
 the surgeon. 
 
 Local recurrence after operation is always due to incomplete re- 
 moval of the growth, or to infection of the wound during the 
 operation. The operator must ever keep in mind that although 
 in a healthy organism the implantation of cancerous material has 
 apparently but little or no effect, yet in a cancerous individual 
 positive results are only too certainly obtained. The recurrence 
 appears either in the neighbourhood of the cicatrix, the most 
 usual situation, or in adjacent lymphatic glands. The progress 
 is often slow, but occasionally the disease spreads more rapidly 
 than if no operation had been undertaken. Another attempt 
 should always be made to remove the growth, if such be feasible. 
 
 Recently a proposal has been made by Beatson of Glasgow 
 to deal with inoperable cases of cancer by oophorectomy, com- 
 bined with the administration of thyroid extract, and two or three 
 cases of apparent recovery under this regime have been recorded. 
 Certainly, if the patient is made to fully understand what is 
 involved by such a proceeding, there can be no objection to 
 trying it, although our present experience seems to indicate that 
 the improvement, often unquestionable at first, is only temporary. 
 
CHAPTER XXXII. 
 ABDOMINAL SURGERY. 
 
 Injuries of the Abdominal Walls. 
 
 These may be divided into three main classes — contusions, non- 
 penetrating and penetrating wounds. 
 
 Contusions of the abdominal walls vary in their results with 
 the cause and character of the injury, and with the condition 
 of the subjacent viscera. If due to a slight blow, the effects are 
 probably not serious, the patient merely suffering from pain and 
 bruising, as in any other part of the body. If the blow, although 
 slight, falls upon a distended viscus, such as the stomach or 
 bladder, the organ may be torn, and the contents extravasated 
 into the abdominal cavity, with fatal results from peritonitis. If 
 a solid viscus, such as the liver or spleen, is injured, alarming 
 haemorrhage may occur into the peritoneal cavity, from which the 
 patient may die. An account of these visceral injuries is given 
 seriatim under the appropriate headings in this chapter. Any 
 sudden sharp concussion, especially if directed to the epigastrium, 
 is liable to be followed by severe shock from irritation of the 
 subjacent solar plexus of the sympathetic nerves, and life itself 
 may be destroyed in this way by syncope without the appearance 
 of an evident lesion. 
 
 If the injury is limited to the abdominal walls, rupture of one 
 or more of the constituent muscles, especially the rectus, may 
 occur. A haematoma of considerable size usually follows, and 
 this is especially liable to suppuration and the formation of an 
 abscess, which may point directly at the injured spot, or burrow 
 widely between the muscular planes. The smell of the pus is 
 always suggestive of the presence of the Bac. coli, and this organism 
 probably finds its way into the extravasated blood from some 
 slightly damaged coil of intestine in the neighbourhood. As a 
 further complication, laceration of the parietal peritoneum may 
 be mentioned, causing shock and intraperitoneal extravasation of 
 blood ; if the latter is abundant, as from a large vessel, peritonitis 
 is almost certain to follow. 
 
892 A MANUAL OF SURGERY 
 
 The Treatment of an abdominal contusion is always a matter 
 of some anxiety to the surgeon, as it is difficult at first to make 
 certain of the exact nature of the injury, and as to whether or not 
 visceral complications are present. In the more simple cases 
 all that is needed is to put the patient to bed, combating shock 
 in the usual way by the application of warmth, but stimulants 
 should be avoided, if possible, for fear of restarting haemorrhage. 
 In the more severe cases, a decision has to be made as to whether 
 expectant treatment is to be depended on, or whether an explora- 
 tory laparotomy is to be undertaken. No absolute rules can be 
 laid down as to when operation is necessary, but the surgeon 
 should remember that exploration in a doubtful case will probably 
 do far less harm than delaying operation until the diagnosis is 
 made certain by an outbreak of diffuse inflammation, providing 
 always that the patient is not so profoundly collapsed as to contra- 
 indicate all interference. The examination of the abdomen and 
 of the patient may bring to light facts which make operation essen- 
 tial, such as (a) severe intraperitoneal haemorrhage, (b) general 
 tympanites or free gas in the peritoneal cavity, as indicated by loss 
 of the area of hepatic dulness, (c) blood-stained vomiting, or (d) the 
 phenomena due to a lacerated bladder. Under such circum- 
 stances, no delay is justifiable, and, even if severe shock is 
 present, operation should be commenced, unless death is evidently 
 imminent. A large intravenous injection of hot saline solution 
 will usually rally the patient sufficiently to warrant the surgeon 
 in proceeding, whilst freely washing out the peritoneal cavity with 
 the same hot solution has often a similar effect. If, however, 
 well-marked shock is present, with perhaps localized pain, but 
 with no absolute evidence 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 peristalsis, but as little as possible should be given, since 
 symptoms are so completely masked thereby. If there is any 
 vomiting, rectal alimentation should be employed after the lower 
 bowel has been washed out. If, at the end of twenty-four hours, 
 the patient is still in a condition of collapse, and especially if 
 manifestations of intraperitoneal haemorrhage or of commencing 
 peritonitis have made themselves evident, operation can still be 
 undertaken with some prospect of success. 
 
 Non-Penetrating Wounds of the Abdominal Wall do not demand 
 separate attention, since there is no special significance about 
 them, and if uncomplicated by contusions are treated on general 
 principles. If the epigastric artery is divided, extensive extrava- 
 sation is likely to ensue ; the wound must then be enlarged, 
 and the bleeding-points secured. It must also be remembered 
 that the sheath of the rectus is divided anteriorly by the lineae 
 transversae into separate compartments ; but as these do not 
 extend through the whole thickness of the muscle, collections of 
 
ABDOMINAL SURGERY S93 
 
 blood or pus may be limited anteriorly, whilst behind they become 
 diffuse. If the abdominal muscles are widely divided, steps 
 should be taken, after thorough purification, to draw together 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 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 congested, or even strangled. Neces- 
 sarily, in all cases the great danger is that of diffuse septic 
 peritonitis, caused either by rupture of the intestine or by 
 infection from without. It is an interesting point to note that 
 the peritoneum that covers the viscera has but little sensation 
 of pain, whilst the parietal peritoneum and that forming the 
 mesentery are very sensitive ; on the other hand, the visceral 
 peritoneum is much more liable to bacillary invasion. 
 
 The Treatment of these abdominal wounds has been entirely 
 altered in recent years, as a result of increased confidence in 
 antiseptic methods. The external wound is carefully 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, or with weak antiseptic lotions, such as boric acid lotion, 
 or sublimate (1 in 4,000), and then replaced ; if slightly bruised, it 
 may be returned, but the external wound should not be entirely 
 closed and a drainage wick of gauze inserted, so that if faecal extra- 
 vasation occurs a ready exit is provided. Small incisions or punc- 
 tures must be sutured, but when intestine is hopelessly damaged, 
 enterectomy should be undertaken if the patient's general con- 
 dition is sufficiently good ; but if unfit to undergo such an opera- 
 tion, the gut must be fixed in the wound as in colotomy, 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 had 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. The peritoneum and divided muscles 
 are united by buried stitches of catgut or well-boiled silk, and 
 
894 A MANUAL OF SURGERY 
 
 finally the skin is brought together with a continuous suture. A 
 drain-tube may need to be inserted for a time. 
 
 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 tetanic convulsions, and a hernia is very likely to follow. 
 One of the segments may become spasmodically contracted, 
 constituting what is known as a ' phantom tumour,' usually 
 occurring in hysterical females, and disappearing under an anaes- 
 thetic. 
 
 Affections of the Umbilicus. 
 
 The various forms of umbilical hernia are described at p. 991. 
 
 Inflammation and Ulceration, perhaps running on to eczema, 
 may arise from want of cleanliness after separation of the cord. 
 Tetanus neonatorum probably owes its infection to this source, 
 as also the erysipelas of infants, both of which diseases are ex- 
 ceedingly fatal, whilst the latter is often accompanied by sloughing 
 of the neighbouring abdominal parietes. The eczematous con- 
 dition merely requires cleanliness, and the application either of an 
 antiseptic dusting-powder or of some simple ointment. 
 
 Occasionally a 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 required is to ligature the base and cut it 
 away. 
 
 Warts and Nsevi are also found here, but need no special notice, 
 as also syphilitic and epitheliomatous disease. 
 
 Umbilical Fistulae not unfrequently occur, and may be congenital 
 or acquired. Three varieties are described : 
 
 (a) A Fecal Fistula of congenital origin arises from non-closure 
 of the vitello-intestinal duct, and either opens into the intestine 
 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. Acquired cases are usually due to per- 
 foration 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 suture. 
 
 (c) A Biliary Fistula sometimes forms at the umbilicus, resulting 
 from an abscess connected with the gall-bladder. 
 
 In Ectopia Vesicae the umbilicus is absent, the extroverted 
 portion of the bladder extending up to what should normally be 
 its situation. 
 
ABDOMINAL SURGERY 895 
 
 Affections of the Peritoneum. 
 
 Inflammation of the peritoneum, or Peritonitis, arises from a 
 variety of conditions, and presents many diverse manifestations. 
 It is a disease which may be limited to some particular locality, 
 or may involve the whole serous membrane. In discussing the 
 subject, we shall avail ourselves of the large mass of information 
 gathered together by Sir Frederick Treves in the Lettsomian 
 Lectures for 1894. 
 
 From an etiological point of view, it may be stated that peri- 
 tonitis is almost invariably due to the action of micro-organisms, 
 the symptoms being largely those of toxic poisoning, death, 
 when it occurs, resulting from toxaemia rather than from the 
 inflammation. 
 
 The following forms may be distinguished : 
 
 1. Peritonitis due to infection from the intestine, the organism 
 usually present being the Bacillus coli communis. Entrance to the 
 peritoneal cavity may be gained either through some actual breach 
 of surface, such as a penetrating wound or perforating ulcer, or 
 through an intestinal wall, the resisting powers of which have 
 been diminished by inflammation or injury. The peritonitis 
 associated with appendicitis, or secondary to strangulated hernia, 
 is of this type. 
 
 2. Peritonitis due to infection from without, the ordinary 
 pyogenic organisms being present, especially the Streptococcus 
 pyogenes. This variety occurs in penetrating or operation wounds 
 where the bowel is uninjured, as also in puerperal peritonitis. 
 
 3. Peritonitis may be due to the gonococcus, which has travelled 
 up the Fallopian tube from the vagina. 
 
 4. Tuberculous peritonitis also occurs, and is usually chronic 
 in type. 
 
 5. There is a group of cases in which peritonitis is of doubtful 
 origin, possibly arising from chemical or local irritants, rheumatism, 
 etc. ; but it is still a moot point whether such can be caused apart 
 from the activity of micro-organisms. 
 
 Clinical History. —From a purely clinical standpoint, 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. 
 
 Acute Diffuse Peritonitis. — 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 at first be localized to some particular region, or referred 
 to the umbilicus ; it soon, however, becomes diffuse, and is 
 associated with exquisite tenderness and great distension. In 
 a typical case the phenomena are very characteristic. The patient 
 
896 A MANUAL OF SURGERY 
 
 lies on his hack 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 com- 
 pressible. The respirations are quick, shallow, and thoracic in 
 character. The temperature, raised at first, tends to become 
 subnormal from toxaemia before the end is reached. Vomiting is 
 usually a prominent symptom, associated perhaps with hiccough ; 
 to commence with, the contents of the stomach alone are expelled, 
 but later on they may be mixed with bile, or even faecal material. 
 Though very constant and troublesome, it is much less distressing 
 than that which arises from intestinal obstruction, and, owing to 
 the pain induced by any sudden contraction of the abdominal 
 muscles, the patient ejects the vomit with but little force. Con- 
 stipation and arrest of flatus are always present in peritonitis, 
 owing to the cessation of peristalsis induced by the inflammation. 
 As the case progresses, the patient's strength rapidly diminishes, 
 his face becomes pinched and drawn (fades Hippocratica), 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 extravasated. 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 
 gradually. 
 
 The Post-mortem Phenomena of acute diffuse peritonitis consist 
 in an exudation into the peritoneal cavity of turbid serum or pus, 
 mixed with flocculi of lymph. The serous coat of the intestine 
 is roughened, and adjacent coils may be matted together by 
 greenish semi-puriform lymph. The effusion is mainly found in 
 the pelvis and lower part of the abdominal cavity, and is not 
 always very abundant ; it is intensely infective, and any wounds 
 caused during the performance of the post-mortem examina- 
 tion are likely to be followed by severe cellulitis or even fatal 
 septicaemia. The omentum sometimes forms a barrier shutting 
 off the lower from the upper portion of the peritoneal cavity, and 
 limiting the mischief to one or other section. 
 
 Treatment of Acute Diffuse Peritonitis. — In former days treat- 
 ment consisted in fomenting the abdomen, and keeping the patient 
 fully under the influence of opium, whilst abstinence from food 
 was enforced, and possibly calomel given as an absorbent ; but 
 since peritonitis is very rarely idiopathic in nature, and usually 
 results from some very definite local lesion, such measures are 
 
ABDOMINAL SURGERY 897 
 
 rarely adequate. In diffuse peritonitis, expectant treatment of 
 this character is almost certain to be followed by a fatal issue ; 
 and although treatment by operation has no great results to boast 
 of, it is the only rational plan to adopt. The virulent nature of 
 the toxins produced by the inflammatory process, and the late 
 date at which operation is usually performed, fully suffice to 
 explain the high death-rate associated with it. An exploratory 
 laparotomy should therefore be undertaken as early as possible, 
 the incision being made in the linea alba, and usually below the 
 umbilicus, unless there is tolerably clear evidence that the causative 
 lesion is in the upper part of the abdomen. The effusion is allowed 
 to escape, and by gently separating the coils of intestine localized 
 pockets of fluid may be evacuated. Collections of blood or pus 
 should be swabbed out by gentle sponging, or possibly general 
 irrigation of the abdominal cavity with sterilized salt solution 
 (o*6 per cent.) may be adopted. In this proceeding care must be 
 taken to maintain the fluid at a constant temperature (105 to 
 1 io° F.), to prevent abdominal distension, and not to allow the fluid 
 to play on the under surface of the diaphragm for fear of causing 
 respiratory embarrassment. If the original lesion can be reached 
 without much difficulty, it must be dealt with according to the 
 rules given hereafter, provided that the patient's general condition 
 is sufficiently satisfactory. Drainage of the peritoneal cavity by 
 a glass drainage-tube, or perhaps better by strips of gauze passed 
 amongst the intestines in different directions, is usually essential. 
 
 In cases of threatening peritonitis following abdominal opera- 
 tions, as indicated by pain, distension and vomiting (peritonism), 
 the chief causative factor is often a paralytic condition of the gut, 
 which permits of the retention and decomposition of the intestinal 
 contents, thus assisting the activity of the Bac. coli. In such cases 
 a smart saline purgative (e.g., sodii sulphas, gr. xx.-xxx., every 
 hour) is often useful, in order to free the intestine from its 
 irritating contents. When, however, general septic peritonitis 
 is present, purgatives can only do harm. 
 
 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 between adjacent coils of intestine, the process 
 being thereby localized. It is usually, although not invariably, 
 followed by suppuration, the abscess being thus intraperitoneal, 
 although not involving the general peritoneal cavity. The 
 abscesses arising in connection with appendicitis or pelvic peri- 
 tonitis are not uncommonly of this nature. They may burst 
 through the barrier of adhesions, and thus light up a diffuse in- 
 flammation of the peritoneal sac, or they may burrow to the 
 surface and burst, 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, 
 
 57 
 
.J MANUAL OF SURGERY 
 
 vomiting, and constipation. At first no swelling or tumour is 
 to he 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 usually 
 becomes evident ; it is mainly due to a matting together of the 
 intestines, but associated with a variable amount of effusion. If 
 the abscess travels towards the surface, the abdominal wall 
 becomes infiltrated, red, and cedematous, the component tissues 
 being brawny to the touch, and cutting like 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 
 contained therein may be thin and offensive, or it may be free from 
 odour, and then is often somewhat inspissated, and like custard 
 in consistency. Of course this process is attended with con- 
 siderable increase in the pain and constitutional disturbance. If 
 the cavity is treated antiseptically, it rapidly contracts and a cure 
 is accomplished, although intraperitoneal adhesions may persist 
 and lead to trouble later on from hampering the intestinal move- 
 ments. If a communication is established with the intestine, a 
 faecal fistula is very apt to follow ; whilst if the cavity becomes 
 septic, chronic suppuration may result, and thereby the patient's 
 health and strength are undermined. 
 
 Treatment of Acute Localized Peritonitis. — In these cases, 
 resolution can be obtained in favourable cases by keeping the 
 patient quiet and on a low diet, with perhaps a little morphia, 
 and by applying fomentations locally, whilst the lower bowel is 
 emptied by an enema. Such a course must, however, not be per- 
 sisted in for too long when suppuration is likely to have occurred, 
 for fear of the inflammation spreading to the general peritoneal 
 cavity, or of the abscess bursting into it. An early exploratory 
 laparotomy is advisable under such circumstances. The line of 
 treatment marked out for appendicitis (p. 950) is that which 
 should always be followed. 
 
 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 
 thickening of the peritoneum, giving rise to adhesions, whereby 
 the intestinal wall is strengthened, and bacterial invasion limited. 
 It is localized or diffuse in character, and arises either as a result 
 of pre-existing acute inflammation or as a primary affection. In 
 the more diffuse forms the intestines are hopelessly matted together, 
 and the omentum may be 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. Occasionally the existence of persisting 
 localized pain may indicate the presence of a solitary adhesion, 
 passing between the abdominal wall and one of the viscera, such 
 
ABDOMINAL SURGERY 899 
 
 as the anterior wall of the stomach. In such cases an explanatory 
 laparotomy is permissible, the adhesion if found being divided 
 between ligatures. The importance of dealing with such adhe- 
 sions, where possible, is evident from the fact that internal 
 strangulation beneath them, or acute kinking of the gut over 
 them, is one of the commonest forms of acute obstruction. 
 
 Tuberculous Peritonitis. — This disease is almost limited to 
 young people, and is usually secondary to some other focus of 
 intra-abdominal tuberculosis, e.g., in the intestine, mesenteric 
 glands, Fallopian tube, etc. It is sometimes limited in its 
 development to a portion of the peritoneal cavity, especially when 
 it is of pelvic origin, but is more frequently diffuse. It manifests 
 itself in several different ways: (1) In the ascitic variety the 
 peritoneum becomes thick and hyperaemic, and studded over with 
 tubercles, some of them small, grey 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 encapsuled, giving rise to cystic swellings shut in between 
 the coils of intestine. (2) In the fibrous variety the intestines 
 become matted together by extensive adhesions, and between 
 them foci of tubercle are found. The mesentery may become 
 infiltrated 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 
 encapsuled. It is obvious that such a condition is very likely to 
 lead to obstructive phenomena, due to kinking of the intestine. 
 (3) The ulcerous variety is characterized by an exaggeration of the 
 above phenomena. Tuberculous foci are found between the 
 coils of intestine, and open into them, giving rise to various inter- 
 intestinal fistula? (Vistula bimucosa), or even opening externally. 
 
 In each of these varieties acute manifestations may develop at 
 any time as a result of infection from the bowel with the Bac. coli, 
 and then the symptoms of acute diffuse peritonitis may supervene. 
 
 The symptoms are very variable. Any and every form of diges- 
 tive disturbance may occur, including diarrhoea, or alternating 
 attacks of constipation and diarrhoea, with some amount of colic 
 and vomiting. The onset is generally gradual, but intermissions 
 and relapses are of frequent occurrence. Wasting is, however, 
 always a marked feature. The abdomen is enlarged, perhaps 
 tender to the touch, and may contain free fluid or not. 
 
 Treatment in the early stages is often successfully undertaken 
 by the physician ; but if the condition is progressing, the surgeon 
 may be called upon to deal with it by laparotomy. When marked 
 ascitic accumulation is present, all that is needed is to remove 
 
 57—2 
 
900 A MANUAL OF SURGERY 
 
 the fluid and close the wound with or without irrigation, and in 
 nearly 75 per cent, of the cases a cure may be anticipated. Where 
 diffuse or localized suppuration is present, adhesions which can 
 be reached may be gently broken down, exit given to the pus, 
 and the peritoneal cavity washed out ; but no prolonged search 
 after suppurating foci should be made, or the intestine may be 
 torn. The results of treatment in this 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, opinions 
 differ, some authorities considering that it is due merely to the 
 admission of atmospheric air, some to the alteration produced 
 thereby in the intra-abdominal tension, whilst others maintain 
 that it is simply in consequence of the removal of the exudation 
 and its contained toxins. The most plausible idea, however, 
 attributes it to a flushing of the intra-abdominal tissues with 
 blood serum (a well-ascertained fact after laparotomy) and the 
 effect of the antitoxic substances contained therein, the tubercles 
 thereby having their vitality destroyed. In this connection one 
 may note the statement that too early a laparotomy does but 
 little good, an insufficient amount of antitoxin having presumably 
 developed in the system. 
 
 Paracentesis Abdominis is required in cases of general or 
 encysted ascites. The usual plan adopted is to seat the patient 
 on a chair, and to encircle the abdomen with a flannel binder, 
 the ends of which are split to within 6 inches of the middle line. 
 The unslit portion is placed over the abdominal wall in front, 
 whilst the divided portions cross behind, and are held by assistants, 
 so as to make continuous pressure upon the abdominal contents. 
 The abdomen is carefully percussed, and a spot of absolute dul- 
 ness selected ; here a small skin incision is made with a scalpel, 
 and a suitable trocar and cannula inserted. The median line 
 below the umbilicus is the place usually chosen for the puncture, 
 but there is no objection to inserting the trocar through the 
 flanks. Some surgeons prefer to withdraw the fluid more slowly, 
 so as to prevent the shock often experienced from its rapid 
 removal. Two or three Southey's trocars and cannula' may then 
 be inserted. 
 
 Subphrenic Abscess is the term applied somewhat loosely to a 
 suppurating focus which is in more or less intimate relation with 
 the under surface of the diaphragm. Two main varieties are 
 described, viz., the intraperitoneal, which is much the more 
 common, and the retro- or extra-peritoneal. The causes are very 
 diverse, and the manifestations vary somewhat with the causative 
 lesion. 1. 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 limited by the lesser 
 omentum and stomach behind, by the diaphragm and left lobe of 
 
ABDOMINAL SURGERY 901 
 
 the liver above, by the falciform ligament on the right, and 
 by adhesions between the stomach or omentum and anterior 
 abdominal wall below. This type of abscess usually points to the 
 left of the 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 adhe- 
 sions, whilst the stomach itself is pushed forwards, and the pus 
 travels up and presents above it to the left of the middle line. 
 More often the lesser sac has been previously obliterated, and the 
 abscess develops in the retroperitoneal tissues. 2. Ulcer of the 
 duodenum may give rise to very similar conditions. If the abscess 
 is intraperitoneal, it is bounded by the liver, colon, omentum, and 
 anterior abdominal wall ; occasionally it has also tracked up 
 behind the liver. Retroperitoneal suppuration also occurs in con- 
 nection with the duodenum, the pus then travelling up between 
 the liver and diaphragm, or downwards towards the loin. 3. The 
 append/'. >• vermiformis is also a cause of subphrenic abscess, the pus 
 burrowing behind the peritoneum, or finding its way along the 
 inner or outer walls of the ascending colon. 4. It may also 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 Bacillus colt without any direct 
 opening being present. It w r as to this condition that Leyden 
 originally gave the name of subphrenic pyo-pnciimothorax. The 
 extension of the abscess along the under surface of the diaphragm 
 often leads to that structure being displaced considerably upwards, 
 and to a secondary infection of the pleura, either by lymphatic 
 absorption and extension, or by an actual solution of continuity. 
 The effect is an effusion of serum or pus into the base of the 
 pleural cavity, the latter constituting a basal empyema. 
 
 The symptoms vary considerably. They may commence ab- 
 ruptly, as from a perforated stomach, or come on more gradually. 
 Ordinary febrile phenomena, and perhaps one or more rigors, may 
 occur, whilst the patient complains of pain in the upper portion of 
 the abdomen, where a swelling, dull or tympanitic according to 
 circumstances, appears, over which the abdominal muscles are 
 rigidly contracted. The condition is very liable to be mistaken 
 for an empyema or pneumothorax, but one most important dis- 
 tinguishing feature is that the heart is displaced directly upwards 
 and not to one side, as in the pulmonary conditions, whilst the 
 
902 A MANUAL OF SURGERY 
 
 liver is pushed downwards. Left to itself the abscess may burst 
 into the general peritoneal cavity, or into one of the hollow viscera, 
 or may open externally. 
 
 The treatment of subphrenic pyo-pneumothorax consists in 
 opening the abscess wherever it is most accessible. Opinions 
 differ as to whether it is necessary to make a counter-opening 
 behind ; in all probability, it is wiser not to attempt this at 
 first, but if the temperature still keeps up, and the cavity does 
 not seem to drain well after a few days, then further interference 
 will be reqviired. The best situation for a counter-opening is 
 behind the mid-axillary line, a portion of the eighth or ninth rib 
 being excised. If, as often happens, there is also an empyema, 
 this is readily accomplished, and an additional opening can be 
 made through the diaphragm if one does not already exist ; if, 
 however, the pleural cavity is not affected, then the serous mem- 
 brane covering the upper surface of the diaphragm must be stitched 
 to the parietal pleura before the diaphragm is incised. 
 
 Affections of the Stomach. 
 
 Rupture of the Stomach results from blows or falls upon the 
 epigastrium, especially after a heavy meal, and then usually in- 
 volves the pyloric end or the greater curvature near the cardiac 
 orifice. It may also follow a penetrating injury, such as a stab 
 or a fall upon a spike or railings. Neighbouring viscera are not 
 unfrequently involved in the lesion, especially the liver or spleen. 
 
 The Symptoms are those of severe and prolonged shock, with 
 epigastric pain and vomiting, the ejected material often containing 
 blood ; acute septic peritonitis usually ensues in a very short time, 
 destroying the patient's life in a few days. Occasionally, when 
 the wound is small, or the organ empty at the time of the accident, 
 there is but little or no extravasation, and then a localized intra- 
 peritoneal 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 
 tracking along the parietal wound so as to reach the surface, or 
 even sometimes breaking down the barrier of adhesions, and 
 originating a late general peritonitis. 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 (q.v.). 
 
 Treatment. — When a wound perforating the abdominal parietes 
 is present in the region of the stomach, it is always the surgeon's 
 duty to enlarge the opening, and ascertain what amount of internal 
 damage has been done ; but if there is no external wound, or 
 merely a superficial one, a certain diagnosis cannot be made 
 unless blood-stained vomiting is present. In doubtful cases the 
 persistence of shock for some considerable time and the onset of 
 peritonitis indicate that an exploratory laparotomy should be 
 
ABDOMINAL SURGERY 9°3 
 
 undertaken. No time must, however, be lost in cases where 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 clamped by forceps so as to prevent 
 any further exit of the gastric contents whilst the peritoneum is 
 being cleansed. All extravasated material should be carefully 
 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. The wound in the stomach 
 is closed by a row of Lembert's sutures, which tuck the margins 
 inwards, and these must extend a little beyond the lesion on either 
 side (Figs. 328 and 329). If the posterior wall is also injured, as 
 by a bullet wound, an opening should be made through the omen- 
 tum 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 drain the upper 
 part of the serous cavity by inserting a plug of gauze down to and 
 around the site of the injury. If the general cavity is inflamed, the 
 treatment suitable to acute peritonitis must be instituted (p. 897). 
 It will probably be wise under these circumstances to place a 
 drainage-tube immediately above the symphysis pubis, as well as 
 leaving the upper incision partly open. 
 
 Foreign Bodies in the stomach consist either of those which 
 have been swallowed accidentally or intentionally, or of con- 
 cretions, 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 symptoms of gastric 
 irritation, the cause of which is inexplicable until the mass has 
 attained such a size as to suggest the presence of a tumour. The 
 only treatment possible where the foreign body is 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. 
 
 Ulcer of the Stomach is an exceedingly common ailment, the 
 consequences of which are often very serious, a considerable 
 mortality being associated with it, its complications, or its 
 sequelae. Two chief types may be mentioned here, although 
 others are not unknown : 
 
 (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 ' (Fenwick). It is not unusually multiple, two ulcers 
 being often found exactly opposite one another, suggesting an 
 
9 04 A MANUAL OF SURGERY 
 
 infective origin of the trouble. They are of a circular shape, 
 and with the edges sharply defined and clearly cut ; each succes- 
 sive coat is destroyed to a lesser degree than the one internal to 
 it, so that the sore is truncated or funnel-shaped. Should per- 
 foration occur, the opening is not central, but slightly to one side. 
 These acute ulcers heal without much difficulty, 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 situated within the pyloric orifice. Haemorrhage from this 
 variety is not uncommon, but is rarely fatal.* 
 
 (b) 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 may be involved in the trouble by extension. 
 Its shape is very variable, though in the earlier stages it is 
 rounded ; one important 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 destruction of tissue, external viscera, such 
 as the pancreas, being sometimes exposed in the wound. 
 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 
 proportion 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 
 described in medical text-books. A number of complications, 
 however, arise which may require surgical assistance, whilst it 
 must be remembered that the mere persistence of symptoms may 
 justify operative measures, especially since the observation has 
 
 * 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, 1901. 
 
ABDOMINAL SURGERY 905 
 
 been made and confirmed that malignant disease may commence 
 on the site of an old-standing ulcer. 
 
 1. Excessive and Persistent Hemorrhage is responsible for quite 
 a considerable proportion of the deaths from gastric ulcer. It may 
 arise from arteries, veins, or capillaries, and at first it is difficult 
 to say from what source it is derived. Inasmuch, however, as in 
 over go per cent, of the cases it can be stopped by medical means, 
 it is obvious that the capillary origin is most common. It is like- 
 wise unusual for the patient to succumb as the result of the first 
 attack of bleeding, 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. 
 
 Under the latter circumstances 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 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 ligatured en masse ; or the 
 base of the ulcer may be cauterized ; or excision of the ulcer 
 may be practicable. Failing these measures, gastroenterostomy 
 will be indicated, in order to give the organ as much rest as 
 possible. 
 
 2. Perforation of the Ulcer is by no means an uncommon occur- 
 rence in connection with the acute type of ulcer, and is therefore 
 seen most frequently in young women ; it is always fraught with 
 the greatest danger. The anterior wall is that most frequently 
 involved, owing to its greater mobility, which prevents the forma- 
 tion of protective adhesions. The cardiac end is more often 
 affected than the pyloric. The character of the symptoms varies 
 with the size of the perforation, and with the distension or not 
 of the viscus. If a large opening is produced in the anterior wall, 
 so that the gastric contents are allowed a free entrance into the 
 peritoneal cavity, the patient is seized with severe epigastric pain 
 and profound shock, and this is followed by acute septic peri- 
 tonitis, which rapidly proves fatal if surgical interference is not 
 at hand. When the perforation is small, and only a gradual 
 leakage occurs, the onset is subacute ; the primary shock is then 
 inconsiderable, but epigastric pain and tenderness are present, 
 and 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. Barling states that 
 95 per cent, of patients that are untreated are sure to die, whilst 
 the later the operation, the worse the results. 
 
 Treatment. — Should it be decided for any particular reason not 
 
9o6 A MANUAL OF SURGERY 
 
 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 early 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 penetrating injury hold good in connection with 
 this subject, especially as to the use of swabs for the removal 
 of any extravasated gastric contents, and as to the value of 
 peritoneal irrigation. There is no need to excise the ulcer when 
 found ; all that is required is to close the aperture by means of 
 Lembert's sutures, applied perhaps in a purse-string fashion, so 
 as to bury the ulcerated surface. In some 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 intra- 
 peritoneal leakage. The patient is fed by the rectum for some 
 time, and the fistula usually closes without much difficulty at a 
 subsequent date. 
 
 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, 
 consisting 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 lying 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. Such give rise to a 
 localized fixed epigastric pain, usually increased considerably by 
 distension of the organ. It may be treated safely by abdominal 
 section, and division 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. 900), 
 which may or may not contain gas. It may burst anteriorly 
 through the abdominal wall, or may perforate the diaphragm, 
 giving 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 
 
ABDOMINAL SURGERY 907 
 
 various places, through which the contents of the stomach may 
 be discharged. 
 
 The abscess should be opened and drained in the way already 
 indicated, but should a fistula form, it is almost hopeless to 
 attempt to deal with it locally, so that it would be wise to perform 
 a gastro-enterostomy. 
 
 4. Stenosis is always liable to occur after ulcers of the stomach, 
 as in other situations. If it is located near the pylorus, that 
 orifice may become contracted, giving rise to special symptoms, 
 and necessitating treatment of a particular character (p. 911). 
 Occasionally, however, the cicatrisation of a horseshoe ulcer 
 leads to an hour-glass contraction of the body of the viscus, which 
 in some cases is so marked as almost to divide the organ into two 
 halves, only a narrow neck persisting between the two. The 
 symptoms of such a condition are almost identical with those of 
 pyloric stenosis, and the treatment required consists either in 
 excision of the sulcus and reunion of the gastric walls, or in 
 establishing an artificial opening between the two segments, as by 
 a Murphy button. In still other cases the contraction may be 
 situated near the cardiac orifice, the symptoms then being 
 similar to those of a stricture at the lower end of the oesophagus. 
 The clinical phenomena of an hour-glass stomach vary with the 
 situation of the contraction, resembling sometimes those of 
 pyloric stenosis, at others those of contraction at the cardiac 
 orifice. The diagnosis is best made by inflating the organ with 
 air, when its shape can be easily detected. 
 
 Treatment of stenosis at the cardiac end consists in gastrostomy. 
 An hour-glass stomach may possibly be treated by excision of the 
 stricture, or by its division and suture by a method similar to 
 that employed for the pylorus (see Pyloroplasty, p. 916), or the 
 two segments may be united below the contraction by a Murphy 
 button, or a double gastro-enterostomy may be performed to 
 connect each segment to 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 
 treatment, and it is now considered quite justifiable to submit such 
 cases to operation. Two lines of treatment are possible, (a) The 
 ulcer may be excised, if it be in a convenient position for such a 
 procedure, and if the infiltration around it be not too extensive. 
 (b) In other cases gastro-enterostomy (p. 918) maybe undertaken 
 with a view to relieve symptoms by enabling the viscus more 
 readily to empty itself after the ingestion of food. The results 
 of this latter procedure have been very satisfactory. 
 
 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 frequency. Any and every part of the viscus may be 
 
9o8 
 
 A MANUAL OF SURGJ-hV 
 
 affected, but in 60 per cent, of the cases the tumour starts in or 
 about the pylorus, and is of a scirrhous nature. When the cardiac 
 end is attacked, the disease may spread from the (rsophagus and 
 is a squamous epithelioma, but when the body of the organ is 
 invaded, the condition is usually a columnar carcinoma. 
 
 Cancer occasionally starts at the site of an old ulcer, but 
 there is generally 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 under- 
 going ulceration ; 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, con- 
 stituting a firm mass incapable of dilatation or much contraction, 
 which has been aptly termed the 'leather-bottle stomach.' At 
 
 Fig. 318. — Cancer of Pyloric End of Stomach. (King's College 
 
 Museum.) 
 
 The abrupt limitation of the growth at the commencement of the duodenum is 
 
 well seen. 
 
 the pyloric end (Fig. 318) the growth is always of a hard nature, 
 and forms an annular constriction, through which it may be 
 difficult to pass even a small catheter ; it is sharply limited on its 
 duodenal aspect, but spreads into the body of the organ, and 
 especially towards the lesser curvature, following the main line of 
 the lymphatic stream. The lymphatic glands lying along the 
 lesser curvature are involved, usually extending as far as the 
 point where the coronary artery reaches the stomach, whilst those 
 along the pyloric end of the great curvature are implicated to a 
 less degree. Thence the affection spreads to the liver and to the 
 coeliac glands, and there may compress the inferior vena cava and 
 thoracic duct. Adhesions form around the growth, tending to fix 
 it to the under surface of the liver, to the head of the pancreas, 
 the colon, and even when of large size to the anterior abdominal 
 
ABDOMINAL SURGERY 909 
 
 wall. These adhesions often prepare the way for an extension of 
 the disease to the peritoneum, over which disseminated nodules 
 of cancer may be scattered, often 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 often begins with certain 
 indefinite symptoms, the significance of which is easily overlooked 
 in the early stages ; the case is then often allowed to run on 
 with the idea that it is merely one of ' dyspepsia,' ' internal 
 influenza ' or the like, so that a thorough and exhaustive examina- 
 tion is not made, and the time for radical interference passes 
 without the disease being recognised. Pain is often the first 
 symptom, slight at first, but gradually increasing, and referred to 
 the epigastrium or back. Food may increase or relieve 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. 
 Loss of appetite and steady wasting are also marked features in 
 the early stages. The persistence of such a group of symptoms 
 should always lead to 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 composi- 
 tion of the gastric juice may be investigated by the use of a test 
 meal and the stomach tube. In cancer the amount of HC1 is 
 usually diminished, whilst that of lactic acid is increased. The 
 latter is probably a fermentation product, (iii.) The motor power 
 of the viscus is very considerably lessened, so that the passage of 
 its contents into the duodenum is delayed ; this can be demon- 
 strated by the salol test, (iv.) A blood count in carcinoma usually 
 reveals a well marked diminution in the amount of haemoglobin, 
 sometimes fewer red corpuscles, and a moderate leucocytosis, 
 especially involving the mononuclear leucocytes, (v.) Microscopic 
 examination of the vomit may also throw light on the case. 
 
 To these general signs certain special ones may be added, 
 varying with the location of the growth. 1. If the cardiac end is 
 involved, a tumour can rarely be detected, the stomach being 
 small and contracted. The patient complains chiefly of pain on 
 
9 io A MANUAL OF SURGERY 
 
 swallowing, and the vomiting occurs immediately alter each meal. 
 The symptoms are practically those of oesophageal cancer. 
 
 2. When the pylorus is affected a tumour can often be felt a 
 little above and to the right of the umbilicus, which is at first 
 rounded and definitely limited, except on the left side, where it 
 shelves off into the stomach ; it is moveable in the early stages, 
 but later on becomes fixed ; it is firm in consistence, and some- 
 what 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 two or three days he 
 brings up a large quantity of fluid and decomposing food, covered 
 with a yeast-like scum, and containing sarcinae in abundance. 
 Haematemesis is not uncommon. 
 
 3. When the body of the organ is involved, a tumour may or 
 may not be felt, according to its situation. The ' leather-bottle ' 
 stomach can be sometimes detected as a solid mass projecting 
 forwards from under the left costal margin. The organ is not 
 dilated, and the vomiting has no special characters ; haematemesis 
 may or may not be present. 
 
 In the later 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 pres- 
 sure 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. 
 
 Treatment. — So many cases of this affection reach the surgeon 
 too late that, at the risk of wearying our readers, we would 
 reiterate what has been already stated. 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 leucocytosis and a diminishing 
 quantity of haemoglobin, then an exploratory operation is quite 
 justifiable. On the other hand, we would give a word of warning 
 against the common practice of considering that the mere presence 
 of a tumour in the epigastrium warrants an operation. When a 
 well-marked tumour is present, the probability is that 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 
 
ABDOMINAL SURGERY 911 
 
 of the physician. Of course, in many cases an operation is under- 
 taken 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 dissemination are present, 
 the surgeon should be very chary of interfering. 
 
 For cancer of the cardiac orifice, gastrostomy 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 
 gastrectomy may be feasible in the absence of massive adhesions ; 
 but the conditions which permit of such procedures are unusual. 
 If the patient's nutrition is seriously failing, and no radical 
 operation is possible, jejunostomy (or the formation of an artificial 
 opening into the jejunum) may enable the patient to be fed 
 without utilizing the stomach. 
 
 For cancer of the pylorus, operation is more frequently possible, 
 whilst, even if removal is impracticable, palliative measures to 
 short-circuit the grow r th may be desirable. If the mass is compara- 
 tively moveable, and there are but few adhesions, pylorectomy or 
 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 has extended beyond the bowel to 
 adjacent viscera, and extensive adhesions are present, gastro- 
 enterostomy is alone practicable, and will do much good by per- 
 mitting of the passage of food into the bowel without passing 
 through the pylorus. It will also allow the dilated organ to be 
 more completely emptied, and consequently the patient will not 
 be so likely to absorb toxic material. 
 
 Simple Stenosis of the Pylorus generally results from the healing 
 of a simple gastric ulcer of the usual type, situated within or 
 close to the pyloric orifice ; it is sometimes due to the contraction 
 of adhesions around an inflamed gall-bladder (cholecystitis), and is 
 occasionally caused by hypertrophy of the muscular tissue of the 
 sphincter. The effects produced are hypertrophy and dilatation of 
 the stomach, which becomes enlarged downwards, and forms a sac, 
 in which food collects perhaps for days, and undergoes fermenta- 
 tive changes, being finally ejected in large quantities, mixed with 
 frothy mucus and a yeast-like scum containing an abundance of 
 sarcina;. The stomach may in time almost reach the pelvis, the 
 pylorus being dragged down with it. Succussion or splashing 
 sounds are heard on shaking the patient's abdomen. 
 
 The Treatment consists at first in washing out the stomach 
 regularly, but when that fails to give relief one of the following 
 proceedings may be undertaken, (a) Loretas Operation consists 
 in dilating the stenosed orifice with the finger. The viscus is 
 opened midway between the curvatures and about 2 inches from 
 
912 A MANUAL OF SURGERY 
 
 the pylorus, and first one finger is introduced, slowly and care- 
 fully, then two, and even perhaps three ; no violence is admissible, 
 or the walls of the orifice may be torn or ruptured. The results 
 of this procedure have been on the whole encouraging, but it is 
 now being replaced by other more certain and satisfactory 
 methods, (b) Excision of the Pylorus can be undertaken in suitable 
 cases, and the results have been so much improved by the use of 
 the Murphy button and other similar contrivances that it need 
 not be greatly feared. Of course, when the stomach is much 
 dilated and very atonic, it is possible that this operation may not 
 succeed in improving the function of the organ, (c) Pyloroplasty 
 is useful in cases where the stricture is free from adhesions, and 
 where it is narrow and annular, but will be useless in conditions 
 similar to those under which pylorectomy is contra-indicated. 
 (d) Under such circumstances Gastro-cntevostomy should be under- 
 taken, and may be expected to give admirable results. 
 
 Operations upon the Stomach. 
 
 i. Washing oub the Stomach is needed in cases of poisoning, in 
 chronic catarrh, in dilatation of the organ, and as a preliminary to 
 operations in which its cavity is to be laid open. It may be accom- 
 plished by the ordinary stomach-pump, or by the simpler method 
 of passing a long tube of good-sized calibre, 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. Before open operations, a warm solution of boric acid 
 should be employed as the agent for irrigating the viscus. 
 
 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). It has also been employed with advantage for the 
 removal of masses of cancerous disease by curetting. 
 
 Operation. — When a foreign body can be distinctly felt within 
 the viscus, any incision that seems to promise ready access may 
 be employed ; but it is generally made on the left side, parallel 
 to, and about a finger's breadth from, the edge of the costal 
 cartilages, and about i\ inches in length (Fig. 319, A). The 
 position of the left lobe of the liver must be previously ascertained 
 by percussion, and the centre of the incision is best placed 
 about \ inch below it. The abdominal wall is completely divided, 
 and the peritoneum opened. The fingers are then introduced, 
 and the stomach sought for ; it is recognised by its position im- 
 mediately under the liver, and by the thickness, pink colour, and 
 opacity of its wall. If the omentum or transverse colon presents 
 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 
 
ABDOMINAL SURGERY 
 
 9IJ 
 
 decided on, and two silkworm gut sutures introduced through 
 the serous and muscular coats, so as to enable the organ to be 
 kept against the abdominal wall, a careful packing with a known 
 number of sponges or gauze swabs being also interposed between 
 the viscus and the parietes, so as to prevent any escape of fluid 
 into the general peritoneal cavity. An 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. It is subsequently closed by the Lembert or prefer- 
 ably the Czerny-Lembert suture. The stomach is now replaced 
 
 Fig. 319. — Incisions utilized in Various Abdominal Operations. 
 
 A, Fenger's incision for exposing the stomach ; A,, additional incision in 
 Frank's gastrostomy; B, incision for exposing gall-bladder; C, iliac 
 colotomy ; D, incision for operations on appendix; E, median incision 
 for ovariotomy or supra-pubic cystotomy ; F, for radical cure of inguinal 
 hernia or varicocele. 
 
 in position, and all traces of blood, etc., removed, the external 
 wound being closed in the usual way. 
 
 If the surgeon desires to reach the cardiac orifice, a somewhat 
 larger opening in the parietes is needed, in order to allow of 
 greater space for the introduction of the hand into the abdomen, 
 since the orifice lies deeply just in front of the aortic opening in 
 the diaphragm. When this is accomplished, the opening may 
 be dilated by the fingers or by suitable dilators, and a foreign 
 body can by this means be 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 
 and damage of the pneumogastric nerves, the terminations of 
 which pass through this opening in the diaphragm. 
 
 58 
 
9'4 
 
 A MANUAL OF SURGERY 
 
 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 cesophagus, where the patient is exposed to the risk of 
 starvation, owing to his inability to take nourishment. 
 
 Not many years back the only operation performed was one in 
 which a direct opening was made into the viscus without any 
 
 *N\/j 
 
 J 
 
 V- 
 
 V ,/ 
 
 /'i 
 
 
 m^i/ 
 
 # 
 
 V*""' ;//', 
 f / 
 
 yJ 
 
 Figs. 320, 321. — Gastrostomy (Modified Frank's Operation). 
 
 In Fig. 320 the base of the cone is seen sutured to the peritoneum and sheath 
 of the rectus; in Fig. 321, the stomach has been opened, a tube stitched in, 
 and the sutures passed through the rectus are in place. 
 
 attempt to form a valve, trusting to various flanged tubes or 
 umbrella-like plugs to close the aperture. The results were most 
 unsatisfactory, since even if the patient survived, he usually 
 suffered great inconvenience from the prolapse of the mucous mem- 
 brane, and from irritation and ulceration of the surrounding skin, 
 owing to escape of the acid gastric juice and its digestive powers. 
 During the last few years a number of excellent operations 
 have been introduced so as to prevent these complications, most 
 of them depending on the formation of a muscular valve or 
 sphincter, and there can be no doubt that the improvements thus 
 effected have been very great. Two chief methods have been 
 suggested — viz., Witzel's and Frank's ; the latter of these is, to 
 our minds, the preferable, and the results gained thereby are so 
 satisfactory as to warrant us in describing it in detail. 
 
ABDOMINAL SURGERY 
 
 9*5 
 
 Frank's Operation. — The usual oblique incision (Fig. 319, A) for 
 exposure of the stomach is first made, the viscus withdrawn and 
 examined, and a silk sling passed through the serous and muscular 
 coats at the site selected for the artificial opening, so that a cone- 
 shaped portion of the wall can 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 incision (Aj), about 1 inch in length, is now made on the 
 
 *f3& 
 
 Figs. 322, 323. — Gastrostomy (Frank's Operation Modified). 
 
 In Fig. 322 the sutures in the rectus have been tied, and only a small portion 
 of the stomach projects ; in Fig. 323 the operation is completed. 
 
 outer side of the first wound, parallel to it, and about 1^ 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, in which the silk sling is located, and the mucous membrane 
 stitched accurately to the skin in the centre of the incision. The 
 remainder of this incision is then closed in the ordinary way, as 
 also the first. Healing readily occurs, and thus a valvular 
 opening is established, which passes in an angular fashion round 
 the margin of the costal cartilages, tending to prevent regurgita- 
 tion of the gastric contents. The patient may be fed by the 
 artificial opening at once. 
 
 We have somewhat modified this operation of late, and the 
 results have been still better than when we utilized Frank's 
 
 58-2 
 
9 ,6 A MANUAL OF SURGERY 
 
 original method. Instead of the oblique incision, a vertical one 
 (as suggested by Kocher) is employed, extending for 3 or 4 inches 
 downwards from the eighth costal cartilage and passing through 
 the substance of the rectus muscle (Fig. 320), which is split by the 
 ringers or handle of the knife into two portions. The peritoneum is 
 opened, and the stomach withdrawn ; a cone-shaped portion is 
 selected, and its base stitched to the parietal peritoneum and pos- 
 terior layer of the sheath of the rectus. A small hole is made in 
 the apex of the cone, and through this is passed a piece of rubber 
 drainage-tube, free from lateral openings, and about the size of a 
 No. 10 catheter, fitting the opening in the stomach exactly ; it 
 should project 1 J inches inside the cavity, and about 6 inches of it 
 should remain outside (Fig. 321). This is stitched firmly to the 
 stomach wall, and the apex of the cone is then drawn to the upper 
 angle of the incision. 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 forms a nipple-like projection, 
 around which the muscle fits like a sphincter (Fig. 322). The in- 
 cision 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 procedure have been most satisfactory, many 
 cases having run their course without a drop of gastric juice escap- 
 ing. 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 oz. can be retained four times a day. The patient 
 should be kept in the recumbent posture for three weeks.* 
 
 WitzeVs Operation. — This 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 functional result of this operation is very 
 good, but the fixation to the abdominal wall is not so secure as in 
 the former plans. 
 
 4. Gastrectomy. — A good many cases have now been reported 
 in which a limited portion of the gastric wall has been removed 
 successfully, either for simple or malignant ulcers or growths. 
 Incisions are made so as to include the mass, and the wound is 
 subsequently closed by Lembert or Czerny-Lembert sutures. 
 
 Total excision of the stomach is a proceeding which has only 
 recently been attempted, but several successful cases are now on 
 record. It has been undertaken for extensive malignant 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 
 
 * For further details, see Carlcss, ' On Gastrostomy,' King's College Hospital 
 Reports, vol. v., 1897-1898, and in Edinburgh Medical Journal, July, 1902. 
 
A BDOMINA L SUliGER Y 
 
 917 
 
 coil of the jejunum. The actual union has been effected either by 
 simple suturing, or by introducing a Murphy button. 
 
 5. Pyloroplasty consists in exposing the pylorus and clearing 
 it from adhesions. A longitudinal incision is then made through 
 the stricture, and by a little careful manipulation this wound can 
 be opened out and brought together in a transverse manner so as 
 
 
 Fig. 324. — Pyloroplasty. 
 
 The contracted bowel is divided longitudinally, and the aperture thus made 
 opened out, so that it can be brought together transversely. 
 
 to greatly increase the lumen of the orifice (Fig. 323). Two rows 
 of stitches are inserted, one through the mucous membrane, and 
 the other through the muscular and serous coats. 
 
 6. Pylorectomy is an operation which has been performed both 
 for simple and malignant stricture of the pylorus, but until quite 
 recently the mortality connected therewith was so great as to 
 
 ~^^€^.i~^^^^^ Fig. 325B. — Method of suturing 
 
 Fig. 325A— Malignant Growth of the Unequal Wounds left 
 
 the Pylorus, and Incisions in a " er Removal of the Growth 
 
 Stomach and Duodenum needed (Iillmanns.) 
 
 for its Removal. (Tillmanns.) The upper end of the gastric incision 
 
 is first closed, so as to render the 
 openings in the stomach and duo- 
 denum of equal size. 
 
 render it almost a hopeless procedure. Thus, in seventy-two 
 cases deal twith for malignant disease by the old plan of operating, 
 fifty-five died from the immediate effects, whilst in ten cases 
 of simple stricture only four recovered. The latest statistics of 
 operations in which the Murphy button was employed are, how- 
 ever, much more encouraging. (a) In Billroth' s operation the 
 abdomen is opened by an incision which suits the exigencies of 
 the case, though perhaps the best to employ is a median one or an 
 
9i8 
 
 A MANUAL OF SURGERY 
 
 oblique one 4 or 5 inches long, extending from the median line 
 above downwards towards the right, nearly parallel to the right 
 costal margin (Fig. 319, B). The diseased area is now explored, 
 and a final decision made as to the practicability or not of reriioving 
 it. If an operation is determined on, the growth is carefully 
 isolated from surrounding parts by dividing the attachments of 
 the great and lesser omenta, any enlarged glands being also 
 enucleated. Clamps are then applied to the stomach and duode- 
 num, and the operation area well packed round with sponges. The 
 mass is now removed (Fig. 325A), the incision being so placed 
 as to extend beyond the pylorus about f inch into the duodenum 
 on the one side, and on the other so as to remove the greater 
 portion of the lesser curvature, thereby including the lymphatic 
 glands. The divided ends are apposed and united (Fig. 32513), 
 but for exact details we must refer to larger text-books of operative 
 surgery. The operation is prolonged and difficult, and profound 
 shock is usually experienced. Carefully regulated stomach- 
 feeding should not be too long delayed after the operation, the 
 best results having occurred in those cases where it was started 
 early, (b) When the Murphy button is employed, the same steps 
 are followed until the growth is isolated, and then the mass is 
 cut away at once. The gastric wound is then entirely closed 
 by a row of Czerny-Lembert sutures. The heavier male end 
 of a Murphy button is inserted into the open mouth of the 
 
 duodenum, and the purse- 
 string suture tied, as de- 
 tailed below (p. 936), 
 whilst the female half is 
 placed in a new opening 
 made for it in the posterior 
 wall of the stomach, as for 
 a lateral anastomosis (p. 
 938). The two halves are 
 united, and the operation 
 is then completed by the 
 usual toilette of the peri- 
 toneum and the closure of 
 the parietal incision. 
 
 7. Gastro - enterostomy 
 may be undertaken by 
 simple suturing of the 
 required viscera together 
 (Worrier's operation), or 
 by the use of the Murphy 
 button. The portion of bowel which is selected as the site of the 
 artificial opening should be the upper part of the jejunum, since 
 if the communication is established too low, a much greater ab- 
 sorbing surface is isolated, with the result that even if the 
 operation is successful the patient gradually emaciates owing to 
 
 Fig 326. 
 
 Anterior Gastro -enteros- 
 tomy. 
 
 A, Transverse colon ; B, jejunum dragged 
 up over the colon and omentum (pur- 
 posely omitted) to be brought into apposi- 
 tion with the stomach 
 
ABDOMINAL SURGERY 
 
 919 
 
 lack of nutriment ; and the rapidity of the emaciation will increase 
 as the communication is placed further from the duodenum. 
 
 The incision employed is usually one in the middle line through 
 the linea alba. The stomach is readily found, and the condition 
 of the growth examined so as to determine whether or not it is 
 removeable. Formerly it was the practice to unite the bowel to 
 the anterior wall of the stomach (Fig. 326), but there are two 
 obvious objections to this method : (a) The jejunum is drawn up 
 over the transverse colon, and is likely to constrict it and lead to 
 obstruction ; and (b) the necessary drag of the gut is apt to bring 
 the two ends parallel to each other, and thus produce a spur or 
 kink, by means of which the bile is directed into the stomach 
 instead of into the efferent limb. Severe bilious vomiting results, 
 which may prove fatal. 
 
 Hence the majority of surgeons nowadays follow with advantage 
 the plan recommended by Von Hacker of utilizing the posterior 
 gastric wall for this purpose. It is accomplished in the following 
 manner : The transverse colon is withdrawn from the wound, 
 together with part of the 
 
 omentum. By tracing down 
 the transverse meso-colon to 
 its attachment to the pos- 
 terior abdominal parietes, the 
 termination of the duodenum 
 is reached as it crosses the 
 middle line along the lower 
 border of the pancreas, and 
 with the superior mesenteric 
 vessels lying in front of it ; 
 by this means the upper 
 portion of the jejunum is 
 easily found, and a suitable 
 spot for making the anasto- 
 mosis selected. A hole is 
 then made through the trans- 
 verse meso-colon (Fig. 327), 
 so as to open into the lesser 
 sac of the peritoneum, and 
 enable the posterior wall of 
 the stomach to be reached. 
 A clamp is placed on either 
 side of the selected portion 
 
 Fig. 327. — Posterior Gastroenteros- 
 tomy. (Von Hacker's Operation.) 
 
 A, Transverse colon turned up together 
 with the omentum (which is omitted 
 from the drawing) ; B, coil of small 
 intestine, which is brought into con- 
 tact with the posterior wall of the 
 stomach through C, a hole in the trans- 
 verse meso-colon, the margins of which 
 are fixed down by stitches to the back 
 of the stomach. 
 
 of bowel, so as to prevent 
 
 the escape of intestinal contents when the gut is opened ; but, 
 of course, it is impossible to do the same to the stomach ; the latter 
 viscus ought, therefore, to be thoroughly washed out with some 
 dilute antiseptic, such as boric acid, before the operation com- 
 mences. Sponges are also packed around the site of operation, 
 so as to receive any fluid which may escape. 
 
920 A MANUAL OF SURGERY 
 
 If Wolfler's plan of simply suturing is adopted, two incisions 
 about an inch long are made, one in the stomach and the other in 
 the jejunum, involving at first only the serous and muscular 
 coats. In the stomach it is made parallel to the great con- 
 vexity, and about i^ inches from its lower edge, whilst in the 
 jejunum the incision is longitudinal, and situated along the anti- 
 m jsenteric border. Both of these wounds gape to such an extent 
 as to allow of the union of the divided coats on the lower side by 
 the insertion of a row of fine catgut stitches. The mucous mem- 
 branes are then incised, and a row of catgut sutures is introduced 
 to unite them to the same extent, the knots being located within 
 the lumen of the bowel. The surgeon then deals with the remain- 
 ing unconnected lateral and upper segments of the openings, 
 taking up the mucous membranes and serous coats separately by 
 a double row of stitches, the knots being placed on the outer 
 aspect of the viscera. Thus, the deeper parts of the opening are 
 scaled by what is known as Wolfler's suture (Fig. 332, p. 930), 
 and the upper and more accessible portions by the Czerny- 
 Lembert stitch (Fig. 330). 
 
 If the Murphy button is employed, one of medium size should 
 be selected, and it is introduced according to the rules given 
 below (p. 938) for lateral anastomosis. 
 
 The operation is completed by suturing the margins of the 
 opening in the meso-colon to the stomach, so as to prevent any 
 subsequent contraction, by cleansing the peritoneum, and closing 
 the parietal incision in the usual way. 
 
 The after-treatment consists in abstaining from stomach-feeding 
 for at least forty-eight hours, if practicable, rectal alimentation 
 being resorted to in the interval. 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 satis- 
 factory, it soon passes off, especially when food is administered 
 by the mouth, as may usually be undertaken on the third day. At 
 first only fluid nourishment should be permitted, but in a week's 
 time soft solids may be given, and gradually a more liberal diet is 
 ordered. The effect of the operation is necessarily only palliative 
 when cancer is present, but the general condition often improves 
 considerably for a time, and the final exitus lethalis is associated 
 with less suffering. 
 
 In comparing Wolfler's and Murphy's methods, the great 
 advantage of the former consists in its introducing no foreign 
 body, which may give rise to trouble by slipping back into the 
 stomach or by impaction lower down the gut ; hence it should 
 always be used in non-malignant cases. The proceeding is, 
 however, much more tedious, and the shock caused by the 
 prolonged operation is often sufficient in itself to turn the balance 
 against a patient whose powers have been considerably dimin- 
 ished by a malignant growth associated with semi-starvation. 
 
ABDOMINAL SURGERY 921 
 
 Murphy's operation, though placing a solid body of some size 
 within the intestinal canal, has the great advantage of rapidity, 
 and, on the whole, we are inclined to recommend this proceed- 
 ing as the better in malignant disease. The results hitherto 
 obtained have been most encouraging, Murphy being able to 
 report twenty-nine cases, with only eight deaths, and we our- 
 selves have had several successful cases. The button, if all 
 goes well, should appear in the motions about a fortnight after 
 the operation. 
 
 Ulcer of the Duodenum is occasionally met with after burns, as 
 already described at p. 87. It may also occur in the same way 
 as a gastric ulcer — i.e., more or less spontaneously, and without 
 any apparent cause. The symptoms to which it gives rise are 
 deep pain in the right hypochondrium, worse after food, together 
 with vomiting. Haemorrhage may be caused by the ulcer laying 
 open some branch of one of the pancreatico-duodenal vessels, 
 and this may prove fatal. Perforation is sometimes induced, 
 and, according to its situation and size, it gives rise to acute or 
 chronic suppurative peritonitis, or, if it opens posteriorly, to a 
 subphrenic abscess, which tends, however, to come to the surface 
 to the right of the suspensory ligament of the liver ; in fact, the 
 symptoms and results are very similar to those of perforating 
 gastric ulcer (q.v.). Stenosis of the duodenum may follow this 
 lesion. 
 
 Affections of the Intestine. 
 
 Congenital Conditions are occasionally met with affecting the 
 intestines, and perhaps giving rise to serious complications. 
 (a) The most common of these consists in what is known as 
 Meckel's diverticulum. It occurs as an outgrowth from the lower 
 end of the ileum, which may be patent for 1 or 2 inches, terminat- 
 ing possibly in a fibrous cord, which floats free amongst the intes- 
 tines, or may contract adhesions, and thus determine an internal 
 strangulation ; sometimes it persists as an open tube as far as the 
 umbilicus, giving rise to a congenital faecal fistula. It is due to non- 
 obliteration of the omphalo-mesenteric duct, (b) Congenital stenosis 
 of the duodenum also 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. 
 
 Injuries of the Intestine. 
 
 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 
 
922 A MANUAL OF SURGERY 
 
 wall, followed by a subacute or chronic enteritis, from which with 
 care the patient quickly recovers. In the more severe cases, an 
 acute enteritis ensues, due to bacillary invasion, which may even 
 run on to ulceration or sloughing of the coats of the bowel. 
 The latter result is more likely to follow if the mesentery has 
 also been involved in the injury so as to produce thrombosis of 
 the mesenteric vessels. Under these circumstances, the final 
 issue depends largely upon the rapidity of the inflammatory pro- 
 cess. If adhesions have had time to form between the parietes 
 and the injured gut, the mischief is limited, and the patient may 
 recover with an artificial anus or faecal fistula, the formation of 
 which has been preceded by a localized intraperitoneal abscess, 
 containing extremely offensive pus, owing to the presence of the 
 Bac. coli, which has migrated through the intestinal wall. If, 
 however, the inflammatory affection is rapid in its onset, and 
 adhesions have not had time to develop, acute diffuse peritonitis 
 is almost certain to follow. When the injured portion of the bowel 
 is retroperitoneal, as in the duodenum or colon, a retroperitoneal 
 abscess may form. 
 
 The Symptoms of intestinal contusion consist primarily of shock 
 and pain. The amount of shock varies necessarily with the 
 severity of the injury and the nervous susceptibility of the patient. 
 The pain may not be severe during the period of shock, but is 
 always very marked subsequently, and increased by examina- 
 tion, movement, or during violent respiratory 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 contu- 
 sions of the abdominal wall (p. 892), viz., where there is no 
 absolute evidence of rupture, an expectant attitude must be 
 adopted. If, however, at the end of twenty-four or forty-eight 
 hours signs of acute peritonitis manifest themselves, an exploratory 
 laparotomy is justifiable. 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 is alone permissible. 
 
 Rupture of the Intestine follows abdominal injuries of a more 
 severe character than those causing contusion, such as when a 
 cart or cab has traversed the abdomen, or when the patient has 
 been tightly squeezed. The amount of distension of the gut is a 
 most important factor in the aetiology, since it is obvious that a 
 distended coil is much more likely to give way than one that 
 is empty ; in the latter case it is quite possible for a small 
 wound to occur, through which the intestinal contents are unable 
 
ABDOMINAL SURGERY 923 
 
 to escape. The bowel does not always give way at the point of 
 impact, but occasionally at a distance from it ; under these cir- 
 cumstances the tear is more likely to be ragged and irregular, 
 whilst if it yields at the point struck, the gut may be cleanly torn 
 across. The parts most frequently affected by this form of injury 
 are the junction of the moveable jejunum with the fixed duodenum, 
 and the lower 3 feet of the ileum. The effect of the accident on 
 the mesentery is also of importance, since in the first place it may 
 give rise to considerable intraperitoneal haemorrhage, and later on 
 may cause sloughing of the gut as a result of thrombosis. 
 
 The Effects of rupture of the intestine are always extremely 
 serious, if extravasation of the contents follows, since acute diffuse 
 peritonitis is almost certain to be lighted up ; in a few cases a 
 localized intraperitoneal abscess has been known to result, but 
 such is by no means common. 
 
 The early Symptoms consist of severe and usually lasting shock, 
 accompanied by intense abdominal pain. Owing to escape of the 
 intestinal contents, a virulent form of acute peritonitis follows 
 immediately, from which the patient rapidly succumbs. Free 
 gas is sometimes, but not frequently, met with in the peritoneal 
 cavity, as in rupture of the stomach, and may be recognised by 
 the existence of a resonant note on percussion in front of the liver. 
 In a few cases emphysema of the abdominal walls has been caused, 
 and in the absence of thoracic injuries or of diffuse cellulitis is an 
 absolutely certain sign of rupture of the intestinal tube. Vomiting 
 occurs, but not to an excessive degree ; if blood is found in the 
 vomit, it suggests that either the stomach or upper part of the 
 intestinal canal has been injured. Occasionally a blood-stained 
 motion is passed, but only late in the case. 
 
 The Diagnosis of a ruptured intestine is always a matter of 
 uncertainty in the absence of such symptoms as resonance in 
 front of the liver or emphysema of the abdominal walls, which are 
 very uncommon. The amount of shock is an uncertain guide, 
 although, if prolonged and severe, it is suggestive ; whilst the 
 presence of an area of deep fixed tenderness and pain with, perhaps, 
 a rigid abdominal wall over it, and the incidence of early acute 
 peritonitis are probably the only signs that we can depend upon 
 with any certainty. The history and nature of the accident are 
 important, and should be carefully investigated. 
 
 In the non-existence of any distinct signs of rupture, Treatment 
 in the early stages can only be expectant, and directed towards 
 combating the shock and relieving the pain. A small dose of 
 opium should be administered with this object, and also to check 
 peristalsis, and hinder further extravasation of the intestinal con- 
 tents ; but as little as possible should be given, since it tends to 
 mask symptoms. If the surgeon has good grounds for suspect- 
 ing that the intestine is torn, he ought at once to undertake an 
 exploratory laparotomy, which in careful hands will do less harm 
 
924 A MANUAL OF SURGERY 
 
 to the patient than waiting for the onset of acute peritonitis to 
 make the diagnosis certain. If severe shock is present, an injec- 
 tion of hot saline solution into a vein will sufficiently restore the 
 patient in the majority of cases to warrant such a procedure. 
 When a rupture is found, the same rules of treatment should be 
 followed as those which have been enunciated for a ruptured 
 stomach. 
 
 In Punctures or Stabs involving the intestine, the results differ 
 considerably according to the amount of distension of the bowel, as 
 also with the fluidity of the faeces and the direction of the incision. 
 Thus, a longitudinal cut (running parallel to the axis of the bowel) 
 is more likely to gape than a transverse one, owing to the greater 
 power of the circular muscle fibres ; a small puncture may be 
 almost closed by a protrusion of mucous membrane. Wounds of 
 the small intestine are more likely to be accompanied by extrava- 
 sation than when the colon is involved, owing to the contents of 
 the former being in a much more liquid state. 
 
 The Symptoms are very similar to those already detailed as 
 characteristic of rupture of the intestine. As far as regards the 
 immediate phenomena, there is nothing absolutely typical unless 
 gas or faecal material is escaping either from the abdominal wound 
 or from a prolapsed portion of bowel. Shock is not necessarily 
 so severe as when the intestine is ruptured by violence without 
 penetration ; abdominal pain is always present, and the pheno- 
 mena of acute peritonitis quickly follow. 
 
 Treatment. — Every case of suspected penetration should be 
 carefully and thoroughly explored ; a probe is first passed, and 
 then the abdominal parietes divided on either side of the probe, 
 so as to enable the extent of the mischief to be ascertained. If 
 the peritoneum is not opened, no harm has been done, since after 
 purification the different layers of the wall are sutured together. 
 If the peritoneum has been involved, the opening in it should 
 be enlarged, so as to explore the viscera and determine with 
 certainty whether or not the gut has been wounded. If a small 
 punctured or incised wound of the intestine is present, it is closed 
 by a purse-string stitch or by a row of Lembert or 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 tem- 
 porary artificial anus, which is subsequently dealt with when the 
 patient's general condition has improved. As to the treatment of 
 the resulting peritonitis, we must refer to what has been written 
 concerning rupture of the stomach (p. 902). 
 
 For Gunshot Wounds and their treatment, see pp. 203 and 205. 
 
ABDOMINAL SURGERY 925 
 
 Perforation of the Intestine arises from many different causes, 
 such as the impaction of a foreign body, or the yielding of an 
 intestinal ulcer, as occurs in tuberculous disease or typhoid fever, 
 or from that form of enteritis which follows strangulated hernia. 
 We have already discussed the phenomena resulting from the 
 perforation of an ulcer of the stomach or duodenum (pp. 905 and 
 921), and another variety caused by perforation of the appendix 
 will be alluded to subsequently (p. 947). 
 
 When the jejunum or upper portion of the ileum is involved, 
 perforation is usually due to the impaction of a foreign body, 
 such as a fish-bone, or to yielding of a tuberculous ulcer. In acute 
 cases, general peritonitis is almost certain to follow, and what we 
 have written as to the results and treatment of such a lesion in 
 the stomach applies here with equal force. Occasionally the 
 lesion is of a more chronic type, especially when due to tubercle, 
 and then adhesions may form, allowing an intraperitoneal abscess 
 to develop, and should it open externally, a faecal fistula follows. 
 In not a few cases the process of cicatrization may lead to a spon- 
 taneous closure of the fistula, and no operation should be under- 
 taken until sufficient time has elapsed to determine whether or 
 not this will occur. A similar condition sometimes results from 
 tuberculous peritonitis, the umbilicus being a common site for 
 such a fistula to develop. In other cases several coils of intes- 
 tine may be matted together by adhesions, amongst which an 
 abscess forms, and this by opening into the bowel in two or more 
 places gives rise to a fistulous communication, known as a fistula 
 bimucosa. 
 
 In the lower portion of the ileum, typhoid fever is the most usual 
 cause of perforation. It generally occurs about the end of the 
 second or in the third week of the disease, and rarely more than 
 one perforation is present. It is most commonly seen in bad 
 cases associated with meteorism and haemorrhage, but is not 
 limited to such. The 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 followed 
 by distension indicates the development of general peritonitis. 
 Even when the patient is already collapsed by the disease, some 
 slight fall of temperature with acceleration of the pulse may occur, 
 followed by abdominal pain and meteorism. Early rigidity of the 
 belly w r all is an important diagnostic sign, whilst there may be 
 some irritability of the bladder. The only treatment which holds 
 out any prospect of saving the patient is operation, but owing to 
 his depressed condition the outlook is not particularly bright. 
 Obviously, when he is moribund, it is useless to interfere ; but the 
 fact that at least seven cases of recovery have been reported, out 
 of rather more than forty that have been subjected to operation, 
 shows that in suitable circumstances a certain percentage of 
 success may be anticipated. The abdomen should be opened in 
 
926 A MANUAL OF SURGERY 
 
 the middle line below the umbilicus, and if the lesion is not at 
 once obvious, the ileum is sought for at its junction with the 
 caecum, and the bowel brought up and carefully examined inch by 
 inch till the perforation is found ; it may then either be closed by 
 sutures, or stitched to the margins of the wound so as to create 
 a temporary artificial anus. The peritoneum is cleansed and 
 drained in the usual way. 
 
 In the large intestine the most common cause of perforation is 
 ulceration due to chronic obstruction. Masses of faeces accumu- 
 late within the bowel, and by their pressure give rise to inflam- 
 mation of the walls, which runs on either to ulceration or to 
 actual necrosis. Most usually the peritoneum is by this means 
 laid open, and acute perforative peritonitis follows. In malignant 
 disease of the colon, perforation also occurs in some instances, 
 giving rise to a localized abscess, and subsequently to a faecal 
 fistula. 
 
 Stenosis of the Intestine. 
 
 This arises from two main causes, viz., the contraction of 
 cicatrices, and the development of malignant growths. 
 
 Cicatricial Stricture usually results from the healing of ulcers 
 which have extended more or less circularly around the bowel. 
 After typhoid fever they are therefore rare, since the ulcers are 
 rather longitudinal than transverse, and, indeed, there is only one 
 certain case of stricture arising from this source on record. In 
 the small intestine tuberculous ulceration is one of the commonest 
 causes, since it always tends to travel round the gut along the 
 line of the vessels ; it is usually found in the neighbourhood of 
 the ileum, and may involve an extensive portion of the bowel, or 
 be multiple. It also arises from syphilitic disease, or as a sequela 
 of strangulated hernia, injury, or the separation of an intussus- 
 ception. In the large intestine dysentery is perhaps the most 
 important cause of stricture, whilst syphilis or pelvic cellulitis 
 may determine its occurrence in or near the rectum. 
 
 Owing to the contents of the small intestine being of a some- 
 what liquid nature, a stricture in this situation often exists for 
 some time before symptoms of any urgency arise. The patient 
 may complain of a certain amount of indigestion and discomfort, 
 but sooner or later the narrowed aperture of the gut becomes 
 blocked either by a fold of 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 recurrence is likely to increase 
 in severity, until finally an acute attack supervenes, which kills 
 the patient, unless relieved by prompt surgical interference. 
 
 In the large intestine very similar phenomena appear, but the 
 attacks of obstruction are of a somewhat different character, since 
 there is less pain and vomiting ; and aperients, instead of re- 
 
ABDOMINAL SURGERY 927 
 
 lieving the patient, as they often do in the earlier attacks in the 
 small gut, always aggravate the symptoms ; there is also much 
 greater distension of the abdomen. The diagnosis of stricture, 
 though strongly suggested by the symptoms, can only be abso- 
 lutely confirmed by an exploratory operation, except when the 
 lower part of the rectum is 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 we must refer readers to the chapter 
 on obstruction for details of the treatment to be adopted. If on 
 operating the stricture is found and recognised, enteroplasty or 
 enterectomy should be undertaken, if the small gut is involved. 
 For stricture of the caecum or ascending colon, some short- 
 circuiting method, whereby the ileum is implanted into the colon 
 below the stricture (ileo-colostomy), is perhaps the best plan to 
 adopt ; in the transverse colon excision is possible, as also in the 
 sigmoid flexure, whilst in the descending colon enteroplasty may 
 be undertaken. Failing any of these radical measures, the 
 establishment of an artificial anus in the bowel above the stenosis 
 suffices to give relief. It must be remembered, however, that no 
 permanent opening can be made more than a foot above the ileo- 
 cecal valve, since the absorption of nutrition is thereby so inter- 
 fered with that death from asthenia is certain to follow in a very 
 short time. The intestinal contents, too, are fluid and very acid 
 at this level, and give rise to much irritation of the skin. 
 
 Cancer of the Bowel is almost always primary in nature, and 
 is then usually a columnar carcinoma, to which colloid degenera- 
 tion is sometimes added. Secondary growths are occasionally 
 met with, and are necessarily of the same nature as the original 
 tumour. The disease may occur as a localized plaque imbedded 
 in the mucous membrane, and undergoing the usual ulcerative 
 changes ; but more frequently it appears as a circular infiltration 
 of the bowel. Secondary deposits arise after a time in the mesen- 
 teric glands, the liver, or even in distant parts ; the general history 
 of these growths suggests, however, that they are not so malignant 
 in type as cancer elsewhere. At first they merely give rise to 
 dyspeptic Symptoms of varying character, according to the size 
 and situation of the mass, and then to these may be superadded 
 intermittent attacks of chronic or subacute obstruction, which 
 originally come under the care of the physician, but at length the 
 surgeon's assistance is needed to relieve or deal with an acute 
 attack. Two other manifestations of the disease may determine 
 surgical action, viz. : (1) The existence of a tumour, which, 
 though at first readily moveable, soon becomes fixed owing to 
 the formation of adhesions to surrounding tissues ; and (2) the 
 development of an abscess due to an invasion of the growth by 
 
928 A MANUAL OF SURGERY 
 
 the Bac. coli, which finds its way through the ulcerated surface of 
 the tumour. This complication is most likely to occur when the 
 colon is affected, and all the manifestations of an acute or sub- 
 acute intraperitoneal abscess supervene. In favourable cases it 
 bursts externally, or is opened, giving exit to exceedingly offensive 
 pus, and for a while the patient's symptoms are relieved ; a fiscal 
 fistula follows, and the disease runs a rapid course to its inevitably 
 fatal issue. 
 
 Treatment. — Whenever a diagnosis of malignant disease of the 
 bowel has been made or is suspected, an exploratory laparotomy 
 is justifiable in order to confirm or disprove the fact. Unfor- 
 tunately, physicians are only too liable to leave the case until 
 the progress of the disease has settled the question, and then 
 palliative treatment may alone be possible. If found early 
 enough, the growth, together with a good margin of healthy tissue 
 on either side, should be removed, and the intestinal canal re- 
 stored by enterorrhaphy. A V-shaped portion of the mesentery 
 is included in the part excised, so as to remove if possible any 
 affected lymphatic glands. Should this be impracticable owing to 
 the extent or fixity of the growth, the following plans of treatment 
 may be considered, and that which best suits the requirements of 
 the particular case undertaken : 
 
 i. The growth may be 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 sutured. This lateral implantation is the 
 best plan of treatment to employ for cancer of the caecum which 
 cannot be extirpated ; the ileum is divided above the valve, and 
 its open end implanted into the ascending colon well above the 
 growth (ileo-colostomy), whilst the lower end is totally closed. 
 
 3. The affected coil of gut has been excluded from the intes- 
 tinal tube by dividing the bowel above and below, and uniting 
 the divided ends, whilst the open ends of the diseased coil are 
 either entirely closed by sutures, or one end is closed and the 
 other is brought to the surface, and fixed there so as to establish 
 a fistulous track. The latter practice is probably the safer to 
 adopt, since there is always a certain amount of discharge from 
 the cancerous growth, and, at any rate, in the small intestine the 
 mucous membrane itself secretes, so that total closure would be 
 accompanied by danger. 
 
 4. Finally, if none of these measures are applicable, or if the 
 patient's condition is such as to make it unwise to attempt them, 
 and if the growth is situated in the colon, an artificial anus may 
 be established. 
 
ABDOMINAL SURGERY 
 
 929 
 
 Operations on the Intestines. 
 
 Before describing in detail the actual operations which are 
 undertaken upon the small or large intestine, it is essential that 
 the various Sutures employed in such work should be discussed. 
 The interior of the bowel is occupied by material which, as long 
 as it remains in its proper place, is innocuous enough ; but let 
 it once 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. For this reason a continuous stitch must 
 never be employed except in the long axis of the bowel, or 
 unless there is some button or bobbin within it. Again, it is 
 essential that on its peritoneal aspect the line of union should 
 present nothing but serous membrane, as otherwise adhesions are 
 certain to form, and the comfortable action of the bowel will be 
 
 Fig. 328. — 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. 
 
 Fig. 329. — L emberi's 
 Suture seen in Section, 
 to show Character of 
 Approximation. 
 
 I., Suture ; a, serosa ; b, 
 muscularis ; c , mucosa. 
 
 subsequently impaired. Hence, special forms of stitches have to 
 be adopted, the more important of which are described below. 
 
 Laiiberfs Suture, originally proposed at the end of last cen- 
 tury, 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 by leakage of the intestinal contents, and possibly 
 peritonitis. The needle is passed at right angles to the axis of 
 the wound through a small fold of the serous and muscular coats, 
 going down to the submucosa ; each fold is placed about one- 
 twelfth of an inch from the margins of the incision (Fig. 328). 
 On drawing up and tightening the stitch, the margins of the wound 
 are tucked in (Fig. 329), and only the serous coats brought into 
 apposition. A series of similar stitches are inserted along the 
 whole extent of the wound, numbering about ten or twelve to 
 the inch. In closing a longitudinal incision in this way, a groove 
 will be formed at either end which must be obliterated by two or 
 
 59 
 
93° 
 
 A MANUAL OF SURGERY 
 
 three extra sutures. For a small puncture the same type of stitch 
 is 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. 
 
 The Czerny-Lembert Suture is very similar in its nature, but 
 consists of two rows : the first has for its object the closure of 
 the wound in the mucous membrane (Fig. 330, I.), and in a 
 
 h c 
 
 Fig. 330. — Czerny-Lembert Suture. 
 
 I., Stitch securing divided mucous 
 membrane; II., ordinary Lembert 
 suture, for the serous coats ; a, serosa; 
 b, muscularis ; c, mucosa. 
 
 Fig. 331. — Halsted's Mattress 
 Suture. 
 
 longitudinal wound this may be of the continuous type ; the 
 second row consists of the ordinary Lembert stitches, con- 
 tinued or interrupted according to the requirements of the case 
 (Fig. 330, II.). By this means the knots of the first series of 
 sutures are covered over and buried by the second row. 
 
 Halsted's Mattress Suture (Fig. 331) is a very valuable one, 
 
 Fig. 332. — Wolfler's Suture. 
 
 , Stitch through serous and muscular coats 
 applied and tied from within ; II., stitch 
 uniting divided mucous membrane over 
 the former, so as to cover it in ; a, serosa ; 
 b, muscularis ; c , mucosa. 
 
 Fig. 333. — Paul's Tubes 
 (Glass), Large and Small 
 Sizes. 
 
 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 exactly the same pre- 
 cautions as the original Lembert. 
 
 Occasionally it happens that two segments of bowel have to be 
 stitched together, although the surgeon cannot reach the outer 
 coats owing to this portion being fixed. Thus, in dealing with 
 the posterior segments of the walls of the bowel, either in 
 pylorectomy or gastroenterostomy, it is found that one can only 
 work from the front, and the stitches must then be inserted by 
 
ABDOMINAL SURGERY 931 
 
 what is known as Wolfiey's Method (Fig. 332). The sutures 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 gut. The mucous membrane is then 
 secured by a second row of stitches (II.), so as to cover over the 
 first series of knots. Of course, only a portion of the circum- 
 ference of the bowel has to be dealt with in this way ; as soon as 
 possible, one changes to the Czerny-Lembert method. 
 
 Passing on now to the actual operations, the following have to 
 be described : 
 
 1. Enterotomy is a term which is only correctly applied to an 
 incision 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-mesenteric border ; it is closed by a row of Lembert, Czerny- 
 Lembert, or Halsted stitches. 
 
 2. Enterostomy, or the formation of an artificial opening into 
 the bowel, is an operation sometimes undertaken for the relief of 
 intestinal obstruction when the patient is almost moribund, and 
 one is unable to make an exact diagnosis of the cause. It is 
 especially useful when the obstruction is probably due to some 
 lesion located in the caecum or ascending colon. An incision 
 is made, either in the middle line or in the iliac region on the 
 right side, somewhat similar to that employed for removal of 
 the appendix ; the first distended coil which presents is drawn 
 well out, and opened after carefully protecting the peritoneal 
 cavity from faecal infection. A large trocar and cannula are first 
 introduced, so as to allow the flatus and fluid contents of the gut 
 to escape ; the opening is then enlarged and a Paul's (glass) tube 
 tied in (Fig. 333), so as to carry away the intestinal contents clear 
 from the wound, to the margins of which the bowel is fixed. This 
 proceeding is sometimes known as Nelaton's operation, and is at 
 the best merely a temporary expedient. 
 
 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 for fibrous 
 stenosis of the pylorus (p. 917). A longitudinal incision is made 
 through the stenosed gut along the anti-mesenteric border ; this 
 is opened out, and converted into a transverse cleft, which is care- 
 fully sutured, the lumen of the bowel being thereby considerably 
 increased. 
 
 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 gun- 
 shot injury; (c) in dealing with an artificial anus or faecal fistula; 
 (d) for the removal of simple or malignant strictures ; and (e) in 
 some cases of intussusception. Not long ago the operation was 
 
 59—2 
 
932 A MANUAL OF SURGERY 
 
 but rarely undertaken, and the results were most unsatisfactory; 
 but at the present time a very considerable degree of success may 
 be expected, and enterectomy is frequently practised. Naturally, 
 the results vary largely with the condition for which it is per- 
 formed, and with the experience and skill of the operator ; a 
 much higher rate of mortality follows when the excision is done 
 for malignant disease, for gangrene following strangulation, or for 
 intussusception, than when performed for other causes. 
 
 Whenever practicable, the bowel should be thoroughly emptied 
 prior to operation, and rendered as sterile as possible by the use 
 of such drugs as calomel (gr. i. daily), salol, /i-naphthol, naphtha- 
 lene, bismuth subnitrate, etc., for a few days previously. The 
 abdomen is opened by any suitable incision, and the portion to be 
 removed clearly defined, the general peritoneal cavity being pro- 
 tected by a careful packing with sponges or gauze. 
 
 The bowel must then be clamped on either side of the seat of 
 operation, so as to prevent the escape of intestinal secretions or 
 faeces. Any of the forms of clamps figured in surgical instrument 
 catalogues will effect this purpose, and amongst the best are 
 Makins' or Lane's ; but perhaps it is wiser to do without them, 
 the same result being 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 little lateral anastomosis, and therefore it is 
 desirable that the incisions should slightly diverge 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 
 junction ; 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 one of the many forms 
 of enterorrhaphy described below. 
 
 5. Enterorrhaphy is required for any condition in which there is 
 a solution of continuity of the canal, and necessarily the methods 
 employed must vary according to the character and situation of 
 the lesion. We have already alluded to the plans that are 
 utilized in dealing with longitudinal wounds of the gut. The 
 two chief methods that remain to be discussed are the end-to-end 
 union of a totally divided segment of the bowel, and the means 
 whereby lateral approximation or union is secured. 
 
A BDOMINA L SURGERY 
 
 933 
 
 For end-to-end union the following are the chief plans that 
 have been adopted : 
 
 A. Enterorrhaphy 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 gut is united by 
 a series of interrupted Lembert or Czerny-Lembert sutures, in- 
 serted around the circumference at distances of about one-twelfth 
 of an inch. The greatest care must be employed in dealing with 
 the mesenteric attachment, where the peritoneal layers separate 
 in order to enclose the bowel, and where there is a consider- 
 able likelihood of the muscular coat being missed ; if this happens, 
 leakage is almost certain to ensue. This method in skilled hands 
 is very satisfactory in its results, but there is one great objection 
 to it, viz., the time taken in its performance. 
 
 Fig 334. — Maunsell's Operation I 
 for uniting divided segments 
 of Gut Fig. 335- — Maunsell's Operation. 
 
 The mesenteric and anti-mesenteric Taction stitches carried through the 
 traction stitches have been intro- ? u ° e . and out of the lateral P en " 
 
 duced, and A shows the situation of in S- 
 
 the lateral incision, and its forma- 
 tion by transfixion. 
 
 B. Maunsell's opevation, in which a temporary invagination 
 enables the coats of the gut to be accurately sutured together, is 
 a most valuable proceeding. It may be described in stages as 
 follows : (a) Two long horsehair sutures are passed through the 
 whole thickness of the mesenteric and anti-mesenteric borders of 
 each end of the divided intestine, and tied together with the knots 
 on the inner aspect of the bowel (Fig. 334). (b) A longitudinal 
 incision about three-quarters of an inch in length (Fig. 334, A) is 
 then made through the anti-mesenteric border of the bowel, about 
 an inch from the end of the upper or lower segment, according to 
 convenience, (c) The horsehair sutures (Fig. 335, D) are now 
 passed within the intestine, and drawn out of the lateral opening. 
 Traction upon these, assisted by a little careful manipulation, 
 enables the surgeon to produce an artificial intussusception 
 (Fig. 336). Difficulty may be experienced in this if the lateral 
 opening has been placed too far from the section, or if the 
 mesentery is loaded with fat or very oedematous. The divided 
 
A MANUAL OF SURGERY 
 
 934 
 
 ends of the bowel now present through the lateral aperture as 
 two tubes one within the other (Fig. 337), their serous coats 
 being in contact, and the mucous coats lining both the inner 
 and outer aspects of the protrusion. (d) A sharp straight 
 needle (Fig. 337, A) carrying after it a thread of fine silk or cat- 
 gut, is passed through one of the diameters of the protrusion, 
 transfixing the serous, muscular, and mucous coats. The 
 central portion of the suture, as it passes across the inner tube, 
 is drawn out and divided, and the two halves are tied on 
 either side. Similar sutures are passed in other diameters, until 
 some sixteen or more are present. By this means the two tubes 
 are securely united together, (e) All the sutures are cut short, 
 and the intussusception reduced. The bowel will be found 
 
 Fig. 336. — Maunsell's Operation, 
 showing Position of Intestine after 
 Invagination has been accom- 
 plished. 
 
 The dotted lines indicate the mucous 
 membrane ; the continuous lines, the 
 serous. 
 
 Fig. 337. — Method of insert- 
 ing Stitches in Intestine in 
 Maunsell's Operation. 
 
 A shows the needle passed through 
 both sides of the bowel, and 
 through all the intestinal coats, 
 so that one passage of the 
 needle places two sutures. 
 
 accurately sutured (Fig. 338, A), the knots of all the stitches being 
 placed within the lumen of the gut. (/) The lateral opening in the 
 bowel (Fig. 338, B) is closed by a continuous row of Lembert's 
 sutures, and if need be a row of the same is inserted around the 
 circular junction, as an additional safeguard in order to bury the 
 penetrating stitches, and so prevent leakage. The operation can 
 be rapidly performed, and gives excellent results. 
 
 Should it be necessary to unite unequal portions of intestine, the 
 larger segment is first reduced in size by the insertion of a row of 
 Lembert's or Czerny-Lembert's sutures, so as to make the opening 
 correspond in size to that of the smaller ; invagination may then 
 be accomplished through a lateral opening in the larger portion, 
 and the operation completed as before. 
 
 A modification of this method has been recently suggested and 
 practised with success by Ullman. After the invagination through 
 the lateral incision has been accomplished, a hollow bobbin made 
 of decalcified bone or carrot, and with a circular groove around its 
 
ABDOMINAL SURGERY 
 
 935 
 
 middle, is inserted into the inner canal, lined by mucous mem- 
 brane (Fig. 339). Around this the two tubes of gut are firmly tied 
 by a single silk thread. The intussusception is now reduced, the 
 bobbin being drawn into the bowel, and the operation is completed 
 by closing the lateral opening. The bobbin retains its shape and 
 
 Fig. 338. — Maunsell's Opera- 
 tion COMPLETED AFTER THE IN- 
 VAGINATION HAS BEEN REDUCED. 
 
 A shows line of union with serous 
 coats turned well in, so that none 
 of the sutures appear outside ; 
 B, longitudinal incision stitched 
 up. 
 
 Fig. 339. — Ullman's Modification 
 of Maunsell's Operation. 
 
 A bobbin is seen in place in the centre 
 of theinvaginated canal, and a single 
 suture, S, secures it in position. 
 
 texture sufficiently long to enable the segments of the intestine to 
 become firmly united by plastic lymph. If further use confirms 
 Ullman's experiences, we shall have in this method a most 
 valuable addition to our means of obtaining rapid and secure 
 end-to-end union. 
 
 Full Scze 
 
 A, Male half; B 
 by c, spring 
 
 A P" B 
 
 Fig. 340. — Murphy's Button. 
 
 female half ; P, inner cup or flange of male half, governed 
 ; S, spring catches working along a screw thread on the 
 
 inner aspect of the central stem of the female half. 
 
 C. Enterorrhaphy by the use of special apparatus. Under this 
 heading various bobbins and Murphy's button must be included. 
 
 Murphy s Button is represented in Fig. 340. It consists of two 
 portions, a male and a female, which can be easily insinuated one 
 into the other and closed, but which can only be separated by un- 
 twisting, the spring catches (S) seen in the side of the stem of the 
 
936 
 
 A MANUAL OF SURGERY 
 
 male working along a screw thread in the interior of the female. 
 
 Each half consists of a central stem, which is hollow for the passage 
 of faeces, to the outer end of which is attached 
 a cup-shaped expansion. In the male half 
 there is an additional inner cup or flange (P), 
 separated from the former by a spring (c), so 
 that when the two halves are approximated, 
 the inner cup is kept constantly pressed 
 against the female half, and thus pressure- 
 atrophy of the tissues grasped between the 
 two segments results, ultimately setting the 
 button free. In the meantime, however, a 
 sufficient formation of lymph will have oc- 
 curred along the line of junction of the two 
 to prevent extravasation and to secure union. 
 In performing end-to-end anastomosis, a 
 running thread is inserted through each end 
 of the divided intestine in the manner shown 
 in Fig. 341. It commences at the anti- 
 mesenteric border (b), and traverses the 
 whole thickness of the gut two or three times 
 until it reaches the mesentery (a), when a 
 return overstitch is introduced so as to gather 
 without fail the two layers of the mesentery 
 into the grasp of the button. The same 
 stitch is continued along the opposite side of 
 the tube, and brought out again at the anti- 
 mesenteric border. A half-button is now 
 and two ends of introduced into each end of the divided gut, 
 suture; c, mesenteric and preferably the heavier male end into 
 attachment. ftie lower segment ; the stitch is then drawn 
 
 tight and tied, so as to gather up the 
 
 gut wall round the central stem of the button (Fig. 342). The 
 
 two halves are now pressed together (Fig. 344), sufficient force 
 
 Fig. 341. — Method of 
 inserting Suture 
 for End-to-End 
 Anastomosis with 
 Murphy's Button. 
 
 a, Overstitch 
 
 mesenteric 
 
 b, anti- 
 border 
 
 DOWN BROS LONDON 
 
 Fig. 342. 
 
 -Appearance of Intestinal Segments with Murphy's 
 Button Tied in. (Down Brothers.) 
 
 being employed to bring the walls of the gut into accurate apposi- 
 tion, but without exercising injurious pressure. 
 
 The button is generally set free about the seventh day, and 
 
ABDOMINAL SURGERY 
 
 937 
 
 should pass downwards, and be expelled with the faeces any time 
 from the fourteenth to the twenty-first day. Occasionally there 
 are difficulties in the onward passage of the button, which may 
 either be retained entirely, or may become impacted ; under these 
 circumstances it has been known to ulcerate through the walls of 
 the gut, and cause fatal peritonitis. The results of the operations 
 undertaken by means of the button are very satisfactory, as com- 
 pared with ancient statistics ; but it is doubtful whether they are 
 any better than those obtained by many of the methods intro- 
 duced more recently. The one great advantage of this appliance 
 is the rapidity with which the anastomosis is completed. There 
 are, however, several very grave objections to its employment as 
 a routine measure ; the fact of its being made 
 of metal is of itself a drawback, and fatal 
 issues have certainly occurred from slough- 
 ing, from want of union due to the use of too 
 large a button, or of one badly constructed, 
 and even from subsequent obstruction and 
 perforation when it has passed lower down. 
 On the whole, one would be inclined to use 
 it when time is of value, and the patient's 
 general condition such as necessitates the 
 utmost speed in operating ; under other 
 circumstances one would prefer some other 
 method. 
 
 Many other useful contrivances, such as 
 Mayo Robson's bobbin (Fig. 343), Allingham's 
 
 bobbin, Chaput's button, etc., have been introduced of late, and 
 with most of them good results can be obtained. The majority 
 consist of a hollow tube of decalcified bone made of different sizes 
 to fit the varying lumen of the gut. The object is not so much 
 to bring about apposition of the divided ends of the bowel as to 
 act as an internal splint, steadying the part during and after the 
 operation, facilitating thereby the introduction of the stitches, and 
 shielding the line of union from the irritation of faeces for some 
 days. Mr. Robson recommends that two continuous sutures 
 should be employed, one to unite the divided ends of the mucous 
 membrane, and the other to approximate the serous and muscular 
 coats. It will be found advantageous to have a curved needle at 
 each end of these. The sero-serous suture is first introduced for 
 the posterior half of the incision, each stitch taking a firm grip of 
 the sero-muscular coats up to about a centimetre from the margin. 
 The muco-mucous suture is then put in for the same extent. The 
 bobbin is now placed in position ; the muco-mucous suture is first 
 finished and tied, and finally the anterior half of the sero-serous 
 suture is similarly completed. Each of these sutures must be 
 firmly tied around the bobbin, so that no slipping is possible. The 
 material of which it is composed (decalcified bone) is such as to 
 
 Fi g. 343. — Mayo 
 Robson's Bobbin. 
 (Down Brothers.) 
 
938 A MANUAL OF SURGERY 
 
 do no subsequent harm to the mucous membrane, since it becomes 
 soft and pulpy in the course of a few days. 
 
 6. Lateral Anastomosis of the intestine is usually undertaken in 
 order to effect the short-circuiting of some malignant growth, or 
 of a stricture which cannot otherwise be dealt with. It is some- 
 times employed instead of end-to-end anastomosis to unite divided 
 segments of intestine. The open ends are first entirely closed by 
 Lembert or Czerny-Lembert stitches, and the portions of bowel 
 made to overlap. Corresponding lateral incisions are then made 
 into each. 
 
 The anastomosis may be effected in the following ways : 
 
 (a) By Simple Suturing, or, as it is sometimes called, by Wolfler's 
 operation. This has been already described under gastroenteros- 
 tomy at p. 920. The longitudinal openings in the two portions 
 of bowel lying exactly opposite each other are secured by sutures, 
 inserted in the posterior half of Wolfler's plan, and in the rest of 
 the opening by the Czerny-Lembert method. In order to prevent 
 subsequent contraction, it is absolutely essential that the mucous 
 membrane be continuous all round the aperture. 
 
 (b) Murphy's Button is probably the quickest, and certainly the 
 most satisfactory, of all the plans that have yet been suggested. 
 The details of its insertion differ slightly from those employed in 
 effecting an end-to-end anastomosis. Incisions are made in the 
 two sections of bowel to be united, each incision being two-thirds 
 of the diameter of the button to be used. The wounds at first 
 only involve the serous and muscular coats. A purse-string 
 suture is inserted round the incision, traversing the whole thick- 
 ness of the intestinal walls ; the mucosa is then incised, and the 
 half-button introduced. By drawing the stitch tight and tying it 
 around the stem of the button, the wall of the gut is gathered 
 into the hollow of the cup. This is accomplished on each side, 
 and then the halves of the button are pressed together in the way 
 shown in Fig. 344. Murphy recommends that after the operation 
 the bowels should not be confined, but should be kept loose, so as 
 to prevent any solid mass of faeces blocking the channel through 
 the button. 
 
 (c) A Robson's Bobbin may be employed, the sutures being 
 applied in exactly the same way as for end-to-end anastomosis. 
 
 7. The establishment of an Artificial Anus has frequently to be 
 undertaken in cases of intestinal obstruction, where the onward 
 passage of faeces is prevented by some irremoveable barrier. 
 It is sometimes required in the treatment of intussusception, 
 and for rupture or penetrating wounds of the gut. When the 
 small intestine is involved, enterostomy may be undertaken 
 as described above (p. 931); but it must be noted that life 
 is impossible for any length of time with an artificial anus 
 situated more than a foot above the ileo-caecal valve, on account 
 of the interference with nutrition owing to cutting off such a large 
 
ABDOMINAL SURGERY 
 
 939 
 
 extent of absorbent mucous membrane. Some form of short- 
 circuiting operation, or some means whereby the continuity of 
 the bowel is restored, must therefore be subsequently undertaken. 
 Things are, however, different in the large intestine ; colotomy is 
 frequently employed in dealing with diseases of the lower bowel, 
 and is an extremely successful proceeding. 
 
 The character of the artificial anus varies considerably accord- 
 ing to whether or not it is intended to be a permanent condition. 
 If merely a temporary opening is required, the smaller the portion 
 of bowel secured to the parietes the better, since the subsequent 
 operation for its closure is so much simpler (Fig. 345). But 
 
 Fig 3^ . — Method of closing Murphy's Button in Lateral Anasto 
 
 MOSIS BETWEEN GaLL-BlADDER AND DUODENUM (DOWN BROTHERS.) 
 
 where a permanent aperture has to be established, the surgeon's 
 aim should be to totally deflect the course of the faeces ; and 
 hence it is desirable to entirely withdraw a portion of the gut 
 from the abdominal cavity, and to cut away a complete segment, 
 including also, if possible, a portion of the mesentery. By this 
 means the upper and lower openings are brought to the surface of 
 the skin, and separated from one another by an area of cicatricial 
 tissue representing the section of the mesentery (Fig. 346). 
 
 Colotomy, or, as it should be correctly termed, ' colostomy,' is 
 an operation for the establishment of an artificial anus in some 
 portion of the large intestine. Any part of the colon may be thus 
 dealt with through a median laparotomy ; but one usually prefers 
 
940 A MANUAL OF SURGERY 
 
 to open the termination of the descending colon through the peri- 
 toneum in the left iliac region. Formerly the favourite method 
 was to open the descending colon in the left loin behind the peri- 
 toneum (left lumbar colotomy or Amussat's operation). Callisen's 
 name has also been associated with this proceeding, but he merely 
 proposed to do it through a vertical incision ; Amussat was the 
 first to perform the operation, utilising a transverse incision, and 
 extending its applicability to both sides of the body. 
 
 Uses of Colotomy. — 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 obstruc- 
 tion of the large intestine, which cannot be relieved by enemata 
 
 
 
 
 '"'-'-' :-. "\ 
 
 
 
 
 :■'"' ({ X"' 
 
 > )■ I 
 
 
 • «ESfju .. 
 
 
 '\«W \ 
 
 
 
 ,&: 
 
 \ 
 
 
 
 
 
 
 
 
 *A^ 
 
 Fig. 345. — Diagram of Temporary Fig. 346. — Diagram of Temporary 
 
 Colotomy, showing the Single Colotomy, showing the Two 
 
 Opening on a level with the Openings separated one from 
 
 Skin, the passage to the Lower the other by a section of the 
 
 Bowel being merely blocked by Mesentery. 
 
 A SPUR OF MUCOUS MEMBRANE. ^ ^^ ^^ indicates the 
 
 amount of Bowel cut away ; but, of 
 course, such an extensive resection 
 is only practicable when there is a 
 very long mesentery, which is un- 
 usual . 
 
 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 and other forms of 
 ulceration of the large bowel, which cannot heal as long as they 
 are irritated by the passage of faeces ; (5) for irremediable cases 
 of recto-vesical and recto-vaginal fistula, whatever their origin ; 
 (6) for volvulus of the sigmoid flexure, the inguinal operation 
 being needed, not only to relieve the obstruction, but also to 
 prevent recurrence. 
 
ABDOMINAL SURGERY 941 
 
 The ascending colon is occasionally opened in cases of mem- 
 branous or ulcerative colitis in order to prevent the irritation 
 caused by the passage of faeces over the inflamed tissues. The 
 result, however, is somewhat unpleasant, in that the contents of 
 the bowel at that level are usually fluid and very acid, giving rise 
 to much local irritation. 
 
 Lumbar Colotomy. — We shall here merely describe the operation 
 as performed on the left side of the body. 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 half an 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 mid- 
 way 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 spinas, and 
 pass outwards for about 4 or 5 inches (Fig. 375, A, p. 1068). 
 This incision is carried through the layers of the abdominal 
 muscles, dividing the latissimus dorsi and a small portion of the 
 external oblique, and beneath this the posterior attachments of 
 the internal oblique and transversalis muscles, constituting the 
 fascia lumborum. This should be cleanly divided along the whole 
 length of the incision, the last dorsal nerve and first lumbar artery 
 being usually included. The sheath of the quadratus lumborum 
 is opened, and the outer fibres of the muscle notched, if necessary. 
 The deeper portions of the wound are now held apart by spatulas, 
 and the loose fatty subperitoneal tissue gently torn through with 
 the fingers and forceps ; it varies considerably in amount and con- 
 sistency. The gut must then be looked for, and may be readily re- 
 cognised, if distended ; but if collapsed, a good deal of difficulty is 
 often experienced, though the hand of an assistant pressing back the 
 anterior abdominal wall may bring it into view. It is well to define 
 the lower edge of the kidney by the fore-finger, and the portion of 
 gut lying immediately in front of it is usually the colon. In other 
 cases it may be made evideni by inflating the rectum with air. 
 
 In about 20 to 30 per cent, of individuals a true peritoneal 
 ascending or descending meso-colon exists, and under such cir- 
 cumstances it is necessary to open the general peritoneal cavity 
 in order to bring the required portion of gut into view ; the opera- 
 tion is then completed in the same way as for iliac colotomy, the 
 bowel not being opened for some days if possible. 
 
 When, however, the gut has only a partial serous investment, 
 the peritoneal reflections are carefully defined, and the uncovered 
 portion drawn upwards between the fingers into the wound. The 
 highest attainable segment of gut should be selected, so that no 
 loose or slack part may remain above the wound, to give rise 
 later on to prolapse. If possible, the bowel should be left for a 
 
942 A MANUAL OF SURGERY 
 
 day or two before being opened, and is secured to the skin by 
 sutures which merely pass through the muscular coat. The horns 
 of the incision are then closed, and the gut incised at a later date. 
 
 If, however, the patient is suffering from obstruction, and an 
 immediate opening of the bowel is desirable, the best plan to 
 adopt is to pull the gut well out of the wound, which is then 
 carefully guarded by an antiseptic compress, and to tap it with 
 trocar and cannula, subsequently making a small incision into it, 
 in which a Paul's tube is at once tied, so as to allow the intestinal 
 contents to escape without soiling the wound. A few fixation 
 stitches are then introduced into the walls of the bowel, so as to 
 prevent it from retracting. The tube is probably set free about 
 the fourth day, but by this time the wound will be in such a state 
 that no great harm will come from the escape of faeces in the 
 neighbourhood. If a Paul's tube is not to hand, the patient is 
 rolled over on to his back, and a large trocar and cannula inserted, 
 so that the first gush of flatus and fluid faeces may be clear of the 
 wound. On removing the cannula the mucous membrane of the 
 gut is stitched to the margin of the skin, whilst the anterior 
 portion of the incision is sutured, and the small cavity behind the 
 gut packed with gauze. By fixing the bowel as far back as 
 possible, this cavity will be diminished in size. An antiseptic 
 dressing is then applied over a piece of protective to the anterior 
 portion of the incision, and a pad of tenax is placed behind to 
 receive the faecal discharge. 
 
 Lumbar colotomy is not much in favour at the present day. 
 It is always a difficult proceeding if the bowel is not distended ; 
 and if an immediate opening is necessary, there is a considerable 
 risk of suppuration of the wound and cellulitis. It has been 
 almost entirely replaced by the iliac operation. 
 
 Iliac Colotomy, or Littre's Operation, consists in opening the 
 lower portion of the colon or sigmoid flexure through the anterior 
 abdominal wall. An incision 2 to 3 inches in length is made at 
 right angles to a line extending from the anterior superior spine 
 to the umbilicus, the centre of the incision corresponding to the 
 junction of the outer and middle thirds (Fig. 319, C). The 
 abdominal parietes are divided, and the peritoneum opened. Two 
 fingers are then inserted, and the sigmoid flexure sought for ; it 
 is recognised by the presence of the appendices epiploicae and the 
 longitudinal bands of muscle fibres. It is carefully examined, 
 and the upper part of it selected for fixation in the wound, so as 
 to diminish the risk of subsequent prolapse. It is desirable to 
 withdraw a coil about 4 or 6 inches in length, together with its 
 mesentery. Many different plans of fixing it are in vogue, but 
 the method we prefer is to pass a strong silk thread through the 
 parietes and parietal peritoneum on either side of the wound, the 
 stitch traversing the mesentery en route. It is then made to 
 traverse the same structures once more in exactly the same way, 
 
ABDOMINAL SURGERY 
 
 943 
 
 but at a distance of about half an inch from the former (see Fig. 347). 
 The loose ends are then tied together, so as to bring the parietal 
 peritoneum and sigmoid meso-colon into close apposition. A few 
 additional stitches should be inserted, uniting the skin to the longi- 
 tudinal muscular bands at each end of the incision, so as to prevent 
 any subsequent retraction of the exposed bowel or escape of small 
 intestine. Some surgeons simply secure the parietal peritoneum 
 to the gut by a row of carefully inserted sutures ; others pass a 
 glass rod through the mesentery and stitch the peritoneum to the 
 skin, whilst it has also been suggested to make a hole through the 
 mesentery and suture the two edges of the incision through it, 
 i.e., beneath the bowel. The projecting portion of gut is then 
 covered with purified protective, and an antiseptic dressing 
 applied. At the end of two or three days the bowel is opened, no 
 anaesthetic being generally necessary for this proceeding. About 
 the eighth day a portion of the whole lumen of the gut should be 
 
 Fig. 347.— Iliac Colotomy to show Fixation Stitch passing through 
 Mesentery and Abdominal Parietes. 
 
 removed, down to and even including the mesentery, so as to 
 completely separate the upper from the lower end, and thus 
 establish an efficient spur. The deep stitch is removed about the 
 twelfth day. Should it be necessary to open the bowel at the 
 time of operation, the distended coil is first withdrawn and the 
 deep trans-mesenteric stitch passed and tied. The margins of 
 the wound are then carefully protected by antiseptic compresses, 
 and the bowel is tapped with a trocar and cannula. When the 
 first gush of flatus and faeces has escaped, the opening is enlarged 
 and a large-sized Paul's tube tied in. The skin is then carefully 
 sutured all round to the bowel and mesentery, and a collar-like 
 pad of gauze protects the junction. 
 
 When cicatrization of the wound is complete, a protective 
 apparatus is required in order to keep the patient clean. This 
 should consist of a hollow oval cup, made of plated metal, vulcanite 
 or celluloid, with a rolled edge, and kept in position either by 
 a truss spring or an abdominal belt. This hollow cup should be 
 large enough to include a 2-inch margin of skin all round the 
 opening, and in the concavity a small portion of antiseptic dressing 
 
944 A MANUAL OF SURGERY 
 
 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 disturb- 
 ance need occur during the day. 
 
 Comparison of the Two Operations. — As we have already stated, 
 the iliac operation has almost entirely superseded the lumbar pro- 
 ceeding, and the reasons for this change of attitude are as follows : 
 (i) The operator is not hampered by lack of space, as so 
 frequently happens in opening the loin. (2) A clean incision 
 can be made without tearing or bruising the subperitoneal fat. 
 (3) The sigmoid flexure is readily identified, and no other viscus 
 is likely to be opened for it by mistake ; if the colon takes an 
 abnormal course in the loin, or is provided with a complete meso- 
 colon, the peritoneum has usually, if not always, to be opened, 
 and thus the one advantage which can be claimed for the lumbar 
 proceeding is lost. (4) An artificial anus situated in the iliac 
 region can be attended to by the patient himself without assist- 
 ance, and is more easily cleansed and protected. (5) It is occa- 
 sionally possible for a certain amount of sphincteric control to be 
 developed after the abdominal operation, owing to the muscles 
 of the abdominal parietes becoming adherent to the coats of the 
 gut. Of course, this can only be attained when these structures 
 are brought into accurate apposition, as by the fixation stitch 
 described above. (6) A more complete diversion of the faeces can 
 be effected by the iliac operation than by the lumbar. In the 
 latter it is impracticable to withdraw the whole lumen of the gut 
 unless the peritoneum is opened ; an opening is merely made on 
 one side, and one has to trust to the formation of a valve or spur 
 of mucous membrane for the blocking of the lower aperture ; in the 
 former the two segments of the bowel can be entirely separated. 
 
 The objections urged against the iliac operation consist in the 
 following facts: (1) That it involves the opening of the peri- 
 toneum ; (2) that immediate relief to obstruction is more risky 
 than in the lumbar method ; and (3) that there is a somewhat 
 greater tendency to prolapse. The first of these objections must 
 now be entirely waived. The second is certainly valid, but by 
 a careful use of Paul's tube and by fixing the gut firmly to the 
 skin by additional sutures the danger is minimized. Certainly the 
 lumbar operation is not devoid of risk when an immediate opening 
 of the gut is required. Lastly, if the surgeon is careful to see 
 that no slack portion of gut exists above that which he fixes in 
 the wound, i.e., if he opens the lower end of the descending 
 colon, there will be but little likelihood of any subsequent pro- 
 trusion. 
 
ABDOMINAL SURGERY 945 
 
 Appendicitis (Syn. : Perityphlitis, Epityphlitis, etc.). 
 
 Appendicitis is an affection which may appear at any time of 
 life, but is most common in the young. The male sex is more 
 frequently attacked than the female in the proportion of 4 to 1 . 
 The disease is of a most protean type, being sometimes of but 
 slight significance, but occasionally running such a virulent course 
 as to destroy life in a few hours. Its importance necessarily lies 
 in the fact that the peritoneal envelope is always involved, and 
 hence a certain degree of peritonitis is almost necessarily a con- 
 sequence. 
 
 ^Etiology. — Many different conditions contribute either directly 
 or indirectly in determining an attack of appendicitis. (1) The 
 appendix 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-caecal branch of the ileo-colic artery. The main nutrient 
 vessels traverse in the meso-appendix, but a second twig often runs 
 down the base of the mesentery, and is more or less independent 
 of the others. In the female it is said to have an additional twig 
 from the right ovarian trunk, and this may explain why the disease 
 is less common in females than in males. (2) A large amount of 
 lymphoid tissue is present in its walls, so much, in fact, that the 
 title of ' abdominal tonsil ' has been applied to it. Inflammatory 
 processes are thus readily set up within its walls as a result of the 
 absorption of toxins or organisms, which are almost constantly 
 present within it. (3) Its length and direction vary considerably 
 in different individuals. In length it may measure anything 
 between 1^ and 11 or 12 inches, but is usually 3 to 4 inches long, 
 whilst, as to direction, it may lie in any axis ; perhaps most fre- 
 quently it is to be found behind the caecum, and pointing down 
 towards the pelvis. The facility with which the intestinal con- 
 tents find their way into its lumen thus varies in different indi- 
 viduals, and it seems probable that appendicitis is more commonly 
 met with where it is so placed as to readily admit material which 
 is with difficulty expelled, i.e., when it is transverse or directed 
 downwards. A long appendix is also more liable to become 
 twisted 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 rarely extends beyond the junc- 
 tion of the middle with the distal third, and perforation often 
 occurs about this spot. (5) The communication with the caecum 
 is usually a small one, and is guarded by an insignificant fold of 
 mucous membrane, known as the valve of Gerlach. Sometimes 
 this aperture becomes blocked, or the orifice stenosed, so that an 
 
 60 
 
946 A MANUAL OF SURGERY 
 
 accumulation of mucus occurs within the appendix. (6) Faecal 
 concretions or foreign bodies, such as pips, pins, etc., are also 
 met with within it, and by their presence and irritation may 
 determine an attack of inflammation. Foreign bodies are much 
 less common than was formerly imagined (present in less than 
 4 per cent, of cases), occurring most frequently in children and 
 young people. Faecal concretions (present in 15 to 20 per cent, 
 of cases) are oval bodies, rarely more than half an inch in length ; 
 on section they are found to be laminated, and consist of dried 
 faecal material mixed with myriads of bacteria. They are not 
 very hard, and can easily be cut with a knife. They are usually 
 the result of chronic constipation, which is always to be looked on 
 as a predisposing cause of appendicitis. 
 
 Other causes of appendicitis are occasionally described, such as 
 rheumatism, and in chronic cases tubercle or actinomycosis ; 
 typhoid ulceration is rarely met with in the appendix. Dysentery 
 is sometimes associated with appendicitis, though more commonly 
 it leads to a true ulcerative typhlitis, involving the caecum. 
 
 Injury in the shape of a strain or sudden twist is not unfre- 
 quently mentioned as the cause of an outbreak, and probably acts 
 by displacing a long appendix in such a way as to lead to its 
 kinking and possibly to obstruction of the nutrient vessels. 
 
 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 by the Bac. coli, 
 though ordinary pyogenic cocci, especially the Streptococcus pyo- 
 genes, are often present in addition. 
 
 Pathological Anatomy. — Bacteria 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 faecal 
 concretion, or else they are absorbed into the lymphoid tissue 
 so abundantly present, and at once commence to develop and 
 multiply. As a result of this the mucosa becomes greatly 
 swollen and thickened, and as it is surrounded by fairly strong 
 muscular walls, constriction of the vessels follows, preventing 
 recuperative processes from being undertaken, and hence the 
 bacteria are enabled to continue their destructive work. In con- 
 sequence, ulceration of the mucous lining supervenes, or inter- 
 stitial suppuration in the wall. Sometimes the small terminal 
 artery of the appendix becomes thrombosed, or undergoes an 
 obliterative endarteritis, leading to sloughing of one or more 
 portions of the walls, generally at the apex. The veins also 
 are liable to become thrombosed, and bacteria may find their 
 way into the thrombus, causing its disintegration, and if emboli 
 are detached, pylephlebitis or portal-vein-pyaemia, with possibly 
 hepatic abscess, may result. The most important changes, how- 
 ever, are those occurring in the peritoneum, which is always 
 inflamed, and, indeed, upon the condition of this structure depends 
 
ABDOMINAL SURGERY 947 
 
 to a large extent the prognosis of the case. It may merely be 
 thickened by a deposit of lymph, giving rise to adhesions which 
 bind it down to neighbouring parts, or a localized suppurative 
 affection may ensue ; or, again, an acute diffuse and usually fatal 
 peritonitis follows, either as a result of rupture of the appendix, 
 or as an outcome of sloughing or perforation of its walls. 
 The localized abscess is in reality intraperitoneal, but its ex- 
 tension is limited by the formation of adhesions between neigh- 
 bouring coils of gut. When an attack of appendicitis has 
 passed off, some stenosis of the lumen of the tube is a common 
 sequence, and as a result of this the terminal portion may become 
 distended with retained secretion, and the patient may suffer from 
 intermittent attacks of colicky pain due to the efforts of the ap- 
 pendix to relieve itself ; it will also predispose the individual to 
 recurrent inflammation. 
 
 Hence, from a clinical standpoint, the following varieties of 
 appendicitis may be recognised : 
 
 1. Simple or catarrhal appendicitis, associated with a plastic 
 peritonitis. 
 
 2. Ulcerative or gangrenous appendicitis, accompanied by a 
 localized intraperitoneal abscess. 
 
 3. Gangrenous or perforative appendicitis, resulting in an acute 
 diffuse sero-purulent peritonitis. Such a condition is frequently 
 fatal, and constituted one of the commonest causes of the so-called 
 ' idiopathic peritonitis ' of the old days. 
 
 4. Relapsing appendicitis, in which attack follows attack, some- 
 times with very little interval. 
 
 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 sud- 
 denly, the patient being seized with pain in the right iliac fossa, 
 and accompanied by nausea, vomiting, more or less complete 
 constipation, and slight fever (101 or 102 F.). An examination 
 of the abdomen reveals definite tenderness in the right iliac 
 region, most marked at a spot corresponding to the base of the 
 appendix, i.e., i£ inches inwards from the anterior superior iliac 
 spine, along a line drawn towards the umbilicus (McBurney's 
 spot), whilst the right leg is usually drawn up in order to relax 
 the tension of the abdominal muscles. A swelling, generally dull 
 on percussion, may sometimes be detected by palpation, a little 
 below McBurney's spot, and consists of coils of intestine matted 
 together over and around the inflamed appendix. Such symptoms 
 usually last three or four days, and then, if properly treated, 
 resolve satisfactorily without any abscess formation. 
 
 This simple form of the disease is exceedingly common, and 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. 
 
 60 — 2 
 
948 A MANUAL OF SURGERY 
 
 (ii.) The more serious variety, commonly resulting in a localized 
 abscess, may commence in a similar way, but with more acute 
 symptoms. There may be an initial rigor, and the temperature 
 soon runs up, even to 104 F. Some general abdominal tender- 
 ness and distension follow ; constipation is often absolute, and 
 fa?cal vomiting may occur. The muscles on the right side of the 
 abdominal walls are held tense and rigid, and a well-marked 
 swelling can usually be detected in the iliac fossa. Under a 
 careful regime this may disappear, and the symptoms gradually 
 abate in their severity, the temperature and the pulse falling con- 
 currently ; but it is very common for suppuration to ensue, and 
 such is indicated by the temperature persisting at its original 
 high level, or by the pulse-rate increasing in rapidity, whilst the 
 temperature 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 around the appendix, and is, of course, primarily intra- 
 peritoneal. Not unfrequently it bursts into the bowel, and there- 
 by relief is gained without the assistance of surgery ; some 
 authorities, indeed, maintain that this occurs in every case of 
 the more severe type which resolves. In other instances it may 
 point externally, either through the anterior abdominal wall, 
 which becomes congested and oedematous as the pus approaches 
 the surface, or through the loin, the pus having invaded the 
 retroperitoneal cellular tissue. In the latter case, it is sometimes 
 found that the abscess burrows widely up and down the back of 
 the abdomen, and may even extend behind and above the liver, 
 constituting a subphrenic abscess. 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 collection behind 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 evidence of one can be found. Should it burst into the peri- 
 toneal cavity, all the phenomena of perforative peritonitis super- 
 vene, probably indicated by a sudden fall of temperature, and 
 followed by increased abdominal pain and distension. A faecal 
 fistula may follow the bursting or opening of any of these 
 abscesses. 
 
 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 
 
ABDOMINAL SURGERY 949 
 
 the commencement 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 distension persists, or perhaps hiccough is present, 
 or a well-marked, though localized, tenderness continues, perhaps 
 only to be detected per rectum, or the pulse.rate may remain 
 unduly high. After a few days- the temperature begins to rise 
 once more, the focal symptoms become more urgent, and a 
 subacute or chronic abscess forms. 
 
 A complication 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. Such would be indicated by recurrent 
 rigors, and possibly by pain and tenderness in the hepatic area. 
 Necessarily it is almost invariably fatal. 
 
 (iii.) Diffuse septic peritonitis results either from the rupture 
 of a localized intraperitoneal abscess, and will then be preceded 
 by the symptoms outlined above, or is present from the outset, 
 being then due to primary perforation or gangrene of the appendix 
 itself. The ordinary signs of acute peritonitis are developed (see 
 p. 895), but possibly there may be obtainable some history of pain 
 starting in the right iliac fossa, which will give a clue to the 
 diagnosis. 
 
 (iv.) Relapsing appendicitis is characterized by recurrent 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 to entirely incapacitate the patient, and are 
 mainly due to the presence of some abnormal adhesion or con- 
 striction of the appendix. It is not uncommon for the appendix 
 to become fixed to the sheath of the psoas muscle, and then any 
 excessive movements of the limb may light up an attack. Where 
 stenosis exists, secretions containing bacteria may be pent up 
 behind the constriction, and from time to time the patient suffers 
 from severe pain of a colicky nature 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 ap- 
 pendix becomes totally obliterated after a time and incorporated 
 in a mass of adhesions, a natural cure being thus established ; 
 but more frequently, if these recurrences are allowed to continue, 
 the patient finally succumbs from diffuse peritonitis. 
 
 The Diagnosis of appendicitis ought not to be a matter of 
 great difficulty if the practitioner bears in mind the cardinal 
 symptoms, viz., pain and tenderness in the right iliac fossa, 
 together with fever, vomiting, and constipation. If to these are 
 superadded the existence of a localized swelling beneath the tense 
 and rigid abdominal muscles, but little doubt can remain as to the 
 nature of the case. 
 
 The Prognosis, on the other hand, is never absolutely certain, 
 for, as has been well pointed out by many acute observers, the 
 
95 o A MANUAL OF SURGERY 
 
 initial symptoms are frequently 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 con- 
 tinued 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 caecum in a position less favourable to operative 
 measures. 
 
 Treatment. — So much has been written on this subject during 
 the last ten years, that it is extremely difficult to compress even 
 a brief summary of the many facts observed into a necessarily 
 limited space. Formerly typhlitis was the exclusive property of 
 the physician ; but the last decade has brought about a great 
 change, 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 what appear to be simple cases, in which surgical assistance 
 will alone hold out any hopes of saving the patient. In America 
 surgery is the recognised treatment for almost every case of the 
 disease ; in this country more conservative ideas still persist, but 
 we are glad to note that a more healthy opinion is gradually 
 gaining ground, and that surgical interference is becoming 
 recognised as the most appropriate means of treatment in many 
 cases. 
 
 In the milder form of appendicitis, where the temperature does 
 not run above ioi° and the symptoms are not severe, all that is 
 required in the majority of instances is to put the patient to bed, 
 and apply fomentations locally ; the lower bowel should be emptied 
 by an enema, and if it seems likely that there is an accumulation 
 of irritating fasces within the intestine, a dose of castor-oil or of 
 calomel may be administered. A fluid, unstimulating diet is all 
 that is permitted, and should there be much vomiting, rectal 
 alimentation may be resorted to. Possibly a little morphia may 
 be given with advantage to quiet the patient and check peristalsis; 
 but the less the better, since it tends to mask symptoms. 
 
 In the graver cases the same general treatment may be insti- 
 tuted to start with, but the question as to the advisability of 
 operation will soon have to be faced. There are certain conditions 
 in which all surgeons are agreed as to operation being essential, viz., 
 where general peritonitis is present, or when an abscess is pointing. 
 
ABDOMINAL SURGERY 951 
 
 In the former case the only hope that exists, and even that is of 
 the slenderest description, lies in opening the abdomen (usually in 
 the middle line), flushing it out with some weak antiseptic lotion, 
 or perhaps better with sterilized salt solution at a temperature 
 of about 108° F., and searching for the appendix. If found, it 
 should be removed, and drainage, either by Keith's tubes or by 
 gauze wicks, must be arranged for. In the great majority of 
 cases death will ensue in spite of all our precautions, but the 
 more recent reports certainly show better results. 
 
 When an abscess is evidently present, being indicated either 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 cedematous spot, and deepened carefully, since the 
 tissues are probably matted together, and cut like bacon or brawn. 
 The knife or index-finger will suddenly sink into the abscess 
 cavity, and a gush of fcetid pus follows. The cavity is gently 
 explored, so as to ascertain whether or not the appendix can be 
 felt ; no undue force should be used, for fear of breaking down 
 adhesions and thus opening the general peritoneal sac. If the 
 appendix cannot be readily found, it is best left alone ; the abscess 
 is thoroughly irrigated, drainage is provided for, and the incision 
 partly closed. Probably the case will go on well, the discharge 
 losing its smell about the third day, and the remaining sinus will 
 gradually heal by granulation. Should the appendix, however, 
 present itself, it should be removed. 
 
 It is, however, in those cases where neither of the above condi- 
 tions are manifest, and yet the symptoms, both local and general, 
 point to the fact that a lesion of considerable gravity is present, 
 that the greatest difference of opinion exists. We are quite ready 
 to admit that in many instances conservative or medical treat- 
 ment will suffice to bring about a satisfactory result ; but this can 
 never be depended on, and, unfortunately, only too many lives 
 have been sacrificed through an unwillingness to call in a surgeon, 
 except at the last moment. Under these circumstances, even if 
 acute peritonitis has not occurred, the patient is profoundly toxsemic 
 or exhausted by preceding suffering ; hence any operative measures 
 are likely to fail through the asthenic condition of the individual, 
 even if the local phenomena are such as can be efficiently dealt 
 with. Personally, w^e are distinctly in favour of early operation, 
 and the general rule (to which, of course, there are exceptions) 
 which we should suggest as justifiable, is that, if in spite of suitable 
 rest and medical treatment the symptoms, both general and local, are not 
 commencing to abate at the end of forty-eight hours, operation should 
 be undertaken. The great advantages we would claim for this pro- 
 cedure are : (1) That the patient is not in a state of collapse from 
 toxaemia, and hence can stand the shock of an intraperitoneal 
 exploration without much risk ; (2) that the appendix itself is not 
 so likely to be tied down by a mass of firm adhesions, and can 
 
952 A MANUAL OF SURGERY 
 
 thus be found, isolated, and removed ; (3) that such removal is 
 most desirable in order to secure the patient against the danger of 
 recurrence ; and (4) that a much smaller incision will be needed 
 under these circumstances, and therefore there is less chance of a 
 ventral hernia subsequently forming. The following conditions 
 may also be mentioned as specially indicating operation : per- 
 sistent distension of the abdomen, hiccough, or a continued high 
 pulse-rate in spite of a falling temperature. 
 
 Operation. — Probably the best incision is an oblique one, crossing 
 McBurney's spot, or a little below it, and parallel with the outer 
 end of Poupart's ligament, somewhat similar to that for ligaturing 
 the external iliac artery (Fig. 319, D). The whole thickness of 
 the abdominal wall is freely divided, and the peritoneum, if need 
 be, opened, so as to expose the caecum. The appendix is then 
 carefully sought for, after protecting the general cavity by sponges ; 
 it may be necessary to lift the caecum from its bed in order to find 
 it, or to separate agglutinated coils of intestine. In cases of diffi- 
 culty, the longitudinal bands of muscle on the ascending colon 
 should be traced downwards to the appendix, where the three sets 
 of fibres converge. An abscess usually containing extremely 
 offensive pus may be opened in this way ; but if the operation is 
 an early one, there is often no pus around the appendix, although 
 its walls may be yellow from purulent infiltration. Whenever 
 possible, the appendix should be removed ; it is first freed from 
 adhesions, and the meso-appendix ligatured. If sufficiently 
 healthy, a formal amputation, as in the chronic cases, should be 
 undertaken, but such a procedure is often impracticable. A silk 
 thread is then tied around the base about half an inch from the 
 caecum, and the appendix cut off; the stump is, if practicable, 
 buried by the insertion of two or three sutures into the serous 
 membrane covering the caecum. Not unfrequently, however, the 
 tissues are too much infiltrated and matted together to admit of 
 such proceedings ; all that can be done is to stuff the wound with 
 long strips of gauze, and allow it to heal by granulation. In the 
 earlier more favourable cases, where actual suppuration has not 
 occurred, the cavity is washed out after removal of the appendix, 
 a drainage-tube inserted, and the abdominal wall partly closed. 
 After the operation the patient should be fed mainly per rectum 
 for a few days, stomach-feeding being gradually commenced about 
 the third day. A small amount of opium may be needed, and, if 
 all is going well, the bowels may be opened by the use of enemata 
 in about five days if they have not already acted. 
 
 For relapsing appendicitis, radical treatment must be instituted if 
 the attacks are at all frequent, and possibly it would be justifiable 
 to lay down the rule that operation should be undertaken in the 
 quiescent period after the second attack. If left till many attacks 
 have occurred, the task may prove very difficult, owing to the 
 number and density of the adhesions which are then present. 
 
ABDOMINAL SURGERY 953 
 
 They are dealt with in the best way practicable, and the appendix 
 thus freed is amputated. This is accomplished by dividing the 
 serous coat by a circular incision, and retracting a cuff of serous 
 and muscular tissues sufficiently to enable the mucous membrane 
 to be ligatured, divided, and then covered over and buried by 
 stitching or ligaturing the cuff of serous membrane over the end. 
 
 A plan of dividing the abdominal wall suggested by McBurney 
 may be employed in cases which promise to be of a simple nature 
 and not complicated by many adhesions. The incision is as above ; 
 each of the three flat muscles is divided in the course of its fibres, 
 and held aside by retractors. The peritoneum is divided trans- 
 versely. After the appendix has been removed, each layer is 
 sutured separately. This method minimizes the risk of hernia, 
 but it is not suited to cases where many adhesions are likely to be 
 present, since an enlargement of the incision downwards, such as 
 is almost necessarily required, involves a crucial division of one or 
 more of the muscles. 
 
 Sequelae. — A Facal Fistula may result from a perforative ap- 
 pendicitis when the abscess has been merely opened, and no 
 radical treatment undertaken at the same time, or it may follow 
 an amputation of the appendix from sloughing or yielding of the 
 stump. It is usually small in size, and sinuous in its course, and 
 may in many cases close of itself. Occasionally it is necessary to 
 deal with it by laying bare the caecum in the iliac fossa, and re- 
 moving the appendix or suturing the opening. Failing that, it 
 may be necessary 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 cover it with the concave pad of a 
 truss, but in others operation is required ; adhesions must be 
 divided or broken down, and often the opportunity can be taken 
 of removing the appendix, if this has not already been accom- 
 plished. The margins of the divided muscles are then sought for, 
 and united by a row of buried sutures in the ordinary way. 
 
 Affections of the Liver. 
 
 Rupture of the Liver is produced by injuries to the abdominal 
 walls, such as blows, kicks, or crutches, 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 gun- 
 shot 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 some- 
 times produces almost total disorganization. The amount of 
 
954 A MANUAL OF SURGERY 
 
 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 exces- 
 sive, pain and tenderness in the right hypochondrium, and the 
 evidences of loss of blood. The last is, perhaps, the most im- 
 portant, as upon its severity depends to a large extent the result. 
 Sometimes the capsule remains intact, and then, although there is 
 considerable intraglandular ecchymosis and laceration, 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. 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 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 
 forgotten 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. Out- 
 lying ragged portions of the gland may be totally removed, prefer- 
 ably by the cautery, though one usually has to depend upon 
 plugging the wound with gauze in order to effect haemostasis. 
 Clean linear cuts may be sutured with silk, but there is con- 
 
ABDOMINAL SURGERY 955 
 
 siderable difficulty in preventing the stitches from tearing out of 
 the friable hepatic tissue ; it is wise to insert all the stitches first, 
 taking up a good margin of the gland substance before 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- 
 wick drain is placed over them, and brought out of the external 
 wound. 
 
 Abscess of the Liver is due to a variety of causes. 
 
 1 . Multiple A bscesses 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 complication of 
 general pyaemia 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 some- 
 times in typhoid fever, whilst suppurating piles may also lead to it. 
 
 2. Suppurative Cholangitis is another cause of multiple abscess of 
 the liver. It consists of an inflammatory affection of the biliary 
 ducts and passages, and is due to the spread of organisms from 
 the intestine, or occasionally from the gall-bladder after an 
 operation. The biliary ducts in the liver become enormously 
 dilated, and filled with a mixture of bile and pus which looks 
 very like yellow ochre. It is accompanied by pain over the 
 gland and the general phenomena of pyrexia, but rigors are not 
 present. The patient is not usually jaundiced, but bile may be 
 found in the urine. Treatment is of little avail, but if a diagnosis 
 can be made, and the gall-bladder has not been already incised, it 
 may relieve tension to open and drain it. 
 
 3. Hydatid cysts may suppurate, and require treatment as for 
 an abscess of the liver. 
 
 4. The more important abscesses, from a surgical standpoint, 
 are 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 individuals who have travelled in the tropics, and 75 per cent, 
 of the cases are attributed to dysentery. The exact mode of 
 causation has not yet been fully worked out, but it seems probable 
 that they are primarily of embolic origin. They are most fre- 
 quently situated at the back of the right lobe, but, of course, 
 any part of the viscus may be involved. Though often single, the 
 cavity is frequently loculated, indicating that several original 
 foci of suppuration have united together. Any of the ordinary 
 pyogenic organisms may be found within them, and not unfre- 
 quently the Bac. coli is present. In a few cases the Amoeba coli, an 
 
956 A MANUAL OF SURGERY 
 
 organism which is found in the bowel in some forms of dysentery, 
 has been discovered. Occasionally the pus is sterile, the causative 
 organisms having probably been disposed of, possibly as a result 
 of the chronicity of the process. The abscess wall consists of 
 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. The individual usually 
 complains of a sense of weight and fulness in the right hypo- 
 chondriurn, 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. A 
 certain amount of febrile disturbance occurs, the degree of which 
 depends on the rapidity of formation of the abscess ; in the more 
 acute forms the temperature is high and rigors may be present. 
 The pyrexial phenomena are associated with loss of appetite, 
 rapid and well-marked emaciation, and perhaps a certain amount of 
 icterus, though the latter is not usually a prominent phenomenon. 
 On physical examination a more or less evident enlargement of 
 the liver will be detected, with, perhaps, a feeling of elasticity, or 
 even of fluctuation at some spot. The dulness often extends up 
 towards the thorax rather than downwards, though when the 
 abscess is situated not far from the free margin of the liver, this 
 is not the case. A doubtful diagnosis can sometimes be con- 
 firmed by the aspirator or hypodermic needle, but this should 
 not be utilized unless one is fully prepared for immediate opera- 
 tion in the case of pus being found. Manson directs that the 
 aspirator needle should be introduced in the following situations : 
 (i) In the right axillary line through the seventh or eighth costal 
 interspace ; (2) just below the ribs in the right nipple line ; 
 (3) immediately below the lung in the line drawn downwards 
 from the angle of the right scapula. 
 
 Left to itself, several distinct courses are open for the abscess 
 to follow : it may become adherent to the anterior abdominal wall 
 and point in the epigastrium, its onward passage being indicated 
 by congestion and oedema of the parietes ; it may open into the 
 peritoneal cavity, or into one of the hollow viscera, such as the 
 colon or duodenum ; or, again, it may travel upwards, burrowing 
 through the diaphragm, and either bursting into the lung, its 
 contents being expectorated, or into the pleural cavity, leading to an 
 empyema. Occasionally it remains passive as a chronic encysted 
 abscess, and then the walls become very thick. One of us recently 
 opened an hepatic abscess which had been diagnosed by a hypo- 
 
ABDOMINAL SURGERY 957 
 
 dermic needle twelve years previously, and left alone. It con- 
 tained about two pints of pus, and the walls were fully | inch 
 thick. The patient came under observation because the swelling 
 was becoming more prominent, as the result of increased intra- 
 abdominal pressure, due to pregnancy. 
 
 Treatment. — Aspiration, repeated once or twice, has been fre- 
 quently employed, but is of little value, and not a few cases 
 are on record in which septic peritonitis or pleurisy has followed 
 the introduction of the needle from the front or side respectively. 
 Experience proves that the usual law of treating suppuration 
 ought to be strictly obeyed, viz., that the abscess should be 
 opened and drained. If pointing in front and adherent to the 
 parietes, there is no difficulty or danger in making an incision 
 over the most prominent spot and laying the cavity open ; it is 
 then well flushed out and a drainage-tube inserted. If on dividing 
 the abdominal parietes it is found that the liver is not yet adherent, 
 it is perhaps best to plug the wound with sterilized or antiseptic 
 gauze so as to determine the formation of adhesions to such an 
 extent as to cut off the general peritoneal cavity ; in a few 
 days the abscess can then be opened with safety. If there is no 
 great thickness of hepatic tissue between the surface and the pus, 
 a knife may be employed for this purpose ; but if the abscess lies 
 deeply, it has been suggested that the thermo-cautery should be 
 employed so as to prevent bleeding by sealing the mouths of the 
 hepatic veins. When it is urgently necessary to open the abscess 
 at once, even though no adhesions are present, the general serous 
 cavity must be carefully protected by sponges or pledgets of gauze 
 before letting out the pus, 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 a careful 
 packing of the wound. After opening the abscess, it is usually 
 advisable to wash it out, and this may with advantage be repeated 
 subsequently. 
 
 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 difficulty is 
 experienced in shutting off the general pleural cavity. The 
 diaphragm is then divided, and not unfrequently the peritoneal 
 cavity is opened ; if so, it may be stuffed temporarily, so as to 
 determine adhesions, and then the liver incised ; less commonly 
 
958 A MANUAL OF SURGERY 
 
 adhesions may have already formed, or a bare area of the liver 
 may he found, through which the pus can be withdrawn and the 
 abscess opened. 
 
 Hydatid Cysts occur in the liver more frequently than in any 
 other part of the body. For general details as to the life-history 
 of the Tania ccliinococcus and the structure of hydatid cysts, see 
 p. 187. 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 distinguished, and a hydatid fremitus or thrill 
 (arising from the concussion 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 withdrawn from a 
 hydatid cyst is at once conclusive, as it is of low specific gravity, 
 viz., 1007 to 1009, slightly opalescent, with no albumen, and a 
 trace of salt ; the presence of scolices or hooklets is the pathogno- 
 monic feature. 
 
 Terminations. — The cyst may remain latent and innocuous, or 
 may 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 without suppuration. 
 Thus, it may open externally through the abdominal parietes, or 
 into the peritoneal 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 expectorated, 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 ideal plan of dealing with a hydatid cyst 
 would be to dissect it entirely away, and such is not altogether im- 
 practicable in cases where the growth is superficial, since its con- 
 nections with surrounding parts are not very intimate. The great 
 danger to be dreaded is haemorrhage, and owing to the vascularity 
 of the liver and the difficulty of controlling bleeding from it, this 
 is an objection of the gravest importance. However, if the tumour 
 is small and superficial, there need be no fear in attempting it, 
 the cavity being firmly plugged with gauze for a few days. 
 
 The surgeon, however, usually has to content himself with 
 incision of the cyst, turning out the scolices or daughter-cysts, and 
 inserting a large drainage-tube. If adhesions to the anterior 
 
ABDOMINAL SURGERY 959 
 
 abdominal wall are present, this can be accomplished at one 
 sitting ; but if, as more commonly happens, none have been 
 developed, it is wiser to undertake the operation in two stages, as 
 for hepatic abscess, so as to make certain that the general peri- 
 toneal cavity is firmly shut off. Another advantage which follows 
 the division of the operation into two parts is that the latter pro- 
 ceeding, viz., the incision of the liver and cyst, can be undertaken 
 without an anaesthetic, and the patient is enabled to help in the 
 removal of the cysts by coughing when required. 
 
 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 that 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. Secondary sarcoma 
 and carcinoma are by no means uncommon, but of course nothing 
 can be done for them. A few cases are on record of removal of 
 a tumour or gumma together with a portion of the tissue of the 
 organ, but such must necessarily be a matter of such rarity that 
 we cannot spare space to discuss it. 
 
 Affections of the Gail-Bladder and Biliary Passages. 
 
 Rupture of the Gail-Bladder results from such injuries as blows, 
 crushes, kicks, etc., whilst it may also be produced by penetrating 
 wounds or bullets ; occasionally it may follow ulceration from 
 within, as from a large impacted gallstone. It is probable that 
 in health the gall-bladder is occupied not by bile, but by mucus, 
 and its function is apparently not to act as a bile reservoir, 
 but as a pressure gauge regulating the flow of bile into the 
 intestine. Whenever the biliary passages are stenosed or blocked, 
 bile regurgitates, as also after death, and necessarily if the bladder 
 is ruptured, bile will find it easier to escape in this direction than 
 down the long and sinuous bile-ducts, and therefore extravasation 
 into the peritoneal cavity always follows. Pure bile is sterile, 
 but if any inflammation of the biliary passages has been present, 
 organisms are sure to have found their way into the gall-bladder, 
 and thus complications may readily ensue. If a considerable 
 quantity of bile escapes suddenly into the peritoneal sac, acute 
 peritonitis is certain to follow, whether organisms are present 
 
9 6o A MANUAL OF SURGERY 
 
 or not, owing to the irritating nature of the fluid ; jaundice is 
 also developed from absorption of bile by the peritoneum, and it 
 may also be found in the urine. A more gradual escape of the 
 secretion will probably lead to the formation of a localized intra- 
 peritoneal 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 
 hypochondriac pain, and this will be succeeded by either acute 
 peritonitis or by the formation of a localized intraperitoneal 
 swelling, together with jaundice. When the existence of such a 
 lesion is suspected, Treatment always consists in an exploratory 
 laparotomy. The fluid within the abdomen is carefully removed 
 with swabs or washed away, and the gall-bladder carefully 
 examined. Should only a small injury be found, it is perfectly 
 feasible to close it by sutures ; a gauze wick should, however, 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, or else the margins of the 
 wound may be stitched to the abdominal parietes, and a biliary 
 fistula thus produced. Should the common bile-duct be entirely 
 divided, the ends should be closed by sutures and a cholecysten- 
 terostomy undertaken ; a small wound in the duct may be sutured. 
 
 Cholelithiasis is the term applied to the presence in the 
 gall-bladder of Gallstones. These consist mainly of crystals of 
 cholesterine, held together by mucus and coloured by the bile 
 pigment ; they are soluble in chloroform. When first passed and 
 moist, their specific gravity is a little higher than that of water, 
 and hence when immersed in it they sink ; after drying, however, 
 they are found to float. The number present varies immensely ; 
 sometimes a single large one exists, which is more or less barrel- 
 shaped ; more frequently they are multiple, scores or hundreds 
 being present, and are then usually faceted, and with a satin-like 
 yellowish lustre. 
 
 The Origin of gallstones is not yet fully understood, but there 
 seems no doubt that they are primarily due to an inflammatory 
 condition of the wall of the gall- bladder or biliary passages; they 
 occur most commonly in women who have suffered long from 
 dyspepsia and constipation, and may be associated with cancer, 
 either as cause or effect. In a case dealt with by one of us, the 
 origin of the trouble seems to have been the swallowing of a pin 
 many years previously, which worked its way into the gall- 
 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 Symptoms produced are extremely variable. Their occur- 
 
ABDOMINAL SURGERY 961 
 
 rence is usually preceded by dyspeptic phenomena, which have 
 perhaps lasted for years, and by constipation. Some pain is com- 
 plained of in the right hypochondrium, but possibly nothing very 
 serious is noted, until a physical examination reveals the distended 
 gall-bladder, which forms a tumour projecting from under cover 
 of the ribs, usually the 8th or 9th, and tending to enlarge down- 
 wards towards the umbilicus ; it is usually firm, elastic, and 
 perhaps fluctuating ; it moves with the liver during respiration, 
 and there is never intestine in front of it. Such a condition often 
 yields to medical treatment ; the diet has to be carefully regulated, 
 and a sufficient amount of exercise ordered. Alkaline purgative 
 medicines are usually employed, and a well-to-do patient may be 
 sent to Carlsbad to drink the waters. Possibly massage may be 
 utilised to assist in the extrusion of the calculi, and drinking con- 
 siderable quantities of olive-oil is said to be beneficial in effecting 
 the same object. 
 
 There are several complications, however, which may call for 
 surgical treatment. 
 
 1. Inflammatory phenomena connected with the gall-bladder 
 (cholecystitis) may assume considerable proportions. Acute in- 
 flammation is usually due 'to infection with the Bac. coli, which 
 travels up the biliary passages from the intestine. It is evidenced 
 by acute pain and tenderness in the right hypochondrium, together 
 with vomiting, constipation, and fever. The constipation may 
 be of such a marked character as almost to amount to obstruction, 
 and arises mainly from paralysis of the neighbouring coils of gut, 
 e.g., the duodenum and transverse colon. Suppuration may 
 follow, the abscess either bursting externally or into the peritoneal 
 cavity, or possibly into one of the hollow viscera. In other cases 
 the inflammation subsides after a time, but results in a consider- 
 able development of adhesions Avhich interfere with operative 
 proceedings, and may also determine an attack of intestinal 
 obstruction. Should the inflammatory mischief extend up the 
 hepatic duct into the liver substance, diffuse suppurative cholangitis 
 will result, and may lead to a fatal issue. A condition of chronic 
 peritonitis is likely to follow whenever calculi remain lodged in 
 the gall-bladder for some time. 
 
 2. Biliary colic is another most distressing complication, due to 
 the onward passage of gallstones along the ducts. The pain is 
 of a most acute character, doubling the patient up, and causing 
 considerable shock ; it radiates from the right side, shooting over 
 the scapular region and into the back ; it commences abruptly, 
 and continues in paroxysms accompanied by vomiting until the 
 stone is either discharged into the intestine or slips back into the 
 gall-bladder, leading to a sudden cessation of the pain ; a sense 
 of tenderness and discomfort may, however, persist for some time, 
 and possibly a little jaundice, owing to the swelling of the mucous 
 membrane obstructing the passage of bile. These attacks some- 
 
 61 
 
962 A MANUAL OF SURGERY 
 
 times come on at more or less regular intervals, and may be so 
 frequent as to produce great exhaustion. At the time, they should 
 be treated by the application of fomentations to the side, and the 
 administration of opium ; sometimes a large dose of olive-oil by 
 the mouth may assist in the passage of the stone. If they recur 
 at all frequently, cholecystotomy must be undertaken. 
 
 3. A gallstone does not always escape into the bowel ; it may 
 become impacted, and then gives rise to a train of tolerably charac- 
 teristic symptoms, which vary somewhat with the site of obstruc- 
 tion. If the cystic duct is blocked, there is severe pain in the 
 side, and perhaps distension of the gall-bladder with mucus, con- 
 stituting a tumour which can be felt, but there is no jaundice. If 
 the calculus is lodged at the junction of the common and hepatic 
 ducts, there will be intense icterus, but the gall-bladder is not 
 necessarily distended ; the liver, however, is likely to be enlarged 
 from engorgement with bile. When the stone is impacted in the 
 common bile-duct, the jaundice is intense, but the gall-bladder is 
 usually small. Sometimes the stone lodges close to the intestinal 
 end of the duct in what is known as the ampulla of Vater ; it may 
 then ulcerate through into the bowel without much difficulty. 
 If impacted higher up, it may work through into the duodenum 
 or colon by a process of ulceration, or may escape into the retro- 
 peritoneal cellular tissue, leading to an abscess ; or, again, it may 
 open the peritoneal cavity, and thus cause acute peritonitis. 
 
 Operative Treatment of Cholelithiasis. — The conditions which 
 may call for operation in the course of a case of gallstones are as 
 follows : (a) For recurrent attacks of biliary colic, which cannot 
 be prevented by medical treatment ; (b) for persistent jaundice ; 
 
 (c) when the gall-bladder can be felt enlarged and tender ; and 
 
 (d) for acute cholecystitis. 
 
 Cholecystotomy consists in opening the gall-bladder for the 
 removal of calculi, or for purposes of drainage. It is best per- 
 formed through an incision which runs parallel to the costal 
 margin on the right side, and about an inch and a half from it, 
 extending upwards as far as the middle line (Fig. 319, B). The 
 peritoneum is opened, and the gall-bladder sought for, any 
 adhesions present being carefully divided ; it will sometimes 
 happen that these are so abundant as to prevent the surgeon 
 from continuing the operation, the risk of opening the bowel 
 by mistake being too great. The liver is drawn up, and the 
 intestines are pressed downwards out of the field of operation 
 by means of sponges or cloths held in position by a broad re- 
 tractor. The general peritoneal cavity is thus carefully guarded 
 from infection. If the gall-bladder is much distended, it is ad- 
 visable to tap it with a trocar and cannula, and withdraw the 
 chief portion of its contents ; the opening is then enlarged suffi- 
 ciently to allow of the introduction of a scoop, or even of the 
 finger, and by this means the calculi are removed. The bile- 
 
ABDOMINAL SURGERY 963 
 
 ducts are carefully examined both by the finger passed inside 
 as far as possible, and outside along their whole length, and by 
 means of a long probe passed down the duct. If the interior 
 is tolerably healthy, it may be advisable to suture up the wound 
 in the bladder, the threads not being allowed, however, to en- 
 croach on the mucous membrane. A gauze wick should be 
 inserted down to the incision before stitching up the abdominal 
 parietes, so as to provide for drainage should there be any leakage 
 of bile. More usually temporary drainage of the biliary passages 
 is desirable in order to relieve the liver, and then a full-sized 
 drainage-tube without any lateral openings is introduced into the 
 gall-bladder and stitched to its walls, whilst the margins of the 
 wound in the gall-bladder are united to the parietal peritoneum 
 and transversalis aponeurosis. A biliary fistula is thus produced 
 which discharges for a time ; but as soon as the obstruction to 
 the onward passage of bile into the gut is overcome, the fistula 
 closes. Occasionally this does not occur, and then the discharge 
 of bile continues, necessitating further treatment. If there is 
 sufficient evidence of the existence of bile in the motions to indi- 
 cate that the passages are clear, a plastic operation for the closure 
 of the fistula may be undertaken ; but if complete and permanent 
 obstruction to the passage of bile is suspected, an artificial com- 
 munication with the intestine (cholecystenterostomy) should, if 
 possible, be established. 
 
 It is often very difficult to remove a stone impacted in the 
 cystic duct. Possibly it may be extracted by a lithotomy scoop, or 
 pushed on from within, or squeezed forwards or backwards by the 
 finger and thumb from outs'de ; or, again, it has been broken up 
 from within by means of a needle, or crushed from without by 
 forceps, the blades of which are guarded by indiarubber, but these 
 are bad methods to adopt. In difficult cases of this nature it is 
 better to incise the duct and extract the stone, the incision being 
 subsequently secured by Lembert's sutures, long-handled palate 
 needles being employed for the purpose. 
 
 Sometimes the calculus is lodged in the bile-duct behind the 
 second piece of the duodenum ; it is then sometimes possible to 
 push the gut aside and get at the duct behind it, or in other cases 
 it may be necessary to incise the duodenum longitudinally front 
 and back, and after extracting the stone, to make a fistula between 
 the duct and the posterior wall of the intestine. In other cases 
 the stone is left alone, and in the course of a few days it may 
 become dislodged by natural means, as evidenced by the passage 
 of bile into the intestine. 
 
 Cholecystenterostomy, or the formation of an artificial com- 
 munication 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 head of the 
 
 61 — 2 
 
964 A MANUAL OF SURGERY 
 
 pancreas or of the intestine, causing pressure on the orifice of the 
 bile-duct ; it is quite unjustifiable under these latter circumstances, 
 as statistics have shown that the danger of such a proceeding is 
 very great, seven out of eight of Murphy's cases dying. The 
 parts are exposed as described above, the gall-bladder and 
 duodenum are brought into contact, and a lateral anastomosis 
 made by means of a Murphy button, or by simple suturing ; but 
 Murphy's method is undoubtedly the better. 
 
 Cholecystectomy, or removal of the gall-bladder, may be neces- 
 sary for traumatic lesions, and for malignant disease, whilst it is 
 sometimes employed after cholecystotomy in order to prevent any 
 new formation of gallstones. The bladder has to be isolated, and 
 may then be cut away, the divided end of the duct being secured 
 by a double row of sutures. 
 
 Affections of the Pancreas. 
 
 The pancreas is an organ which rarely calls for the attention of surgeons, 
 and only a few conditions need be mentioned. 
 
 Wounds of the Pancreas occur, but are so often associated with damage to 
 neighbouring important tissues that they seldom need treatment per se. 
 Prolapse through an abdominal 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 Purulent Pancreatitis is almost invariably a result of infection from 
 the intestine, or from neighbouring parts. It produces symptoms of deep 
 suppuration with excruciating pain, probably from implication of the cceliac 
 plexus, and often causes death from purulent peritonitis. A pancreatic abscess 
 may be opened from the front, but the greatest precautions must be taken 
 against infecting the peritoneal cavity. The stomach is drawn up, and the 
 surgeon burrows through the omentum between it and the transverse colon. 
 A counter-opening for drainage can be made by the side of the first lumbar 
 vertebra ; but it must be remembered that both the aorta and vena cava, and 
 the root of the superior mesenteric vessels, lie behind the gland. 
 
 Cysts of the Pancreas have been observed and treated in so many cases 
 since 1887 that their characters are pretty clearly known. Simple com- 
 plete obstruction to the duct has been proved exparimentally not to be a 
 sufficient cause for the disease ; some pathological condition of the epithelium 
 must also be present, preventing the re-absorption of the retained secretion. 
 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 emulsifying fat, and of converting starch into sugar. The cyst can 
 be felt as a rounded, tense, fluctuating or elastic swelling, placed deeply in the 
 abdomen, immoveable, and perhaps transmitting the aortic pulsation. The 
 stomach lies directly in front of it, as can be made evident by distending it 
 with gas. It is usually a disease of middle life, occurring most frequently in 
 men ; emaciation is not marked, although a good proportion of the fatty food 
 passes away in the motions ; the skin is often dirty, earthy, and unhealthy- 
 looking. Treatment consists in laying the cavity open, drawing off its contents, 
 and draining it, the surgeon finding his way to the cyst between the stomach 
 and transverse colon. A large tube is inserted, either through the front, or 
 from the back by the side of the vertebrae. The skin around usually becomes 
 irritated by the discharge, owing to a process of digestion. The prognosis 
 
ABDOMINAL SURGERY 965 
 
 with such treatment is very good, Treves having collected fifteen cures out of 
 sixteen cases thus dealt with. 
 
 Carcinoma of the Pancreas is met with either as a primary growth, or 
 secondary to a similar disease of the pylorus. It is usually, but not invariably, 
 of a scirrhous type, and may lead to distension of the stomach from pressure 
 on and constriction of the pylorus, and to jaundice and ascites by involving 
 the bile duct and portal vein. In one or two cases removal has been under- 
 taken 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 cases the blood collects in the left 
 loin, and gravitates towards the pelvis, the right loin being often kept clear by 
 the position of the mesentery. Laparotomy should be undertaken wherever 
 practicable, and, if much damaged, the organ is removed, the splenic vessels 
 being secured by ligature ; the results of such treatment have been most satis- 
 factory. In a few cases it has been possible to stop the bleeding by inserting 
 a gauze tampon, which is removed in a few days. 
 
 Abscess of the Spleen may develop in the course of pyaemia, or follow an 
 injury, especially if associated with a lesion of a neighbouring coil of intestine. 
 The symptoms are merely those of deep suppuration in the left hypochondrium, 
 and the abscess either finds its way externally, or bursts into the peritoneal 
 cavity. It may be opened and drained with the same precautions as for any 
 other intraperitoneal 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 
 known 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 pre- 
 paring a bed for the organ outside the peritoneum in the loose cellular tissue 
 beneath the floating ribs on the left side. The spleen is then slipped 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. 
 
 Tumours of the Spleen are met with either in the form of a general hyper- 
 trophy, as in lymphadenoma or malaria, or as new growths, such as cysts 
 (hydatid most frequently), or secondary carcinoma or sarcoma. The spleen 
 also becomes enlarged in lardaceous disease, rickets, and many of the general 
 fevers. An enlarged spleen constitutes a swelling which extends downwards 
 from the left hypochondrium towards the umbilicus, the notch being felt 
 anteriorly. The condition is recognised by the constant absence of intestine 
 in front of it, by the resonant note obtained in the flank, by its mobility with 
 respiration, and occasionally by its increased size after meals. The treatment, 
 where advisable, consists either of splenectomy, or, in the case of cysts, of 
 incision and drainage. 
 
 Splenectomy, or extirpation of the spleen, has been undertaken for a variety 
 of conditions, and its value and position, as a surgical procedure, are now 
 pretty well established. For traumatic lesions it is both safe and justifiable. 
 For primary hypertrophy, and for malarial enlargement, it may be performed 
 
966 A MANUAL OF SURGERY 
 
 if serious discomfort is being caused, and cannot otherwise be remedied. If 
 drainage fails to cure cysts, excision may be performed. If malignant disease 
 is diagnosed sufficiently early, the organ may be removed. Splenectomy for 
 leucocythsemia is absolutely unjustifiable, all the cases operated on having 
 died. The operation is performed through any suitable incision of sufficient 
 length. The peritoneum having been opened, the organ is carefully examined, 
 and if extensive adhesions are present, the surgeon will be wise to desist, since 
 fatal haemorrhage is very likely to result from any attempt to break them down. 
 If the organ is freely moveable, it is carefully drawn out of the abdomen, the 
 pedicle being isolated, and secured temporarily by pressure forceps. It is then 
 cut away, and the pedicle tied after transfixion with silk ligatures, the ends of 
 which are cut short, and returned into the abdomen. 
 
 General Remarks on Abdominal Operations. 
 
 Before concluding this chapter, it seems desirable to add a few 
 remarks dealing generally with the subject of abdominal opera- 
 tions. Formerly they were of rare occurrence, and perhaps this 
 was as well, since septic peritonitis frequently followed. At the 
 present time no competent operator hesitates to open the abdomen 
 whenever required, and the death-rate from preventible causes 
 has been steadily diminishing. The peritoneum, which formerly 
 the surgeon dreaded to touch, is now one of his best friends, if 
 properly treated. Attention to minute details is essential if good 
 results are to be obtained, and the following are a few points 
 which may prove of service to those aspiring to success in this 
 important branch of work. 
 
 The patient should be carefully prepared, when circumstances 
 permit, by regulating the diet and bowels for some days previously, 
 so that the intestinal canal may be as free from organisms as 
 possible ; a course of internal antiseptics, such as salol, calomel, 
 /3-naphthol, may be advisable. If there seems a likelihood of 
 streptococcal infection, the patient may be immunized to the 
 action of such organisms by the previous injection for a day or 
 two of a sufficient dose of antistreptococcic serum, as suggested 
 by H. E. Durham; 10 c.c. given twice or thrice a day for two 
 or three days will suffice for this purpose. No food should be 
 allowed by mouth for some hours, and immediately before being 
 placed on the table the bladder should be emptied. If the pro- 
 ceedings are likely to be protracted, it is advisable to give a rectal 
 injection of warm saline solution, or of beef-tea and brandy, half 
 an hour beforehand, and possibly a hypodermic injection of 
 strychnine (gr. ^). 
 
 The patient should be warmly wrapped up and protected from 
 cold, no unnecessary exposure being allowed. Chloroform is the 
 best anaesthetic to employ in all abdominal cases, and the more 
 complete the anaesthesia, the less the shock. Intraperitoneal 
 operations are not painless, as has been often stated, for although 
 the visceral peritoneum is not acutely sensitive, yet the parietal 
 layer is, and any handling of this structure gives rise to pain and 
 necessarily to increased shock, if the patient is conscious. 
 
ABDOMINAL SURGERY 967 
 
 The skin of the abdomen, the hands of the surgeon, and the 
 instruments, are rendered aseptic in the usual way, special atten- 
 tion being directed to the umbilical cicatrix. As soon, however, 
 as the peritoneum has been opened, all strong antiseptics must be 
 discarded, since they are likely to irritate this delicate membrane, 
 thus doing more harm than good. Warm sterilized salt solution 
 is the best fluid to employ for irrigating the serous cavity, or for 
 washing out sponges, swabs, or cloths. If sponges are employed, 
 they should be counted both before the operation, and again before 
 closing the abdomen. 
 
 Parietal Incision. — Formerly, whenever practicable, the incision 
 was made in the middle line through the linea alba, in conse- 
 quence of the facts that there is less bleeding in this situation, 
 that all parts of the abdomen are easily accessible from it, and 
 that the wound is more rapidly closed. It has been found, how- 
 ever, that ventral hernia is a not uncommon sequela, and hence 
 the general practice at the present time is to make one's incision 
 in any suitable place, and preferably through vascular structures 
 such as muscle, retaining the linea alba for cases where drainage 
 of a septic focus has to be maintained. Even in such operations 
 as ovariotomy, where the middle line gives the best access, it is 
 wise to go through the rectus a little to one side of the centre 
 rather than through the linea alba itself. The linea semilunaris, 
 again, is a bad situation for an incision, since the traction of the 
 muscles which are inserted into its outer side is so great that 
 hernia is very likely to follow. On the other hand, care must be 
 exercised not to place the incisions too near the bony margins 
 of the abdominal cavity, or subsequent manipulations may be 
 hampered by the rigidity of one side of the wound. 
 
 The muscles should be cleanly divided, and it is wise to see 
 that all bleeding is stopped before opening the peritoneum. 
 Directors are best avoided, since they are very likely to wound 
 the serous membrane, and are quite unnecessary in skilled hands. 
 A small hole should be first made in the peritoneum, through 
 which a blunt-nosed pair of forceps is inserted, and by lifting 
 these up and allowing the blades to separate slightly, a convenient 
 and safe substitute for a director is obtained. If a long incision is 
 required, the left index and middle fingers are passed through this 
 opening ; the intestines and omentum are thus kept out of the 
 way, the peritoneum being well raised and divided by scissors to 
 the required extent. 
 
 The intestines must be most carefully guarded during the 
 intraperitoneal portion of the operation, as if they are exposed 
 to the air, the endothelial lining is quickly shed, and adhesions 
 may form from without, whilst bacterial invasion may be predis- 
 posed to from within. A series of cloths wrung out of warm 
 sterilized salt solution must be kept wrapped round them by the 
 assistant, and no unnecessary handling should be permitted. 
 
968 A MANUAL OF SURGERY 
 
 Closure of the Wound. — A careful toilette of the peritoneum 
 must be undertaken before the abdomen is closed. All blood-clot 
 is removed, sponges are counted, and, if there has been any 
 extravasation of infective material, it is well to wash the site of 
 operation with sterilized salt solution at a temperature of about 
 io8° F., a proceeding which often assists considerably in mini- 
 mizing shock. Many different methods of closing the parietal 
 incision have been adopted, but perhaps the best consists in 
 securing the serous and muscular coats by one set of deep inter- 
 rupted stitches either of purified silk or of silkworm gut, which 
 remain buried, and then in dealing with the skin by means 
 of a continuous suture, which is subsequently removed. There 
 is no advantage in taking up each of the layers separately, and 
 the integrity of the abdominal cicatrix is increased by leaving all 
 the deeper stitches in situ. 
 
 Drainage is not usually called for in abdominal operations. If 
 the surgeon is careful in his manipulations, and avoids measures 
 which are likely to lead to subsequent oozing, the peritoneum 
 may be closed with safety. Where an inflammatory focus has 
 been opened, or when adhesions likely to bleed have been divided, 
 or raw surfaces left such as occur after enucleating a parovarian 
 cyst from the broad ligament, some means should be provided 
 whereby any considerable effusion of fluid can escape. It is 
 found that capillary drainage along a strip of gauze is the best 
 that can be employed for blood or serum. Ordinary indiarubber 
 tubes are liable to become blocked by portions of the intestine 
 protruding into the lateral openings, whilst glass tubes, such as 
 Keith's, are unyielding, and fail to accommodate themselves to 
 the sinuosities of the regions needing drainage. Strips of aseptic 
 gauze are therefore inserted like lampwicks, and along these, by 
 capillary action, the effusion finds its way into the general dressing 
 placed over the wound. Of course a certain amount of adhesive 
 inflammation follows, and therefore the wick should be as small 
 as possible, consistent with efficiency, and is changed or removed 
 at the end of forty-eight hours. In some cases it is an advantage 
 to enclose the gauze- wick in gutta percha tissue which has been* 
 previously perforated here and there. Where, however, pus is to 
 be removed, ordinary drainage-tubes must be employed. 
 
 After-Treatment. — After the completion of the operation, the 
 patient is replaced in bed, with the head low. If restless and 
 irritable, a small dose of opium may be administered, but the less 
 the better, since it induces intestinal paresis, and this in turn 
 assists bacterial invasion from the gut. No food is allowed to enter 
 the stomach for twenty-four hours, although the mouth may be 
 washed out with warm water or with still lemonade, and nutrient 
 enemata administered every four or six hours. The great essential 
 is to avoid vomiting, and this is best accomplished by a complete 
 temporary cessation of stomach-feeding. At the end of twenty- 
 
ABDOMINAL SURGERY 969 
 
 four hours, if all is going well, a little fluid nourishment may be 
 given, and this is gradually increased. The bowels are left to 
 nature, and unless constipation persists for some days no aperient 
 is necessary. 
 
 If peritonitis is threatening, the patient complains of abdominal 
 pain and distension, whilst flatulence and vomiting are distressing 
 symptoms (peritonism). Under these circumstances the adminis- 
 tration of a saline purgative (e.g., 20 grains of sulphate of soda 
 every half- hour) may stop the process by re-establishing peri- 
 stalsis, removing bacteria and their products, and lessening the 
 vascular tension. Failing this, the outlook is grave, though in 
 some cases it may be justifiable to reopen the abdomen, wash 
 out, and drain. 
 
CHAPTER XXXIII. 
 HERNIA. 
 
 By the term Hernia is meant the protrusion of some viscus from 
 its normal situation through an opening in the walls of the cavity 
 within which it is contained. This may affect not only the 
 abdominal viscera, but also the brain and lungs, giving rise to 
 conditions which we have already described. In this chapter 
 we merely deal with hernia as met with 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). Viscera may, however, 
 protrude through the obturator foramen, sciatic notch, the 
 diaphragm, and in various other situations. 
 
 ^Etiology. — A great many conditions may be associated, directly 
 or indirectly, with the production of a hernia. They may, how- 
 ever, be described for practical purposes under two main headings 
 — the congenital and the acquired. 
 
 Congenital Causes are rather predisposing than exciting in nature, 
 and must be looked for amongst the many malformations and 
 conditions of imperfect development to which the abdominal 
 parietes and contents are liable. The following are the most 
 important of these : (a) The non-obliteration of the funicular 
 process of peritoneum, which in the male precedes and accom- 
 panies the testicle on its progress downwards from the abdominal 
 cavity to the scrotum, and in the female passes along the round 
 ligament. The so-called congenital inguinal hernia results from 
 this, although it must be remembered that the rupture does not 
 necessarily show itself at birth, and, indeed, may not appear till 
 after puberty, the term being therefore a misnomer. In females 
 under the age of twenty-five, hernia into the canal of Nuck, as 
 this peritoneal tube is called, is the most frequent variety met 
 
HERNIA 971 
 
 with, (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 of 
 interstitial hernia. (c) Inherited weakness of the abdominal 
 muscles and parietes, with unusual patency of the rings, will 
 certainly predispose to this condition, and, moreover, there is 
 no doubt as to the tendency of hernia to run in families. 
 (d) Abnormal length of the mesentery or omentum has also 
 been looked on as a causative factor ; but, although it may 
 have some influence when other conditions are present, it can 
 per se have but little effect, (e) Congenital phimosis, by inducing 
 forcible acts of micturition, acts as an exciting cause. (/) Con- 
 genital apertures occur in the linea alba or linea semilunaris, 
 especially opposite one of the muscular intersections in the rectus, 
 and through these one form of ventral hernia may develop. 
 (g) The umbilicus is sometimes imperfectly developed at birth, 
 permitting the viscera to protrude into the base of the umbilical 
 cord (congenital umbilical hernia), (h) The diaphragm is also 
 occasionally defective, allowing the stomach or other viscera to 
 find their way into the thoracic cavity. 
 
 Acquired Causes. — Hernia may result from any condition which 
 tends either to weaken the abdominal parietes, or to increase the 
 intra-abdominal pressure. Thus, all violent exercise, especially 
 when of an intermittent nature and accompanied by excessive 
 straining, as in lifting heavy weights, may determine its occur- 
 rence, and the more so if the individual is forced to maintain the 
 upright position, or wears tight bands or girths round the abdomen. 
 Pregnancy stretches the abdominal walls, and parturition, by 
 inducing violent muscular contraction, may originate a rupture, 
 either through a split in the linea alba or through the crural 
 canal. Prolonged and severe bronchitis also favours the occur- 
 rence of a hernia by the increase of intra-abdominal pressure due 
 to coughing, whilst the straining to pass water in cases of enlarged 
 prostate or stricture may act in a similar manner. Chronic con- 
 stipation is a frequent factor in its production, especially if the 
 patient makes use of a closet with a high seat, whereby the 
 inguinal canals are left unprotected ; in uncivilized races, where 
 defaecation is performed in the squatting posture, the lower part 
 of the abdomen is supported by the flexed thighs, and hernia is 
 very uncommon. Patients with weak and bulging inguinal 
 regions may with advantage use a low commode. In old and 
 weakly people, an additional cause may be found in the slipping 
 downwards of the mesenteric attachment, causing the intestines 
 to occupy the lower part of the abdomen rather than the upper, 
 so that the former bulges out over the pelvic brim. This is 
 possibly due to weakening or relaxation of the unstriped mus- 
 cular tissue which normally exists behind the peritoneum, passing 
 from the posterior abdominal wall to the base of the mesentery ; 
 
972 A MANUAL OF SURGERY 
 
 it is sometimes called the muscle of Treitz. Obesity is also a pre- 
 disposing factor to hernia, the accumulated fat being deposited in 
 the omentum, mesentery, and subperitoneal tissue, thus increas- 
 ing the intra-abdominal tension. 
 
 Structure. — A hernia consists of a sac and its contents, the 
 sac being formed of peritoneum, perhaps thickened by additional 
 coverings, derived from the abdominal parietes, 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 as a result of the stretching of that 
 portion of the serous membrane already protruded, and partly by 
 the drawing down of fresh membrane from the neighbourhood ; 
 in the groin this is derived rather from the iliac fossa than from 
 the anterior abdominal wall. The sac is described as consisting 
 of two portions — the neck and the fundus. The neck, sometimes 
 large and open at first, gradually becomes narrowed, and is 
 generally thickened from the irritation to which it has been ex- 
 posed, either from the wearing of a truss or from the pressure of 
 the contained viscera. The body, or fundus, varies much in size 
 and shape, and may undergo considerable alterations in structure. 
 
 (a) The sac, which is at first easily replaced, soon becomes 
 irreducible from adhesions to surrounding parts, though it can still 
 be readily emptied of its contents, (b) Inflammation may occur as 
 a result of injury or pressure, constituting a form of localized peri- 
 tonitis. If this is of a chronic type, the sac becomes thickened 
 and opaque, with dilated vessels coursing over it, as seen especially 
 in old irreducible umbilical hernia. Acute or subacute inflam- 
 mation is also met with, resulting in the formation of adhesions 
 between its inner wall and the contained viscera, or between the 
 opposite sides of the sac if no other structures interpose. Natural 
 cure of a hernia may in this way be occasionally produced by 
 adhesions forming across the neck of the sac, or by an adherent 
 plug of omentum, thus occluding the communication with the 
 peritoneal cavity. The lower portion of the sac may in a similar 
 way be shut off from the upper, either by a band of adhesions or 
 by a septum of adherent omentum ; this isolated cavity is some- 
 times the seat of a serous effusion, known as a hydrocele of a hernial 
 sac. (c) Haemorrhage into the sac wall may result from violence, 
 and will cause it to become much thickened, and even pigmented 
 and leathery in appearance. 
 
 The coverings of the sac are indurated in old-standing cases, 
 and matted together in such a manner as to render it impossible 
 to recognise the constituent parts. This is specially noticeable at 
 the neck of the sac, where their union with surrounding structures 
 is often such as to constitute an important predisposing element 
 
HERNIA 973 
 
 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 supervenes. For a descrip- 
 tion of these conditions, see p. 945. The small intestine is much 
 more frequently involved than the large gut. The amount of 
 bowel protruded varies from a few inches to several feet. 
 
 If omentum is found in a hernial sac, the condition is known as 
 an epiplocele. As long as it remains reducible, it is likely to retain 
 its normal texture ; but when large in amount, and especially if 
 irreducible, it becomes ihickened, 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 between opposed surfaces. In some cases 
 openings are found in it of sufficient size to allow the gut to pass 
 through and become strangulated. When omentum and bowel 
 are present in the same sac, the condition is known as an entero- 
 epiplocele. 
 
 Much discussion has been caused by the occasional presence 
 of the ccecum in a hernial sac. It was formerly supposed that this 
 viscus was only partially surrounded with peritoneum, and hence 
 it was maintained that when found in a hernial sac the peritoneal 
 investment was incomplete. It is now, however, universally 
 acknowledged that a caecum has generally a complete serous 
 covering and usually a mesentery, so that it is freely moveable ; 
 consequently it may pass into a hernial sac in the same way as 
 any other moveable part of the intestine, and several instances are 
 on record in which it has been found in children to occupy the sac 
 of an inguinal hernia on the left side. On the other hand, a few 
 indisputable cases have been related in which the serous envelope 
 was incomplete in a so-called ' caecocele.' 
 
 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 
 
974 A MANUAL OF SURGERY 
 
 the hernia has attained a colossal size. There is then only a 
 partial peritoneal investment, the bladder lying outside the sac, 
 and being adherent to it. Considerable irritability of tlK 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) Occa- 
 sionally a saccule of the outer wall of the bladder becomes ad- 
 herent to the peritoneum, and is drawn down by it into the 
 inguinal canal ; its presence may be suspected if a small hernia 
 is associated with much vesical irritability. Such a protrusion 
 consists merely of thickened mucous membrane and submucous 
 tissue, and is devoid of muscular fibres ; it is very liable to be laid 
 open if an operation for the radical cure is undertaken. If such 
 an accident happens, the opening must be at once closed by 
 sutures, which should not penetrate the mucous membrane, other- 
 wise phosphatic concretions may form on the portion of suture 
 exposed, and cause subsequent trouble. 
 
 Loose foreign bodies, somewhat resembling marbles in size, are 
 occasionally, 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 swelling, 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 pressure slips back into the abdomen with a 
 distinct gurgle. An enterocele 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 per- 
 cussion. 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 palliative 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. 
 
 Special Forms of Hernia. 
 
 Inguii.al 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 
 
HERNIA 
 
 975 
 
 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 incom- 
 plete 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 upwards and 
 inwards. 
 
 Two main varieties of inguinal hernia are described, viz., the 
 oblique and the direct. 
 
 An Oblique Inguinal Hernia (Fig. 348) is one which passes down 
 
 Fig. 348. — Double Oblique In- 
 guinal Hernia. 
 
 Fig. 349. — Diagram of Acquired In- 
 guinal Hernia, showing Serous 
 Sac with Intestine coming down 
 to the Top of the Testis. 
 
 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 ; (b) the cremasteric muscle and fascia, 
 representing and extending from the internal oblique ; (c) the 
 infundibuliform fascia derived from the fascia transversalis ; and 
 (d) finally, a layer of subserous tissue varying in thickness, and 
 closely surrounding the peritoneal sac. In practice, the surgeon 
 does not attempt to recognise these different coverings, the oniy 
 
976 
 
 A MANUAL OF SURGERY 
 
 one of importance being the cremasteric, the muscular fibres of 
 which are often evident, and serve as a useful landmark. 
 
 There are three different forms of oblique inguinal hernia, viz., 
 the acquired, the congenital, and the infantile or encysted. 
 
 i. An Acquired Inguinal Hernia (Fig. 349) is one in which the 
 sac consists entirely of peritoneum protruded from within the 
 abdomen. It gradually increases in size, and finds its way along 
 the cord to the scrotum. The sac usually extends as far as the 
 head of the epididymis, but if of a large size it may overlap 
 the testicle, which lies behind it. The structures 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 may be difficult, apart from operation, 
 to determine whether any particular hernia is direct or oblique. 
 
 r ., r /'"^- 
 
 Fig. 350. — Congenital Inguinal Hernia. 
 A, Vaginal variety ; B, funicular type. 
 
 2. Congenital Inguinal Hernia (Fig. 350) is due to non-closure of 
 the funicular process of peritoneum, which passes down to the 
 scrotum with the testicle, and is usually obliterated completely 
 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 com- 
 plete at once, and its development may be immediately followed 
 by acute strangulation. 
 
 In the majority of instances the patent funicular process is 
 continuous with the tunica vaginalis, and the protruded viscera 
 lie in contact with the testis, and somewhat obscure it ; this is 
 known as a congenital vaginal hernia (Fig. 350, A). Less fre- 
 quently the funicular process is patent only as far as the head 
 of the epididymis, being shut off from the tunica vaginalis. The 
 
HERNIA 
 
 977 
 
 hernia under such circumstances exactly resembles the acquired 
 variety, being unrecognisable from it except by the fact that it 
 
 Fig. 351. — Infantile Inguinal Hernia. 
 
 A., Prehernial condition with tunica vaginalis extending upwards to inguinal 
 canal; B, hernial sac coining down behind tunica; C, sac invaginating 
 the tunica vaginalis. 
 
 becomes complete at once. It is termed a. congenital funicular hernia 
 (Fig. 350, B). 
 
 In every case of congenital hernia the structure* of the cord are 
 spread out over the sac, and more intimately adherent to it than 
 in the acquired form. Phimosis is usually associated with this 
 condition in young boys. 
 
 3. The Infantile or Encysted Hernia is one occurring in individuals 
 in whom the funicular process, although shut off from the ab- 
 dominal cavity above, remains patent below, communicating with 
 
 the tunica vaginalis, which cavity 
 extends, in consequence, as high 
 as the inguinal canal (Fig. 351, 
 A). The hernia has a distinct 
 sac, which passes down behind 
 the open process, or invaginates 
 it (Fig. 351, B and C). It can- 
 not 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 is not so likely 
 to occur at the present day, when 
 the high incision is made. 
 A Direct Inguinal Hernia (Fig. 352) is one which, though passing 
 
 62 
 
 Fig. 
 
 352. — Direct Inguinal 
 Hernia. 
 
978 
 
 A MANUAL OF SURGERY 
 
 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. 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. The hernia traverses the space 
 known as Hesselbach's triangle, which is bounded internally by 
 the outer border of the rectus muscle, by the deep epigastric 
 artery externally, and by Poupart's ligament below (Fig. 353). 
 The obliterated hypogastric artery passes across this space in a 
 
 Fig. 353. — Abdominal Wall from Within, to show Hernial 
 Apertures. 
 
 A, V, Femoral artery and vein ; S V, spermatic vessels ; P L, Poupart's liga 
 ment ; V D, vas deferens; E, epigastric vessels; R, rectus abdominis; 
 H, obliterated hypogastric artery ; i, internal abdominal ring; 2 and 3, 
 sites of external and internal direct hernia in Hesselbach's triangle ; 
 4, crural ring for femoral hernia; 5, obturator foramen and vessels. 
 
 direction parallel to its outer border, dividing it into two parts, 
 and according to whether the hernia protrudes through the inner 
 or outer segment, it is known as an internal or external direct 
 hernia (Fig. 353, 3 and 2). 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 tissue covering the sac. 
 
 The External Direct Hernia is very similar in nature to the 
 acquired oblique form, except that it is placed to the inner side of 
 the deep epigastric artery, and pushes in front of it the trans- 
 versalis, instead of the infundibuliform, fascia. It lies to the 
 
HERNIA 979 
 
 outer side of the conjoined tendon, and has a less complete cover- 
 ing of the cremaster muscle. 
 
 The Internal Direct Hernia issues from the abdomen to the 
 inner side of the obliterated hypogastric artery, rupturing or 
 pushing before it the conjoined tendon, which in such a case is 
 poorly developed. The coverings are the same as for the external 
 variety. 
 
 Interstitial Hernia is the name given to an inguinal hernia which 
 does not follow its usual course, but develops in some abnormal 
 relation to the abdominal wall. Three varieties are described : 
 (a) Where a sac exists between the transversalis fascia and the 
 peritoneum {intraparietal form, or pro-peritoneal hernia), either with 
 or without a hernia in the usual position ; in the former instance 
 one form of ' hernia en bissac ' is produced. This abnormal pocket 
 of the sac is found either between the symphysis pubis and the 
 bladder (hernia inguinalis ante-vesicalis), or it extends outwards 
 towards the iliac fossa (hernia inguinalis intra-iliaca). As no ex- 
 ternal swelling is caused by this condition, it is usually impossible 
 to recognise its existence prior to operation ; occasionally it is the 
 cause of a continuation of the symptoms of strangulation, when 
 apparently successful taxis has been performed, owing to the 
 strangled bowel being pushed backwards from the superficial into 
 the deeper portion of the sac. (b) An abnormal expansion or 
 bulging of the sac is situated between the internal and external 
 oblique muscles (interparietal form). A swelling is thus pro 
 duced in the region of the inguinal canal, covered by the external 
 oblique aponeurosis, and tending to spread upwards and outwards 
 parallel with Poupart's ligament. The sac is often shaped like an 
 hour-glass, a more or less complete septum existing at the level 
 of the external abdominal ring, formed either by adhesions or by 
 a mass of adherent omentum. The usual downward course of 
 the hernial contents is thus prevented, and the sac yields laterally 
 above the site of the obstruction, and passes between the muscles. 
 (c ) The hernia escapes as usual from the external abdominal ring, 
 but travels outward along Poupart's ligament, somewhat simu- 
 lating a femoral hernia iextraparietal variety). This form is 
 generally associated with late descent of the testis, and a con- 
 tracted state of the scrotum, so that it is easier for the hernia, 
 which is always of a congenital type, to pass into the thigh, and 
 be guided by the fascia in the direction indicated ; in a case of 
 this character operated upon a few years back, the testicle was 
 found lying close to the anterior superior iliac spine. There is no 
 difficulty in recognising such a condition. 
 
 The Signs of an inguinal hernia do not require much special 
 notice here, as we have already described the general clinical 
 features of a rupture (p. 974). 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 
 
980 A MANUAL OF SURGERY 
 
 best detected by a finger passed through the external ring into 
 the canal. When it descends into the scrotum, the swelling 
 increases in size from above downwards, and in the oblique 
 variety is continuous with the fulness in the inguinal canal. 
 The structures of the cord are masked by the presence of the 
 hernia, but the testicle is to be more or less distinctly felt at 
 the lower and back part of the swelling. When of the direct 
 variety, the cord lies to the outer side, and although the hernia 
 can be felt projecting from the external ring, it passes directly 
 backwards, and there is no fulness along the course of the canal. 
 
 Inguinal hernia is usually met with in the male sex, the oblique 
 variety being more common in the young, and the direct in elderly 
 patients. In the female sex it is rare, except in girls and young 
 nulliparous women ; in such cases it is almost always congenital, 
 passing into the labium along the canal of Nuck, but rarely 
 attaining any considerable size. 
 
 The Diagnosis of an inguinal hernia is a tolerably simple matter 
 if it is uncomplicated by any other condition ; it may, however, 
 be difficult, and in old-standing cases it is practically impossible 
 to distinguish the oblique variety from the direct. The con- 
 ditions for which it may be mistaken are best considered in two 
 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 charac- 
 teristic gurgle of a hernia is absent ; traction on the testis, more- 
 over, fixes the tumour, and renders it immobile. The exact 
 limitation of the upper end of the swelling, if it can be reached, is 
 very characteristic of a hydrocele, (b) A 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 impulse on coughing, and 
 although the swelling is reducible, it has not the definite outline 
 and characteristic sensation of a hernia, being usually soft and 
 fluctuating. Other evidences pointing to the existence of the 
 original disease may also assist in determining the nature of the 
 tumour. (c) Enlarged glands in the groin which have become 
 adherent to the external oblique are sometimes mistaken for a 
 hernia, owing to the fact that on coughing a distinct impulse is 
 communicated to them ; it is, however, merely heaving in nature, 
 and not expansile, whilst on digital exploration of the inguinal 
 canal the absence of a hernia may be readily ascertained, (d) A 
 testicle retained in the inguinal canal is recognised by that side of the 
 scrotum being empty, and on pressing the swelling testicular 
 sensation may be elicited. The rounded upper end of the testes 
 
HERNIA 
 
 981 
 
 can often be detected, (e) Tumours consisting of fat or other tissues 
 are occasionally seen in the inguinal canal, but are characterized 
 by the strict limitation 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 
 sometimes present, resulting from a protrusion of the subperi- 
 toneal tissue, a hernial sac being found embedded in its interior. 
 (/) Hematocele 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 condition of the cord in its upper region ; moreover, if 
 
 Fig.. 354. — Inguinal Truss. (Down Brothers.) 
 
 the patient is made to assume the recumbent posture, the swelling 
 disappears in each instance, but if a finger is placed firmly over 
 the inguinal canal so as to prevent any protrusion of omentum, 
 and he is then directed to stand up, the swelling immediately 
 reappears if it is venous in character. To the practised finger, 
 the diagnosis is never a matter of difficulty, since the enlarged 
 veins of a varicocele and omentum are not at all alike to the 
 touch, the veins moving freely under the finger ' like worms in a 
 bag.' When a hernia is associated with a hydrocele or sarcocele, 
 a little more care is necessary in order to distinguish between the 
 two swellings. 
 
 The Treatment of inguinal hernia is either palliative by means 
 of trusses, or radical. 
 
 Palliative Treatment. — Many different trusses have been intro- 
 duced in order to prevent the descent of a hernia. No one form 
 is capable of dealing with every case, but the truss must be 
 applied with care, so as to suit the special needs of the particular 
 patient. It is impossible to describe a tithe of the varieties which 
 have been suggested, and hence we must refer our readers to 
 special works on the subject. Suffice it to indicate the essentials 
 
982 
 
 A MANUAL OF SURGERY 
 
 of a good truss. It should consist of a pad kept in position over the 
 hernial aperture by a steel spring (Fig. 354) ; it must fit the patient 
 accurately, resting behind on the middle piece of the sacrum, and 
 passing laterally midway between the crest of the ilium and the 
 top of the great trochanter. If the hernia is unilateral, the spring 
 ends on the sound side just behind the anterior superior spine, and 
 is prolonged anteriorly into a leather thong or cross-strap, which is 
 secured to a stud on the pad. To prevent it from slipping up, an 
 under-strap passes from the affected side close behind the anterior 
 superior spine along the fold of the nates to the inner side of the 
 
 thigh, being fixed finally to a 
 second stud on the pad. The pad 
 may be rounded or oval in shape, 
 and usually consists of soft iron 
 protected by cork, but polished 
 vulcanite, wood, or an indiarubber 
 cushion filled with air, water, or 
 glycerine have been employed in- 
 stead ; it should be well covered 
 with leather, and the strength of 
 the spring must be so adjusted 
 as to retain the hernia under all 
 conditions of strain to which it 
 may be subjected, but without the 
 use of undue force. In ordering a 
 truss from an instrument-maker, 
 the only measurement required is 
 that around the body, following the 
 line taken by the truss, and reaching in front to the symphysis 
 pubis ; it is also advisable to mention the size of the hernia, and 
 whether the opening in the abdominal parietes is large or small. 
 In the earlier cases of oblique hernia, the pad should rest rather 
 over the inguinal canal than over the external abdominal ring, 
 the object being to restore the valve-like action of the canal by 
 approximating its sides. In a direct hernia the pad must be 
 applied 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 cases of con- 
 genital hernia in 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 once allowed to slip down, 
 even after six or twelve months' treatment, all the previous good 
 will have been undone. 
 
 In infants, an efficient support is afforded by a skein of wool 
 (specially known as ' fingering '), divided at one end, so that when 
 placed round the body the cut ends of the skein can be passed 
 through the loop, forming a knot over the inguinal canal, which 
 acts as the pad of a truss. The cut ends are now passed under the 
 perineum, and tied to the transverse portion behind (Fig. 355). 
 
 Fig. 355. — Wool Truss for 
 Treatment of Hernia in 
 Children. 
 
HERNIA 
 
 9S3 
 
 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.356), 
 arranged so as to fit over the inguinal canals, and with suitable 
 straps and studs, will often suffice, and is certainly more comfort- 
 able than a spring truss. In addition to such pressure, it is im- 
 portant to remove all causes of intra-abdominal tension, as by cir- 
 cumcision, 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, though there are still 
 surgeons who only advocate 
 its use under exceptional 
 circumstances, appealing to 
 the frequent recurrence after 
 operation as an argument 
 against its adoption. Whilst 
 fully admitting that recur- 
 rences are more frequent 
 than they should be, we look 
 on them as either being due 
 to an error of judgment in 
 the selection of the cases for 
 operation, or as resulting 
 from imperfect technique, or from inefficient after-treatment. 
 
 The selection of cases for an operation of this type, which is not 
 an essential, but only a desirable means of treatment (or, as it is 
 sometimes termed, an operation de complaisance), is a matter requir- 
 ing considerable judgment and discrimination. In an individual 
 whose occupation does not subject him to heavy strain or exer- 
 tion, and who possesses a hernia which, under ordinary circum- 
 stances, is easily commanded by a suitably applied truss, no 
 operation is absolutely necessary ; although one is perfectly 
 justified in urging him to submit to it, since he will be thereby 
 freed from the irksomeness of wearing a truss, and from the risks 
 of possible strangulation. If, however, the subject is a labouring 
 man, exposed to injury and strain, and who may find it difficult 
 to provide a suitable series of trusses, the operation should always 
 be undertaken unless distinctly contra-indicated (1) by a general 
 inherited weakness of the abdominal muscles ; (2) by a relaxed 
 and atonic condition of the abdominal parietes, which is so 
 commonly associated in elderly people with slipping downwards 
 
 Fig. 356. — 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. 
 
984 A MANUAL OF SURGERY 
 
 of the mesenteric attachment of the intestine (enteroptosis), so 
 that the hypogastrium obviously bulges ; or (3) by such con- 
 stitutional disease as precludes all unnecessary operative inter- 
 ference. (4) Again, in cases of extensive irreducible hernia, the 
 return of large masses of intestine which have lain for years in 
 the hernial sac so increases the intra-abdominal tension as fre- 
 quently to determine recurrence locally or elsewhere, and therefore 
 operative interference, though very desirable owing to the great 
 risk of strangulation incurred by the patient, is often followed 
 by very bad results, unless the patient has previously been put 
 through a course of semi-starvation and persistent taxis in order 
 to gradually reduce 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, owing to the risk of infection of the wound from the 
 constant saturation of the dressings with urine. 
 
 Very many different operations have been described and 
 practised by various surgeons ; in all probability some of them 
 are unnecessarily complicated, and can only be briefly alluded to. 
 The plan we now employ in almost all cases is known as Bassini's 
 operation ; it appears to us as one of the most scientific of all those 
 that have been suggested, since it reproduces more accurately than 
 any other the normal structure of the parts. The instruments 
 required are scalpels, forcipressure forceps, dissecting forceps, re- 
 tractors, transfixion needle, curved hernia needles, and scissors. 
 The operation may be described in the following stages: (1) The 
 pubic region having been previously shaved and thoroughly 
 purified, an incision is made in the direction of the inguinal canal 
 and cord, about o.\ inches in length, its centre being a little above 
 the external abdominal ring. This is carried through the skin and 
 subcutaneous tissues until the structures of the cord are reached, 
 the superficial external pudic artery being necessarily divided en 
 route ; the pillars of the ring are clearly defined, and the external 
 oblique aponeurosis slit up for about f inch beyond the apex of 
 the ring in the direction of the cord. (2) The sac has now to be 
 identified ; if the hernia is one of old standing, or contains adherent 
 omentum or intestine, it is easily recognised ; but if it is thin, 
 empty, and of recent formation, and especially in the case of a 
 bubonocele, its identification may be a matter of some difficulty. 
 The structures of the cord are lifted up out of the wound, spread 
 out over the fingers, the coverings divided, and the white convex 
 border of the fundus of the sac looked for. It is sometimes 
 necessary to induce vomiting by titillation of the fauces, in order 
 to cause the hernia to protrude, particularly when it is of the 
 direct type. (3) If the sac is empty, it is freed from its connection 
 
HERNIA 
 
 985 
 
 with the structures of the cord without opening it, and isolated as 
 far as or beyond the internal abdominal ring, as indicated by a 
 collar of fatty subperitoneal tissue surrounding the neck. If the 
 hernia is irreducible, the sac is laid open, its contents freed from 
 adhesions, and the intestine returned into the abdomen, whilst 
 omental tissue is removed, and the stump replaced. The greatest 
 gentleness must be employed in dealing with the intestines ; if a 
 considerable amount is present, it must be surrounded by a cloth 
 wrung out of warm sterilized salt solution. Adhesions are care- 
 fully divided either by the finger or between ligatures ; if closely 
 
 Fig. 357. — Bassini's Operation for Radical Cure of Hernia. 
 
 A and A 1 , Spencer Wells's forceps, holding aside the divided portions of external 
 oblique aponeurosis ; B, arched fibres of internal oblique, continuous on 
 the inner side with the conjoined tendon ; C, hook or retractor 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.) 
 
 adherent to the sac, it may be necessary to leave a small portion 
 of this attached to the gut, which is then returned. Omentum, 
 whether adherent or not, should be removed, as the elongated 
 fringes are very liable to contract adhesions to the abdominal 
 parietes, and subsequently produce mischief. In removing 
 omentum, it is not advisable to encircle a large mass with a 
 single ligature, as 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, 
 
986 A MANUAL OF SURGERY 
 
 and tied separately and with advantage at different levels, so as 
 to assist in the subsequent return of the stump. The protruded 
 mass is then cut away below the ligatures, and the stump 
 replaced after seeing that no bleeding point remains unse- 
 cured. The sac, being now emptied, is isolated as far as the 
 internal ring. (4) The neck is then transfixed as high as 
 possible, and ligatured with sterilized silk, and the sac cut off 
 below the ligature, the stump retracting well above the internal 
 ring, and presenting a flush surface towards the intestines, as we 
 have been able to demonstrate in a recent post-mortem specimen, 
 obtained from a patient who died of pulmonary embolus ten days 
 after operation. (5) The tissues of the cord are carefully ex- 
 amined, and any varicose spermatic veins removed, as also any 
 downgrowths of the subperitoneal fat and possibly portions of the 
 cremaster. (6) The opening in the abdominal parietes is closed 
 by a row of sutures passing through the arched fibres of the 
 internal oblique and transversalis muscles, or through the con- 
 joined tendon on the inner side, and through Poupart's ligament 
 on the outer, the stitches being all placed behind the cord. To 
 effect this, the cord is drawn up out of the wound and held aside 
 by a retractor (Fig. 357, C), whilst the divided margins of the 
 external oblique aponeurosis are grasped by pressure forceps 
 (A, A 1 ). 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 
 forgotten. It is wise to utilize interrupted stitches and not looped 
 or mattress sutures as recommended by some authorities, since 
 the latter tend to strangle the portions of tissue included in their 
 grasp. The opening in the abdominal parietes is in this way 
 commanded as far down as the pubic spine, but sufficient room 
 must be left at the upper end for the passage of the cord, undue 
 constriction of which would cause atrophy of the testis ; some- 
 times 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 together over it, (7) The wound in 
 the skin is closed by a continuous suture, and usually no drainage- 
 tube is needed. 
 
 After-Treatment. — The patient is placed in bed with the head 
 low, and the knees slightly flexed over a pillow. The wound, as 
 a rule, does not require dressing for seven or eight days, when, 
 on removal of the stitches, it should be found completely healed, 
 if asepsis has been maintained. The patient should turn to the 
 opposite side in order to pass water, and the greatest care must 
 be taken to prevent the dressing becoming soiled. Occasionally 
 retention of urine follows this operation, necessitating the use of 
 
HERNIA 987 
 
 a catheter. In the case of children, it is well to seal the parts 
 down by a collodion dressing, and by preference the collodion 
 should be of the flexile type, but with the guncotton replaced by 
 celloidin (cello id in collodion). 
 
 The recumbent posture should be maintained for three weeks, 
 and nothing but the slightest work undertaken for at least six 
 weeks, and no violent effort until six months after the operation. 
 Under such circumstances the use of a truss is unnecessary, and, 
 indeed, we consider that it is undesirable, as its pressure is liable 
 to produce atrophy of the newly-formed cicatricial tissue. When, 
 however, the abdominal walls are congenitally weak, or if, unfor- 
 tunately, 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 some- 
 times impracticable to completely isolate the neck of the sac. In 
 many cases the old-fashioned Mitchell Banks' operation suffices 
 for a congenital hernia. 
 
 The other operations which require to be mentioned are as 
 follows : 
 
 (a) In Mitchell 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 of the cord. It is 
 obvious 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) Ball's Operation consists in freeing the peritoneum on the 
 inner aspect of the internal abdominal ring, and then the sac, 
 after being isolated, is twisted into a tense cord, so as to throw 
 it into a series of folds, thereby producing a prominence internally 
 rather than an infundibuliform depression. To prevent untwist- 
 ing, a ligature is tied around it as high as possible, and it is also 
 transfixed below the ligature by a thread, the ends of which are 
 passed through the abdominal parietes. 
 
 (c) In what is known as Barker's Operation the neck of the sac 
 is isolated, ligatured, and divided, the fundus being left in situ, 
 whilst the thread used in tying the neck is employed as the first 
 suture to close the deep part of the canal ; by this means it is 
 hoped that the neck of the sac will be displaced, and hence more 
 satisfactorily occluded. It is very doubtful, however, whether 
 this really occurs. 
 
 (d) In Macewen's Method the aponeurosis of the external oblique 
 is most carefully maintained intact, and the inguinal canal is 
 
A MANUAL OF SURGERY 
 
 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 internal ring. This 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 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 diffi- 
 cult operation than Bassini's, and one loses the advantage of opening 
 the canal more freely, and thereby exploring the structures of the 
 cord. One is frequently finding subperitoneal lipomata 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. 
 
 (e) Halsted's Operation is much the same as Bassini's, except 
 that the fibres of the internal oblique are also divided at the outer 
 margin of the internal ring, and the cord displaced upwards and 
 outwards through this opening, so that at the spot at which it 
 pierces the abdominal parietes it may be surrounded by muscular 
 fibres. The canal is then closed as in Bassini's operation, whilst 
 the external oblique is also sutured behind the cord, which is thus 
 made a subcutaneous structure. We see no special advantage to 
 be gained by this departure from Nature's method of conducting 
 the cord and its structures through the abdominal wall in an 
 oblique direction. 
 
 Recurrence after Operation is unfortunately met with only too 
 frequently, and statistics go to prove that in the great majority 
 of cases it happens within 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 infundibuliform opening at the top of the closed peritoneal 
 canal is certain to persist. Another not uncommon cause of 
 recurrence is septic 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 truss 
 subsequently as a precautionary measure. Again, the mere 
 restoration of a mass of intestine or omentum into the abdominal 
 
HERNIA 
 
 989 
 
 cavity may suffice to raise the intra-abdominal pressure, and thus 
 predispose to a recurrence ; 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 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 should 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 increased space beneath Poupart's ligament, and especi- 
 ally 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. 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 f inch in length anteriorly, and 
 1 \ 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 
 opening, and closed by the cribriform fascia. Hence a femoral 
 hernia, as it passes downwards, receives the following coverings: 
 (a) peritoneum ; (b) subserous cel- 
 lular tissue, including the septum 
 crurale, a layer sometimes known 
 as the fascia propria, and occa- 
 sionally represented by a thick 
 fatty envelope ; (c) the anterior 
 layer of the femoral sheath, derived 
 from the fascia transversalis ; (d) 
 cribriform fascia ; (e) subcutaneous 
 tissue ; and (/) skin. In its passage 
 it is situated immediately internal 
 to the femoral vein, and pressure 
 upon this may produce cedema of 
 the leg, whilst Gimbernat's liga- 
 ment lies to the inner side of the 
 
 neck of the sac. The spermatic cord or round ligament passes 
 just above and internal to it, but on a superficial plane, whilst 
 the epigastric artery is not very far from the outer side of the 
 neck. Occasionally the obturator artery arises from this latter 
 vessel (once in three and a half subjects) ; it either passes to the 
 
 Fig. 358. — Femoral Hernia. 
 
99Q A MANUAL OF SURGERY 
 
 inner side of the neck of the sac along the border of Gimbernat's 
 ligament (once in seventy-five times), but more commonly runs 
 between the neck and the femoral vein. When once it has 
 emerged from the saphenous opening, a femoral hernia tends to 
 pass upwards and outwards along Poupart's ligament towards the 
 anterior superior iliac spine, being guided by the attachment of 
 the deep layer of the superficial fascia ; when of large size, it 
 may extend considerably above the level of Poupart's ligament. 
 Femoral herniae 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 
 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 felt (Fig. 358). There is usually but little difficulty 
 in making a diagnosis, although occasionally considerable care 
 is needed, and especially in distinguishing it from the following 
 conditions : (a) From inguinal hernia, which is more common 
 in young males, its neck occupying the inguinal canal, and the 
 saphenous opening being free ; whilst it is also above and internal 
 to the pubic spine, and above Poupart's ligament at its point of 
 exit ; it tends to pass downwards into the scrotum, or in females 
 into the labium. Femoral hernia, on the 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 condition very closely ; 
 but the absence of impulse on coughing and of the usual hernial 
 signs is generally sufficient to distinguish it ; when, however, the 
 hernia is purely omental and irreducible, the impulse is so slightly 
 marked that correct diagnosis in a stout woman is often difficult 
 without an exploratory incision, (c) A small lipoma in the canal 
 somewhat resembles a hernia, but the limitation of the tumour, 
 its greater mobility, and the absence of an impulse on coughing, 
 should suffice to prevent any 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 vavix of the saphena, if a pouch or so-called ampulla 
 forms close to its entrance into the femoral vein, it may be mis- 
 
HERNIA 
 
 991 
 
 taken for a femoral hernia on account of the marked impulse on 
 coughing, and because the swelling disappears on assuming the 
 recumbent posture. It is, however, usually associated with the 
 signs of varix below, and by the fact that, although pressure is 
 made over the upper part of the crural canal after the vein has 
 been emptied, the swelling regains its ordinary size when the 
 patient stands up. 
 
 Treatment. — When reducible and of small size, a femoral hernia 
 may be treated by the use of a truss, similar in nature to that 
 used for an inguinal hernia, except that the pad extends some- 
 what lower, so as to maintain pressure along the course of the 
 canal. A badly fitting truss may compress the femoral vein, and 
 lead to cedema of the leg. 
 
 Operative Treatment is undertaken either for the relief of 
 strangulation, or, if a radical cure is desired, as an operation de 
 complaisance. The remarks already made as regards the cure of 
 inguinal hernia, and the general principles there enunciated, apply 
 also to this variety. Two main methods of operating are em- 
 ployed : (a) The sac is exposed by a vertical incision along the 
 course of the crural canal, emptied of its contents by reduction of 
 intestine and removal or reduction of omentum, and cut away 
 after transfixing and tying the neck. The deep ring is then com- 
 manded by one or two sutures passed vertically between the fascia 
 over the pectineus and the inner end of Poupart's ligament ; this 
 must, however, not be tied too tightly, for fear of constricting the 
 femoral vein, (b) W'atson Cheyne recommends that a portion 
 of the pectineus muscle should be dissected up, and fixed in the 
 crural canal by means of sutures ; and he claims thereby to have 
 had very satisfactory results. The same precautions as to after- 
 treatment must be adopted as in inguinal hernia. 
 
 Umbilical Hernia. — Three different forms of umbilical hernia 
 are described. 
 
 1. Congenital Umbilical Hernia, or Exomphalos, is an exceed- 
 ingly rare condition, due to imperfect closure of the abdominal 
 walls, as a result of which the intestine is not entirely withdrawn 
 into the abdomen at birth, but is found in a cavity at the base of 
 the umbilical cord, which is bulbous and enlarged. If the con- 
 dition is overlooked, it may be included in the ligature with which 
 the cord is tied, and fatal strangulation, or at the best a faecal 
 fistula, will result. If left untreated until the cord has separated, 
 the peritoneal cavity will be laid open, and septic peritonitis 
 ensue. The only treatment is immediate laparotomy, reduction 
 of the gut, and closure of the umbilical opening by sutures. 
 
 2. The Umbilical Hernia of Infants and Young People, or, as it 
 is commonly called, ' starting of the navel,' is due to weakness of 
 the umbilical cicatrix, which yields before the intra-abdominal 
 pressure. Its occurrence is often determined by chronic consti- 
 pation or phimosis, necessitating continual straining in order to 
 
992 A MANUAL OF SURGERY 
 
 evacuate the bowels or bladder. The condition rarely persists 
 till adult life is reached, and it is readily amenable to treatment. 
 This consists in regulating the bowels, the performance of cir- 
 cumcision, if necessary, whilst the local condition is dealt with 
 by strapping the abdominal wall in such a way as to tuck the 
 umbilical cicatrix inwards ; no pad is required. In persistent 
 cases it may be necessary to lay the sac open and remove it, 
 suturing the parts together, as described in detail below. 
 
 3. The so-called Umbilical Hernia of Adults is usually due to a 
 protrusion of omentum or intestine through an opening in the 
 linea alba, either immediately above or below the umbilicus, the 
 former being the more common. It occurs most frequently in 
 women who have borne children, being sometimes due to actual 
 rupture of the linea alba and separation of the recti muscles. In 
 such cases it is possible that the peritoneum is also torn, and the 
 intestines extravasated, as it were, beneath the skin. A peritoneal 
 sac, is, however, usually seen, but in old-standing cases it is ex- 
 tremely attenuated, and so adherent to surrounding parts as to be 
 unrecognisable, whilst the contents may be matted together in 
 an almost inextricable confusion. In such cases 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 strangula- 
 tion. Moreover, the skin over the tumour becomes stretched, 
 atrophic, and not unfrequently ulcerated, so that perforation may 
 threaten. The hernia is often lobulated in character, and a con- 
 siderable deposit of fat may sometimes surround it. 
 
 Treatment. — When of large size, and occurring in stout indi- 
 viduals, it should be supported by a bag truss, whilst the patient 
 is placed on such dietetic and hygienic measures as shall assist 
 in the reduction of excessive corpulency. In favourable cases 
 operative treatment can be undertaken. A vertical incision is 
 made over the site of the tumour, and to effect this without 
 wounding the subjacent gut, it may be advisable to pinch up the 
 skin on either side, and cut it by transfixion. The sac is then 
 opened, the incision being enlarged, if necessary, so as to allow 
 the contents to be drawn aside and the opening in the abdominal 
 wall exposed. When the intestine has been reduced and omentum 
 removed, the sac is dissected up to the margins of the opening 
 into the abdomen, which is usually small in size and circular in 
 shape, whilst the edges are firm and thickened. The sac may now 
 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 thickness of the 
 abdominal wall on each side, and tightened after a row of inter- 
 rupted sutures has drawn the peritoneal surfaces into contact. 
 By this means the circular aperture is obliterated and the margins 
 united in the median line. The external wound may now be 
 closed, any redundant skin being cut away ; it is usually safer to 
 insert a drainage-tube in the more extensive cases. 
 
HERNIA 993 
 
 Most surgeons recommend that the fibrous margins of the deep 
 opening should be freely removed by dissection before the passage 
 of the sutures, so as to expose the fibres of the recti muscles, and 
 permit of their approximation after the peritoneum has been 
 turned in and stitched ; the suggestion is a good one, since the 
 union of healthy vascular tissue must always be more favourable 
 than that of two anaemic cicatricial edges. To accomplish this 
 satisfactorily, it is often necessary to prolong the incision up and 
 down for some distance, since the recti muscles are usually 
 displaced laterally and must be freely detached from their sheaths 
 if they are to be brought together in the middle line. Silkworm 
 gut may be used with advantage in these cases for the deep sutures, 
 since it remains unabsorbed. 
 
 A Ventral Hernia is the term used in describing any protrusion occurring at 
 some spot in the anterior abdominal wall other than those already mentioned. 
 Several forms may be met with : 
 
 1. It not uncommonly consists of a protrusion of subserous fatty tissue 
 through a congenital or acquired opening in the linea alba, lineae semilunares, 
 or lineas transversa?, especially at the junctions of the former and latter. They 
 are more common above than below the umbilicus, and if, as not unfrequently 
 happens, the fatty tissue proliferates, a localized tumour resembling a lipoma 
 is produced, and goes by the name of a ' fatty hernia of the linea alba.' A 
 portion of peritoneum is drawn through the opening into the centre of these 
 masses when they have persisted for some little time, and a true 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. 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 cicatrix, 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. The peritoneum need not always be opened in such a 
 procedure, but it is sometimes wiser to do so. Especially is this the case when 
 a ventral hernia forms after an operation for suppurative appendicitis ; the 
 appendix is rarely dealt with at the primary operation, and the surgeon may 
 rightly take the opportunity of removing it during the operation required for 
 the cure of the hernia. 
 
 3. Not unfrequently in women who have had children the linea alba 
 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 cause, owing to the inefficient 
 support given to the intestines. A firm abdominal belt may be useful as a 
 palliative measure, but operation is very desirable. The thinned linea alba 
 is split 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 
 
 63 
 
994 A MANUAL OF SURGERY 
 
 being secured by mattress sutures passing through it and the left linea semi- 
 lunaris, and being tied superficially. The left free edge is subsequently 
 secured to the right linea semilunaris by a row of stitches. 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 spinas, coming to the surface between 
 the latissimus dorsi and the external oblique, in the space known as Petit's 
 triangle. The ordinary signs of a hernia are present, and with a little care 
 the condition is readily distinguished from a lumbar abscess. Treatment may 
 be conducted along the same lines as for a ventral hernia. 
 
 A Diaphragmatic Hernia is rarely recognised ante-mortem. A few cases of 
 strangulation have, however, been diagnosed. It is usually congenital in 
 origin, arising from imperfect development of one or both halves of the 
 diaphragm ; it is most common on the left side. It may, however, result from 
 traumatic lesions, such as stabs, involving the diaphragm. The transverse 
 colon or stomach generally protrudes into the thorax, and there is usually no 
 peritoneal sac. Treatment is impracticable in the majority of instances, 
 although one or two cases of traumatic hernia have been successfully operated 
 on through the chest wall and pleural cavity, thus permitting the closure of 
 the hole in the diaphragm. 
 
 Obturator Hernia consists in a protrusion of intestine through the upper 
 part of the thyroid foramen, and has usually been observed in elderly females. 
 It is not often recognised in the living, except when strangulated, and even 
 then, unless of considerable size, it is likely to be overlooked. It has, how- 
 ever, been diagnosed by the fact that, in addition to the general signs of 
 strangulation, there was a sense of deep resistance and of fulness close to the 
 origin of the adductor muscles ; whilst pain was referred down the obturator 
 nerve to the inner side of the knee. Rectal or vaginal examination may throw 
 some light on the nature of the case. Treatment has generally been confined 
 to cases of strangulation, and in such an incision is made over the inner aspect 
 of Scarpa's triangle, and the pectineus divided or displaced. The sac when 
 found should be opened, and strangulation relieved by cutting upwards, the 
 obturator vessels being usually situated below the neck of the sac. 
 
 Other forms of hernia, e.g., pudic, pudendal, vaginal, sciatic, etc., have been 
 described, but are so uncommon that they need no special mention. 
 
 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 irreduci- 
 bility, whilst cysts may occasionally form, as already described. 
 
 The local signs of this condition are very evident, whilst dys- 
 pepsia, 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 icebag applied so as to contract the parts ; moreover, the 
 patient, if fat, should be carefully dieted. It is most important 
 
HERNIA 995 
 
 not to operate on large herniae of this nature until some such 
 preliminary treatment has been undertaken ; the sudden reduction 
 of a large amount of intestine into the abdominal cavity 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 herniae. 3. In healthy individuals, and if the rupture is not 
 too large, operation is preferable and much more satisfactory, 
 omentum being removed and adhesions divided, as already de- 
 scribed (p. 986). 4. In a few very aggravated cases, it is only 
 possible to support the hernia by an elastic bag. 
 
 Inflamed Hernia is one characterized by the existence of a 
 localized peritonitis involving the sac, and perhaps also the con- 
 tents. It usually arises from injury, such as ill-directed taxis, or 
 from injudicious truss pressure. The symptoms are those of a 
 local inflammation, the part becoming hot, painful, tender, and 
 swollen, and perhaps the skin over it red; this is associated with 
 general fever, malaise, nausea, and vomiting, whilst constipation 
 is usually present. A condition is thus induced somewhat re- 
 sembling strangulation ; 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, probably more on 
 account of the pain, which prevents taxis, than from any mechanical 
 reason, except in old-standing cases where previously formed 
 adhesions exist. Lymph is deposited on the serous surfaces, and 
 this usually leads to the formation of adhesions. Occasionally, 
 where omentum 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 re- 
 stricting his diet to fluids, whilst fomentations are applied to 
 the part. A little opium may also be administered to allay the 
 pain, and possibly the lower bowel emptied by an enema. 
 
 Obstructed Hernia is a condition in which the onward passage 
 of faeces through the gut contained in a hernial sac is prevented. 
 It is most frequently seen in the umbilical variety, and is of course 
 irreducible. It is due to an accumulation 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 fasculent, whilst constipation is usually present, although 
 the lower bowel may empty itself and flatus may pass. Locally, 
 the tumour becomes distended, but not tense as in strangulation, 
 and a doughy mass, which can be moulded and indented by the 
 
 63—2 
 
99 6 A MANUAL OF SURGERY 
 
 fingers, is felt within the sac. There is no tenderness, but the 
 patient usually complains of a good deal of intermittent colicky 
 pain. If unrelieved, a subacute form of inflammation may super- 
 vene, and this may pass on to strangulation, and even death. 
 
 Treatment consists in the use of copious enemata, and the 
 application 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 
 administered. 
 
 Strangulated Hernia. 
 
 A hernia is said to be strangulated when the contents are con- 
 stricted in such a way as to obstruct and ultimately arrest the 
 flow of blood in the vessels contained therein. Interference with 
 the passage of faeces is not an essential in this condition, since 
 omentum alone may be involved, or the intestine, if present, may 
 only have a portion of its lumen constricted, as in the form known 
 as Kichter's hernia, or in Littre's hernia, where a diverticulum is 
 similarly affected. 
 
 Two chief varieties of strangulation are described : those 
 occurring within the abdomen, which are dealt with more fully 
 in Chapter XXXIV., 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 strangulated 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 ex- 
 trusion of an additional amount of the abdominal contents into 
 the sac, as the result 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 conditions is usually 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, but occasionally it exists else- 
 where. 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 ligament 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 adhesion or through a slit or aperture in the omentum 
 contained in the sac. In those herniae which become strangulated 
 immediately after their protrusion, the constricting cause is in- 
 variably the resistance of the tissues surrounding the opening in 
 the abdominal parietes. 
 
 Pathological Phenomena. — The effects of strangulation vary 
 
HERNIA 997 
 
 somewhat with the tightness of the constriction. The circulation 
 is seldom entirely arrested at the onset of the symptoms ; but the 
 pressure affects first, and more especially, the veins, and later, 
 by the congestion and exudation thus produced, the flow in the 
 arteries is brought to a standstill. Hence the constricted tissues 
 are congested to begin with, and pass over into a state of gangrene 
 with or without an intermediate period of inflammation. 
 
 When a portion of intestine is strangulated, the following changes 
 manifest themselves in its structure and appearance. At first it 
 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 by the formation of gas within its lumen, 
 owing to the arrest of peristalsis and the putrefaction of its con- 
 tents. The surface at first remains smooth and shiny, but as the 
 exudation into the sac increases, the endothelium is usually shed. 
 Occasionally some of the superficial capillaries rupture, giving rise 
 to ecchymoses, whilst in rarer instances, and possibly as the result 
 of injudicious taxis, the congested vessels completely empty them- 
 selves into the sac, which is thus filled with clotted blood, the 
 intestine in consequence becoming lax and yellowish -grey in 
 colour. When the strangulation is relieved in this early stage, 
 the bowel soon regains its former healthy appearance. If inflam- 
 mation occurs, the surface becomes rough from the deposit of 
 lymph, and entirely loses its shiny and polished aspect. Gangrene 
 results partly from the prolonged stagnation of blood, and partly 
 from the action of the Bac. coli, which, as soon as the vitality of 
 the intestinal wall is sufficiently impaired, migrates through it, 
 and by its development produces 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. At the 
 point of strangulation the gut is completely anaemic and liable 
 to ulceration, which may subsequently result in perforation ; 
 adhesions may, however, form between it and the neck of the sac, 
 thus preventing contaminaiion 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. Faecal 
 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 in- 
 testine is usually involved, and solid faeces are absent. In more 
 chronic cases gangrene of the gut may be induced by the pressure 
 of the accumulated contents and the action of the Bac. 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 decree. 
 
998 A MANUAL OF SURGERY 
 
 Omentum, when strangled, is at first congested and of a dark 
 red or purplish 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 grey 
 or brown in colour, and is pultaceous 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 
 subsequently it becomes turbid and mixed with lymph ; finally, it 
 is dark brown or yellowish-green, with a marked and most objec- 
 tionable odour. Occasionally there is but little or no effusion of 
 fluid, a condition more often met with when intestine is absent 
 from the sac, and only omentum, or some solid viscus, such as 
 the ovary, is present. 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 contents, it also becomes inflamed, 
 and ultimately gangrenous owing to the action of the Bac. coli, 
 which by this time has penetrated to the turbid serum contained 
 within it. The skin and surrounding tissues become cedematous, 
 congested, and crepitant, and, finally, a natural cure may be deter- 
 mined by sloughing and the establishment of an artificial 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. It 
 has been shown by placing a ligature around the ear of a rabbit 
 that the amount of reaction, when the constriction is relieved, 
 varies directly with the tightness with which the ligature has been 
 applied, and with the period of constriction. When applied 
 loosely and only for a short time, the restoration of circulation is 
 followed merely by a transient hyperemia, but as the complete- 
 ness and duration of the obstruction are increased, the inflamma- 
 tion becomes more and more intense, and even gangrene may 
 ensue. Similar results follow the relief of strangulated hernia. 
 In the less severe cases the intestine merely becomes temporarily 
 congested, but in the more acute forms the paralysis of the gut 
 may persist, whilst inflammation, possibly running on to gangrene, 
 may be produced, either in the strangulated portion or in that 
 immediately above, and thus, although the operation has been 
 skilfully performed, the patient may succumb. 
 
 The Clinical History of a case of strangulation is usually 
 so characteristic that there can be but little uncertainty as to the 
 diagnosis. The general symptoms are similar to those described 
 at p. ioio, as occurring in all cases of acute intestinal obstruction. 
 The patient during some sudden effort notices a severe pain, 
 
HERNIA 999 
 
 localized at first to one of the hernial regions, or referred to the 
 umbilicus ; this is accompanied by the usual evidences of shock 
 — i.e., he feels faint, the pulse becomes slow and weak, the tem- 
 perature falls, and the surface is covered by a cold, clammy 
 sweat. This shock is often not very prolonged, and is associated 
 with or quickly followed by vomiting, at first gastric, then 
 bilious, and finally stercoraceous or faecal. As this continues, 
 the pain increases in severity, and radiates over the whole of the 
 abdomen, which becomes tense, tender, and tympanitic. Symptoms 
 of exhaustion supervene, caused partly by the pain and vomiting, 
 and partly by the inability to take food ; probably the absorption 
 of toxic material from the intestine also assists in its production. 
 Complete constipation is usually present but the patient may pass 
 flatus or fasces from the lower part of the intestine. The onset of 
 gangrene is generally accompanied by a sudden fall of temperature 
 and a cessation of pain, whilst the pulse becomes weak, rapid, 
 and intermittent, the surface is covered by a cold sweat, the 
 countenance becomes shrunken and drawn (the so-called ' facies 
 Hippocratica '), hiccough follows, and finally the patient dies, 
 usually as a result of toxaemia due to the absorption of products 
 developed either in the bowel wall or sac, or in consequence of 
 acute generalized peritonitis. Locally, the onset of the symp- 
 toms is associated with the formation of a tumour in one of the 
 usual sites of a hernia, or if already the subject of this condition, 
 the patient may notice that his rupture has suddenly become 
 larger. The swelling is irreducible, tense, extremely 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 within the 
 sac is reduced, pain and tenderness cease, whilst the skin over 
 the tumour becomes dusky, inflamed, and cedematous ; 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 artificial anus is produced either naturally or through the inter- 
 vention of the surgeon. Suppuration within the sac is uncommon. 
 
 Occasionally, however, cases are met with in which the above 
 described signs are considerably modified, and in one of our 
 cases 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 symptoms arising from strangulation of a portion of 
 the lumen of the intestine (Richters hernia) are sometimes less 
 marked than when a complete loop is constricted, but the later 
 phenomena are always very 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 always complete at first, flatus and faeces being sometimes 
 
A MANUAL OF SURGERY 
 
 passed ; but where more than half the circumference of the bowel 
 is engaged, 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. The prognosis in these 
 cases is always grave, partly from the difficulty experienced in 
 diagnosis, partly from the tightness of the constriction ; death 
 usually results from perforative peritonitis, which is occasionally 
 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 
 contrast with that of about 35 per cent., which is usually said to 
 be characteristic of strangulated hernia. Our mortality for all 
 cases of strangulated hernia, admitted to King's College Hospital 
 during the years 1892 to 1897, only amounted to 16*6 per cent. 
 
 The occurrence of 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 constipation, 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 
 time goes on, arrest of peristalsis may lead to true obstruction, or 
 even general peritonitis. As already mentioned, strangulated 
 omentum does not per se become offensive ; but occasionally a 
 neighbouring coil of intestine may be dragged upon, and its circu- 
 lation disturbed sufficiently to enable the Bac. coli to escape, and 
 then it may find its way into the sac, and develop therein its 
 characteristic odour without any serious lesion of the intestine or 
 peritoneum being conjoined. 
 
 The Treatment of a strangulated hernia consists in reducing the 
 contents by taxis, or by operation. 
 
 Taxis is the term employed for the manipulation by means of 
 which a hernia is reduced. In cases of strangulation, it must be 
 used with gentleness and great care, since the involved portion of 
 intestine is congested and easily torn. The patient is laid on a 
 couch with the head supported, and the thighs slightly flexed, so 
 as to relax the abdominal muscles. The fundus of the tumour is 
 then grasped with one hand, and steady pressure employed, 
 having for its object the emptying of the congested bloodvessels, 
 and consequently a diminution in the size of the hernia ; the 
 fingers of the other hand manipulate the neck of the sac, in 
 order that the part which has most recently been protruded may 
 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 ex- 
 tended beyond the saphenous opening, taxis is first employed 
 downwards and inwards in order to make the gut re-enter the 
 crural canal, and then finally backwards and upwards, the 
 
HERNIA 1001 
 
 margins of the saphenous opening being relaxed by flexing and 
 slightly inverting the thigh. In umbilical hernia, the pressure is 
 mainly directed backwards. 
 
 Whilst admitting the prima facie desirability of treating a 
 strangulated hernia by taxis (since the patient's general condition 
 is not such as to render any operation free from risk), it must not 
 be forgotten that injudicious taxis may do more harm than even 
 an unnecessary operation. The wall of the gut may be bruised 
 or even ruptured, haemorrhage into the sac may occur, and even 
 if successful one never knows the condition of the bowel that has 
 been reduced. The greatest caution is therefore needed in select- 
 ing cases to treat by this means. If the strangulation has lasted 
 for more than twenty-four hours, if the swelling is very tense and 
 tender, if faecal vomiting is present and the face becoming drawn 
 and pinched, a very perfunctory attempt at taxis should be made. 
 But if the swelling is free from tenderness and not very tense, if 
 the vomit consists merely of unpleasant-smelling bilious fluid, and 
 is not constant, and if the general condition is not really one of 
 gravity, it may be justifiable to prolong one's efforts at taxis for 
 ten or fifteen minutes, but even then the pressure must be con- 
 tinuous and steady, not intermittent and jerky. A final attempt 
 may always be made before operation when the patient is anaes- 
 thetized. 
 
 In some of the slighter conditions of strangulation, and especially 
 if the patient has had similar attacks before which have been 
 relieved without operation, reposition may be assisted by applying 
 fomentations for half an hour, followed by the use of an icebag, 
 reduction sometimes taking place spontaneously or being brought 
 about by taxis. The 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 bloodvessels 
 and muscles. 
 
 Persistence of Symptoms after apparently Successful Taxis. — It 
 occasionally happens that although the surgeon may have appar- 
 ently reduced the hernia satisfactorily, the symptoms of strangula- 
 tion, 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.) The 
 vomiting may possibly be due to the anaesthetic, but then does 
 not usually last for any length of time, and soon loses its faecal 
 character, (ii.) The gut remains paralyzed from the effect of the 
 constriction ; inflammation may then supervene, involving either 
 the released coil of gut or the portions above or below it, and 
 perhaps running on to ulceration, perforation, and death from 
 peritonitis or toxaemia, (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 
 
A MANUAL OF SURGERY 
 
 the omentum contained in the sac. Reduction in such a case 
 would not relieve the symptoms, the whole mass being returned 
 into the abdomen, (v.) 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, (vi.) Reduction en bloc or en masse may 
 occur, but only when considerable force is employed ; in this 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 subserous 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 persistence 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 occurs, 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 
 symptoms of strangulation are still present, a most careful 
 investigation is needed in order to ascertain, if possible, the cause. 
 Thus, the character and frequency of the vomiting must be con- 
 sidered, since, when due to anaesthetics, it usually 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 thoroughly 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 supposed site of strangu- 
 lation, and an exhaustive search made for the sac. If no help is 
 thus obtained, the abdomen must be opened, and an internal 
 strangulation 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 lapar- 
 otomy wound 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 
 
HERNIA 1003 
 
 that the bowel is constricted, and taxis has failed. 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 permit of efficient purification of the 
 parts, whilst it may be desirable to empty the lower bowel by an 
 enema, and if there is much vomiting to wash out the stomach. 
 The administration of an anaesthetic needs care, and in the worst 
 cases local anaesthesia must be depended on (see p. 1015). A 
 suitable incision is then made down to the sac, which should be 
 recognised by its tense and rounded outline. It is isolated as far 
 as possible from surrounding structures, and then carefully opened. 
 There is usually no risk of injuring the bowel, on account of the 
 fluid poured out into the sac ; but if no effusion is present, or if 
 the gut is adherent to the anterior wall, it is more likely to be 
 injured. 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 f inch from the blunt end. If such is not to hand, 
 an ordinary curved bistoury will suffice. The index-finger is 
 employed to repress and guard the intestine, and acts better than 
 a director, since intestine is likely to curl up on either side of the 
 instrument, 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 slightly nick it in two or three places than to incise it 
 by one deep cut, as is often recommended. 
 
 The gut is drawn down into the wound, and its condition at the 
 site of strangulation carefully examined. The omentum, if small 
 in amount and recently prolapsed, may be reduced, but it is better 
 practice to remove any congested portion, or that which has 
 evidently been in the sac for some time. The method of its 
 removal has been already described (p. 986). 
 
 According to the condition of the intestine, the further steps of 
 the operation are modified as follows : 
 
 1. If the gut, though congested, shows no sign of gangrene or 
 perforation, 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 firm. 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. 
 
 2. If the gut has been tightly strangled and gangrene is threaten- 
 ing, it may be 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. 932. If, how- 
 ever, the bowel is in a doubtful condition, but recovery thought 
 
io<h A MANUAL OF SURGERY 
 
 possible, it is gently replaced 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 subsequently 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 treatment is always a matter of difficulty, and one concerning 
 which very different views are held. Two chief methods have 
 been suggested : 
 
 (a) The gangrenous loop of bowel is opened, or the perforation, 
 if such is present, is enlarged sufficiently to allow of the entrance 
 of the finger into the lumen of the gut. A free flow of faeces 
 should result from this proceeding, but if the constriction at 
 the site of strangulation is considerable, a pair of dressing forceps 
 should be passed up the bowel, and the narrowed portion dilated, 
 if possible. Failing this, the adhesions which have formed at the 
 neck of the sac must be gently broken through, and the constric- 
 tion divided ; but if this can be avoided, so much the better, since 
 by such means the general peritoneal cavity is exposed to the 
 risk of septic infection. Hence it may be wiser to divide the 
 constriction from the outside without freeing the adhesions. An 
 artificial anus is thus formed through which for a time the patient 
 can discharge the intestinal contents, and unless this desideratum 
 is at once attained, failure is very likely to follow the operation. 
 The wound is left open and a suitable dressing applied, into which 
 the faeces can be received ; possibly the best application is a layer 
 of protective with a sufficient hole in the centre to allow the faeces 
 to pass, and then over it a thick layer of tenax. 
 
 (b) More recently primary enterectomy with immediate suture 
 of the divided ends has been extensively practised, and with con- 
 siderable success. 
 
 The selection of one of these two plans in any particular in- 
 stance depends mainly upon the age and condition of the patient. 
 If he is in a state of profound collapse or exhaustion, the former 
 method should be adopted, the artificial anus being subsequently 
 dealt with, if possible within a week or ten days. In the majority 
 of cases, however, one is fully justified in at once undertaking 
 an enterectomy, the advantages of which are obvious. The 
 intestinal canal is at once restored to functional utility, so that 
 the fluid and offensive faecal material can pass onwards ; the 
 absorption of toxins from the stinking gangrenous gut wall is 
 stopped, and the patient is freed from the risk and incon- 
 veniences caused by the passage of faeces through an open 
 wound. The relative value of the two methods cannot be fairly 
 
HERNIA 1005 
 
 measured by the death-rate, 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 present 
 methods of intestinal suture, a large measure of success may be 
 expected from the adoption of primary resection in the majority 
 of cases. 
 
 Having dealt with the strangulation, it is always advisable to 
 perform a radical cure in uncomplicated cases, so as to prevent 
 any recurrence of the hernia. This is undertaken according to 
 the methods already described, and the external wound subse- 
 quently closed and drained. 
 
 The 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 allowed 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 ad- 
 ministered, as it tends to maintain the paralyzed condition of 
 the bowel ; severe pain may, however, call for the hypodermic 
 injection of a small dose of morphia. Liquid food can usually 
 be taken at the end of twenty-four hours, and, if the patient's 
 condition remains satisfactory, it is unnecessary to administer any 
 purgative, the bowels often acting naturally ; if they remain un- 
 relieved for five or six days, a dose of castor-oil should be given. 
 
 Various Complications may arise after the operation, needing 
 special notice. (1) Vomiting may persist for a time as a result of 
 the anaesthetic. It loses, however, its faeculent character, and 
 may generally be stopped by washing out the stomach or by the 
 hypodermic injection of morphia. (2) The Paralytic condition of 
 the gut may remain for some considerable time, causing prolonged 
 constipation. If there is no evidence of inflammatory mischief, 
 it is best treated by the administration of a purgative or by a 
 turpentine enema. (3) Acute Enteritis may arise either in the 
 portion of strangulated gut or just above. This is usually indicated 
 by localized pain, and perhaps the passage of mucus, which may 
 be so abundant as to amount to diarrhoea ; the vomiting, more- 
 over, persists, but is no longer stercoraceous. If ulceration or 
 perforation ensues, peritonitis will follow, but whether this occurs 
 or not the case is very likely to terminate fatally from exhaustion. 
 It is best treated by the administration of bismuth combined with 
 morphia, whilst all solid food is interdicted, and stimulants may 
 be freely given. (4) The occurrence of Peritonitis, or of a certain 
 amount of peritoneal activity, is inevitable after all cases of 
 strangulated hernia. In most instances it is productive of no 
 harmful results ; but where the vitality of the gut wall has been 
 so lowered as to allow of the passage of the Bac. coli, or where 
 its integrity has been interfered with by laceration or perforation, 
 an acute form of inflammation is set up which is seldom localized, 
 and rapidly becomes general. Lastly, septic infection of the peri- 
 
ioo6 A MANUAL OF SURGERY 
 
 toneum may be derived from the external wound, or as a result of 
 local contamination by dirty instruments or fingers. Treatment. — 
 As soon as peritonitis threatens, the administration of a smart 
 saline purge is often beneficial, acting by unloading the intestines 
 and encouraging peristalsis. Subsequently opium in carefully 
 regulated doses may be ordered, whilst nutrition is maintained by 
 enemata, or by small quantities of fluid given by the mouth. Dis- 
 tension of the intestine should be prevented, if possible, by passing 
 a long tube, or by giving a turpentine enema ; puncturing the 
 distended coils of intestine has been adopted, but is extremely 
 dangerous. The condition is necessarily one of the greatest 
 gravity, and as a last resource laparotomy may be performed, 
 and the peritoneal cavity washed out. 
 
 Localized Peritonitis may be looked on as a conservative measure, 
 whereby Nature isolates some focus of danger from the general 
 peritoneal cavity. Occasionally localized suppuration follows as 
 the result of a limited ulceration or perforation of the gut ; the 
 pus must then be let out at the earliest possible moment, but a 
 faecal fistula is very likely to follow. 
 
 It is impossible to describe in detail every form of strangulated 
 hernia. A few facts, however, must be stated about the more 
 important varieties. In Strangulated Inguinal Hernia the constric- 
 tion most commonly occurs at the neck of the sac, usually close to 
 the external abdominal ring, as a result of the condensation of the 
 surrounding tissues. The signs are usually very characteristic, 
 and the condition can rarely be mistaken. Some difficulty may 
 be experienced in distinguishing it from inflammation of an unde- 
 scended testis; in this, however, there is no persistent vomiting 
 or constipation, whilst the absence of the testis below, and the 
 existence of the peculiar testicular sensation, when the swelling 
 in the canal is compressed, should clear up the case. Occasion- 
 ally the two conditions co-exist, and then a correct diagnosis, 
 apart from an open exploration, may be almost impossible. 
 Torsion of the testis, and subsequent 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 
 always performed in a vertical direction, the surgeon cutting 
 directly upwards, the reason being that it is impossible in old- 
 standing cases to be certain whether the hernia is oblique or 
 direct, and thus the liability to injury of the epigastric artery is 
 diminished. 
 
 In Strangulated Femoral Hernia it is more common to find bowel 
 than omentum, and it is in this situation that partial herniae 
 (Richter's) are most frequently met with. A tense painful swelling 
 is felt, situated in the neighbourhood of the saphenous opening, 
 
HERNIA 1007 
 
 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 history of the case, and a 
 careful consideration of the physical signs and symptoms, should 
 generally be sufficient to clear up the diagnosis. The constriction 
 is usually met with opposite Gimbernat's ligament, and to divide 
 it the surgeon must cut directly inwards, so as to incise that 
 structure. The plan already mentioned of nicking it in two or 
 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 every 
 150 cases. The accident would be recognised by the occurrence 
 of free haemorrhage after the use of the hernia knife. In such a 
 case, the rupture is first reduced, the wound enlarged upwards, 
 and both ends of the divided vessel secured, if possible ; failing 
 this, carefully adjusted pressure may be employed. Where the 
 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. 
 
 In cases of gangrene where enterectomy is feasible, 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 mesen- 
 tery renders it impossible to perform the necessary manipulations 
 through the wound in the groin. 
 
 Artificial Anus is the only means whereby Nature relieves the obstruction 
 due to strangulated hernia. One applies the term to a condition in which 
 an opening into the gut has been produced in such a way that the greater 
 portion of the faeces finds an exit through it. It 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 by his 
 incising it when gangrenous ; or it may slough subsequently, if left in situ 
 when gangrene is threatening. If no operation is undertaken, the surround- 
 ing parts settle down after a time and heal over, the diversion of the fasces 
 from their natural course becoming more and more complete, owing to the for- 
 mation of what is known as a spur of mucous membrane, which lies across and 
 blocks the entrance to the lower portion of the bowel (Fig. 345). 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 individual 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 neighbourhood is 
 usually produced, resulting from the irritation of the fasces. 
 
 The curative Treatment of an artificial anus, where desirable, consists in 
 the re-establishment of the lumen of the gut, and the closure of the external 
 wound. To effect this, two chief methods have been recommended : (1) The 
 old-fashioned plan necessitates the repression or removal of the spur as the 
 
ioo8 
 
 A MANUAL OF SURGERY 
 
 first stage in the proceeding, whilst the closure of the external wound is 
 effected subsequently. Dupuytren recommended that the spur should be 
 destroyed by dragging it outwards and grasping it by an enterotome (Fig. 359), 
 which consists of two blades fitting into one another, which are maintained in 
 apposition by a screw. The portion thus grasped sloughs slowly away, the 
 peritoneal cavity being protected by a plastic inflammation. After destruction 
 of the spur, the external wound may be closed by turning in flaps of skin. 
 Such treatment of an artificial anus is tedious and uncertain ; whilst even if 
 successful, the patient probably suffers from recurrent colic, owing to the 
 adhesion of the intestine to the abdominal wall, a condition which may also 
 expose him later on to the risk of intestinal obstruction. (2) A much better 
 method of treatment is that by means of an open operation. In this a semi- 
 lunar incision is made on either side of the artificial anus, by deepening which 
 the peritoneal cavity is freely opened, and the artificial anus, together with 
 the surrounding tissues, can be lifted up, exposing the coil of adherent intestine. 
 This is now clamped above and below, divided as near to the opening as 
 possible, a V-shaped portion of mesentery removed, and the continuity of the 
 
 359. — Dupuytren's Enterotome. 
 Brothers.) 
 
 (Down 
 
 intestinal canal restored by some form of enterorrhaphy. It is then returned 
 to the abdomen, and the external wound closed by sutures. In the inguinal 
 and femoral regions it is sometimes impracticable to undertake such an opera- 
 tion, owing to the important nature of the surrounding structures, and then 
 Dupuytren's method may be followed, or a lateral anastomosis established 
 through a separate incision into the abdomen between the portions of intestine 
 going to and returning from the opening ; the external aperture is subse- 
 quently closed by a plastic operation. 
 
 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 cavity, and to 
 allow the extravasated contents of the bowel to find their way outwards 
 through a sinuous tract to the external wound. It may be some days before 
 any evidence 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. 
 
CHAPTER XXXIV. 
 
 INTESTINAL OBSTRUCTION.* 
 
 15y Intestinal Obstruction is meant a condition in which the 
 onward passage of the faeces is prevented. In acute cases it is 
 often associated with strangulation, owing to the circulation 
 through the vessels being impeded and finally arrested. 
 
 Many different types of classification of this condition have been 
 suggested, and many of them are more or less valuable. They 
 may be described as congenital or acquired — under the former 
 term grouping together congenital stenosis, congenital adhesions, 
 etc., and under the latter all the ordinary conditions ; or they may 
 be divided into classes according to whether the obstruction is 
 due to causes within the gut, to changes in the structure or relative 
 position of the intestinal wall, or to pressure from without. The 
 most useful division is the clinical, grouping together those cases 
 which present a similarity in the symptoms ; and this method 
 will be employed here, the subject being discussed under the 
 three headings — acute obstruction, chronic obstruction, and in- 
 tussusception. 
 
 Acute Intestinal Obstruction. 
 
 The following are the chief Causes which give rise to this 
 condition : 
 
 i. Strangulation by bands or adhesions, or through aper- 
 tures, etc. 
 
 2. Volvulus. 
 
 3- The impaction of foreign bodies. 
 
 4. Strangulation over a band or acute kinking of the gut, both 
 \ ery rare conditions. 
 
 5. Acute intussusception. 
 
 6. It may be the termination of a chronic obstruction. 
 
 * 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 
 appeared, and which we'have freely utilized. 
 
 64 
 
A MANUAL OF SURGERY 
 
 Paralysis of the gat, such as that induced by acute peritonitis, 
 localized or diffuse, by acute enteritis following the reduction of 
 a strangulated hernia, by a Littre's hernia, etc., gives rise to 
 phenomena of pseudo-obstruction, but the cause then is not so much 
 mechanical as nervous in origin. It will be mentioned again 
 at p. 1013. 
 
 The General Symptoms of acute obstruction are practically 
 identical with those of a strangulated hernia. The patient is 
 suddenly seized with severe abdominal pain somewhat of the 
 nature of colic, and referred to the umbilicus, coming on perhaps 
 during some special effort, e.g., lifting a heavy weight. At the 
 same time he suffers from shock, as evidenced by a weak pulse, 
 pale face, and cold, clammy sweat, the 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 exacerba- 
 tion 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 faecal character. 
 Signs of constitutional depression and exhaustion follow in a short 
 time, the pulse being weak, rapid, and thready, the temperature 
 remaining subnormal (except occasionally after the supervention 
 of peritonitis, when it may rise a few degrees), the face looking 
 pulled and drawn (facies Hippocratica), and the abdomen being 
 distended and painful. Finally the patient, if unrelieved by treat- 
 ment, dies, and usually within seven to ten days from the onset, 
 owing to exhaustion or perforative peritonitis. Constipation may 
 be absolute from the first, but at any time the lower bowel may 
 empty itself, and raise false hopes as to the prognosis. 
 
 The explanation and variation of these symptoms in different 
 cases is given later on. 
 
 The Special Forms of Acute Obstruction must now be considered 
 seriatim. 
 
 1. Strangulation by Bands or Adhesions, through Apertures, etc. 
 Causes. — (a) Isolated peritoneal bands and adhesions are 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 cordlike ; 
 sometimes they are broad and membranous, constituting a false 
 ligament ; 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 disease 
 of that viscus (usually a pelvic organ, the caecum, or the appendix), 
 or inflammation of a mesenteric gland with localized peritonitis 
 Two methods of producing strangulation exist ; either the bowel 
 passes under the arch or loop formed by a short constricting band, 
 and cannot return ; or, if the band is long, it may form a loop or 
 noose through which the bowel passes, and so becomes strangled 
 (Fig. 360). (b) Cords formed by the omentum result from union 
 
INTESTINA L OBSTR UCTION 
 
 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 pulling 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. 921) 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 may remain fixed 
 to the umbilicus, or floats free in the abdominal cavity, and sub- 
 sequently becomes adherent to some other structure, thus pro- 
 ducing a fibrous cord. Strangulation may be effected by bowel 
 passing under the loop, formed by the 
 adherent diverticulum. (d) The vermiform 
 appendix, appendices epiploica:, or Fallopian tubes 
 may contract abnormal attachments, and 
 thus form arches or loops under which bowel 
 may pass and become strangled, (e) Slits, 
 pouches, and apertures in the peritoneal invest- 
 ment, whether normal or abnormal, may lead 
 to strangulation. All external herniae may 
 be grouped under this heading, as also those 
 rare 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 
 (Tillmanns.) omentum, or the so-called fossa duodeno- 
 
 jejunalis. Slits may also be found in the 
 omentum or mesentery, either congenital, traumatic, or the result 
 of operations. 
 
 Phenomena. — This form of obstruction usually occurs in young 
 people, and is rare after forty ; it constitutes above one-fourth of 
 all the forms of internal obstruction, and the lower 2 feet of 
 the ileum are most frequently involved. There is commonly a 
 previous history of peritonitis, but 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 peristalsis or dilated coils 
 of intestine are to be seen. The average duration is about five 
 to seven days, the patients dying of exhaustion or toxaemia follow- 
 ing peritonitis. 
 
 2. Volvulus is the most common cause of acute primary 
 obstruction of the large intestine. By it is meant a rotation 
 of the gut upon its own mesenteric axis in such a way as to 
 
A MANUAL OF SURGERY 
 
 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 with another. The sigmoid flexure 
 is the part mainly affected, although it occurs in the caecum or 
 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 
 arc 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 
 fasces also aggravates the condition. 
 
 Symptoms. — Volvulus is rare before the age of forty, and 
 apparently occurs more often in the male sex. A history of 
 chronic constipation precedes it, but the acute symptoms start 
 abruptly. Pain is always present, at first intermittent, but finally 
 constant, and there is usually early tenderness over the sigmoid 
 flexure. The pain, vomiting and collapse are not so severe or 
 marked as in other forms of strangulation, but abdominal dis- 
 tension from excessive flatus, and resulting dyspnoea and thoracic 
 embarrassment, are very distressing. Tenesmus is occasionally 
 present. A localized peritonitis is usually developed, but it some- 
 times becomes diffuse. Natural cure is unknown, the patient 
 either dying in five or six days from collapse and interference with 
 respiration, or at a somewhat later date from peritonitis. 
 
 3. Impacted Foreign Bodies, causing intestinal obstruction, may 
 be of three types : gallstones, foreign bodies that have been 
 swallowed, or intestinal concretions (enteroliths). 
 
 Gallstones can only cause obstruction when of large size, and 
 such usually gain entrance to the intestine by ulceration from the 
 gall-bladder into the duodenum. A coating of faecal material is 
 likely to form around them, and thus they increase in size as they 
 pass downwards, whilst the intestine gradually diminishes in 
 calibre from the duodenum to the ileum ; the usual site of im- 
 paction is in the lower ileum. Women over fifty are most often 
 the subjects of this condition, and there may be only a history of 
 some inflammatory condition in the region of the gall-bladder, 
 and none of biliary colic. Such patients frequently suffer from 
 intermittent subacute attacks of incomplete obstruction, which, 
 though severe for a time, are relieved by purgatives. If the gall- 
 
INTESTINAL OBSTRUCTION 
 
 stone is not passed, a final acute attack supervenes, which begins 
 suddenly with the typical signs of acute obstruction, although the 
 pain and collapse are not so marked as in cases of strangulation, 
 death resulting from peritonitis or exhaustion. 
 
 "When the obstruction is due to foreign bodies which have been 
 swallowed, the symptoms are usually subacute to start with, but 
 may lead to perforation if of irregular shape. 
 
 Enteroliths are of three classes : (a) Calculi of phosphate of 
 lime or inspissated fa'ces form around some foreign body as a 
 nucleus, (b) Masses of indigestible vegetable material may be 
 matted together with inspissated faeces, mucus, etc. ; they are said 
 to be not uncommon in Scotland (the so-called avenolith), being 
 mixed up with the husks of the coarse oatmeal there eaten. They 
 have also been known to consist of hair, or of cocoanut fibre in a 
 patient engaged in mat-making. (c) Calculi have been found 
 consisting of insoluble mineral salts, e.g., carbonate of magnesia 
 or chalk, taken as medicine. Whatever their origin, such entero- 
 liths are usually impacted near the caecum, and if causing acute 
 obstruction the symptoms are similar to those produced by a 
 large gallstone, being preceded by chronic attacks and severe 
 colicky pain. In thin persons their presence may be detected 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. 1018. 
 
 6. When acute symptoms are developed at the termination of 
 a case of chronic obstruction, the pain from being intermittent 
 becomes constant, the vomiting more violent and faecal in char- 
 acter, and the fatal termination is due to acute peritonitis or to 
 exhaustion and toxaemia. Absolute constipation is always present, 
 and the abdomen is much distended. 
 
 The Diagnosis of acute obstruction is not per se a matter of 
 much difficulty, since the phenomena are extremely characteristic ; 
 but it is usually impossible to make certain of the cause of the 
 obstruction apart from an exploratory laparotomy. 
 
 Some care is also needed in distinguishing true obstruction from 
 the obstructive symptoms associated with acute localized enteritis 
 or peritonitis, such as is seen in appendicitis, when the intestinal 
 walls are paralyzed. This pseudo-obstruction is sometimes very 
 marked, and even faecal vomiting may occur, but by a careful 
 attention to the history and general condition of the patient a 
 correct diagnosis should be reached. We append a table illus- 
 trating the chief diagnostic points between acute strangulation 
 
ioi4 
 
 A MANUAL OF SURGERY 
 
 and acute appendicitis associated with peritonitis, one of the 
 commonest causes of pseudo-obstruction : 
 
 
 Acute Internal 
 
 Acute Appendicitis with 
 
 
 Strangulation. 
 
 Peritonitis. 
 
 Onset - 
 Rigor - 
 Temperature 
 
 Abrupt. 
 Absent. 
 Subnormal at first, rising at 
 
 Maybe preceded by local pain. 
 
 Often present. 
 
 High at first, falling later from 
 
 
 onset of peritonitis. 
 
 exhaustion or toxaemia. 
 
 Pain - 
 
 Severe ; referred to the um- 
 
 Severe ; primarily referred to 
 
 
 bilicus. 
 
 the right iliac fossa. 
 
 Tenderness - 
 
 Absent till peritonitis comes 
 
 Present over caecum even in 
 
 Vomiting 
 
 on. 
 Early, marked, and soon 
 
 early stages, and gradually 
 spreading. 
 Less urgent, and seldom faecal, 
 
 
 faecal. 
 
 except as a late symptom. 
 
 Abdominal 
 
 Flaccid till peritonitis is 
 
 Tense and rigid from the first. 
 
 parietes - 
 
 present. 
 
 
 The Treatment of acute obstruction is practically included in 
 one word — Laparotomy. The condition of the gut is in most 
 cases identical with that found in a strangulated hernia, and 
 although a few patients may recover by palliative measures, e.g., 
 enemata, opium, ice, etc., yet the majority would be gravely 
 injured in the delay caused by their employment. The danger 
 of laparotomy increases directly with delay ; hence, the sooner 
 it is undertaken, the better for the patient. Whilst prepara- 
 tions for the operation are being made, an enema may be 
 administered to clear the lower bowel, ice being given to 
 suck, and a small dose of opium to relieve urgent pain. Two 
 main objects must always be kept in mind in the operative 
 treatment of such cases, viz., (a) to empty the distended bowel, 
 and (b) to remove the cause of the obstruction. The second of 
 these requisites is always most desirable, but unless at the same 
 time the putrid contents of the upper portion of the intestine are 
 removed, but little real good has been accomplished, since the 
 patient is being slowly poisoned by septic absorption. The late 
 Mr. Greig Smith has declared most emphatically that ' no opera- 
 tion for intestinal obstruction is complete if the patient leaves the 
 operating table with a greatly distended abdomen.' Moreover, it 
 must be remembered that the formation of an artificial anus is 
 often insufficient to give relief, owing to the paralyzed and dis- 
 tended condition of the intestinal wall above. Hence, in many 
 cases, it is desirable to deal with the engorged bowel first, 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 
 
INTESTINAL OBSTRUCTION icis 
 
 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 
 attempted, the patient's life is often lost from stoppage of the 
 respiration, precipitated possibly by a severe attack of faecal 
 vomiting. A few drops of cocaine may be placed under the skin, 
 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 sponges, 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 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 
 preliminary measure before administering the anaesthetic. The 
 head should not be placed on a lower level than the stomach, for 
 fear of fluid regurgitating along the oesophagus 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. 
 The hand is first passed to the hernial regions, and then to 
 the right iliac fossa, so that the caecum may be examined. If 
 this is distended, the cause necessarily lies below it ; if collapsed, 
 above it. In the former case, the condition of the sigmoid 
 flexure should next be investigated, and finally, if this viscus 
 is collapsed, the hand should be run along the colon, special 
 attention being directed to the splenic flexure. If the caecum 
 is collapsed, perhaps the best method to adopt is to gently with- 
 draw from the abdomen successive portions of gut, about a foot 
 at a time. These are carefully examined, and replaced by the 
 assistant whilst the next portion is being withdrawn. The 
 remainder of the intestines during this process are protected and 
 kept back by the application of towels which have been sterilized 
 in hot salt solution. The obstruction is in this way sooner or 
 later discovered, and may be dealt with according to circum- 
 stances. If the intestines are too distended to allow of such 
 manipulation, it may be advisable to open or tap one or more 
 of the dilated coils, and thus reduce the distension before pro- 
 ceeding with any methodical search for the obstruction. 
 
 Omental bands or peritoneal adhesions should be divided 
 between ligatures. The vermiform appendix or Meckel's diverti- 
 
ioi6 A MANUAL OF SURGERY 
 
 culum may be excised according to the method described at 
 p. 951. 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 antimesenteric 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 entetectomy. 
 
 Chronic Intestinal Obstruction. 
 
 The Causes of chronic obstruction are very numerous, and, 
 looked at from an anatomical standpoint, may be divided into the 
 following groups : 
 
 1. Intra-intestinal conditions, e.g., impaction of faeces, foreign 
 bodies, etc. 
 
 2. Affections of the intestinal wall, such as stricture, new 
 growths, adhesions or matting together of coils of intestine, con- 
 traction or kinking of the gut from mesenteric gland disease, etc. 
 
 3. Compression of the bowel by tumour, cicatricial bands, 
 etc., developing outside the intestine. 
 
 The General Symptoms of chronic obstruction are more or less 
 as follows : The patient suffers from gradually increasing con- 
 stipation, alternating occasionally with watery diarrhoea, spurious 
 in nature, and set up partly by a catarrhal enteritis due to the 
 irritation of retained faeces, 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 a mass of 
 undigested food or faeces becoming impacted, assisted perhaps by 
 a valve-like fold of mucous membrane across the passage. These 
 attacks usually pass off after a time, a copious evacuation of 
 the bowels taking place either naturally or as the result of the 
 administration of a purgative. Finally, one of these seizures 
 persists and destroys the patient, either by exhaustion, or perfora- 
 tion followed by peritonitis, unless suitable treatment is promptly 
 adopted. The vomiting is never such a marked feature as in 
 acute obstruction, until the final stage, when it becomes faecal. 
 The abdomen is always more or less distended and tympanic, 
 and its contour varies with the site of the obstruction ; if this is 
 situated above the ileo-caecal 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 intestine can be plainly 
 seen through the abdominal walls in thin subjects, as also evident 
 peristalsis. When arising from simple stricture, no tumour is 
 to be felt ; but if due to malignant disease, and if the abdomen is 
 not very distended, the growth may possibly be detected. 
 
INTESTINAL OBSTRUCTION 1017 
 
 Faecal Impaction occurs in adult females who have previously 
 suffered from chronic constipation. The caecum and sigmoid 
 flexure are the most common seats of obstruction, and 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 acute symptoms are always preceded by 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 symptoms arising from the other conditions which 
 give rise to chronic obstruction, such as stenosis of the bowel, 
 have been already referred to (p. 926). 
 
 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 
 hereafter, must be undertaken, and by this means some con- 
 clusion may be arrived at as to the nature and seat of the 
 obstruction. 
 
 The Treatment of chronic obstruction is always a matter of 
 difficulty and anxiety, owing to the uncertainty often felt as to the 
 diagnosis. It ought to be possible, however, to decide whether 
 the block is located in the large or small intestine, since the 
 character of the abdominal distension and the symptoms are 
 tolerably distinctive in the two forms. 
 
 If the case is not of the most urgent type, the patient is put to 
 bed, the diet restricted to fluids, and belladonna, combined with 
 small doses of calomel, administered. At the same time copious 
 enemata should be given two or three times daily, and preferably 
 in the genu - pectoral position, but purgatives are studiously 
 avoided, as also opium ; probably the patient has taken plenty of 
 the former before coming under observation, whilst the latter, 
 although it may check vomiting and relieve pain, is certain to 
 mask symptoms, and thus prevent the true course of the 
 disease from being watched. Should the symptoms be urgent 
 from the commencement, or the treatment 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 cases. If the cause of the 
 trouble is easily found, a coil situated just above is withdrawn 
 from the abdomen, opened, and a Paul's tube subsequently tied 
 in so as to allow retained faecal material to escape. It is wiser 
 not to deal with the local trouble (unless strangulation is present) 
 until the urgent symptoms have disappeared. If, however, the 
 patient's condition is serious and the site of obstruction cannot 
 readily be found, any distended coil may be withdrawn and 
 opened. The practice of allowing numerous coils of intestine to 
 
,oi8 A MANUAL OF SURGERY 
 
 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, 
 colotomy is usually required. The lumbar operation may possibly 
 be undertaken ; but the majority of surgeons at the present time 
 prefer the iliac proceeding, although the peritoneum has to be 
 opened, and the risk of faecal contamination is thus increased. If 
 the rectum or sigmoid flexure is clearly the seat of the trouble, 
 the usual incision on the left side can be made ; but if there is no 
 indication as to the part of the colon involved, a median lapar- 
 otomy is perhaps preferable, a distended portion of the gut being 
 withdrawn and tapped, and a Paul's tube tied in. 
 
 In chronic peritonitis, where the intestines are hopelessly matted 
 together, but little can be done beyond the administration of 
 enemata, and possibly abdominal massage. The history of the 
 case will generally suffice to suggest its nature, and operative 
 treatment should then be avoided. 
 
 Faecal impaction requires the regular and repeated administra- 
 tion of large enemata, given through a long tube, whilst belladonna 
 and calomel may also be administered. Should hard scybala be 
 lodged in the rectum, it may be necessary to break them up in 
 situ, and remove them piecemeal. 
 
 Intussusception. 
 
 By Intussusception is meant the protrusion or invagination of 
 one part of the intestine into another, giving rise to the condition 
 illustrated in Fig. 361. The constituent parts are seen more 
 diagrammatically in Fig. 362. The upper portion is always pro- 
 lapsed into the lower, except occasionally during the irregular 
 peristalsis which takes place during the death-throes. The 
 invaginated portion (a) is known as the intussusceptum, whilst the 
 lower portion (b) into which it is protruded is known as the intus- 
 suscipiens. An intussusception, then, consists of three layers — the 
 outer or ensheathing layer (i.), an inner or entering layer (hi.), and 
 between the two the returning layer (ii.). Not only does the 
 intestine enter, but with it a certain portion of the mesentery ; 
 and it is to the constriction of the vessels contained therein, and 
 later on possibly to their complete obstruction, that the more 
 serious phenomena are due, e.g., gangrene, perforation, or rupture 
 of the gut. In addition to this, actual obstruction to the passage 
 of the intestinal contents may be brought about by the traction 
 of the mesentery, which renders the orifice of the intussusceptum 
 slit-like, by the swelling and congestion of the intestinal wall, or 
 perhaps by the impaction of a portion of undigested food within 
 the lumen of the gut. Peritonitis usually follows, being possibly 
 due to the invasion of a portion of the damaged intestinal wall 
 by the Bac. coli. 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. 
 
INTESTINAL OBSTRUCTION 
 
 ioig 
 
 In other cases, and especially 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 existence of polypoid tumours, 
 malignant growths, or possibly worms ; the presence of scybalous 
 masses of faeces may also lead to its occurrence. In a few cases 
 
 .y 
 
 Fig. 361. — Intussusception. 
 
 (From Specimen in College of Surgeons' 
 Museum.) 
 
 injury, e.g., blows on the abdomen, or severe strains during 
 jumping, have been held responsible for its onset. 
 
 Intussusception is met with in four chief situations: (1) The 
 ileo-ccecal variety is much the commonest, 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- 
 cecal valve. Owing to the great mobility of the ileum, a con- 
 siderable 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 frequency, 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 
 
I020 
 
 A MANUAL OF SURGERY 
 
 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 1 8 per cent, of the cases. (4) The ileo-colic only occurs in 
 8 per cent. ; in it the ileum is protruded through the ileo-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 
 being always formed by the same portion of gut ; but in the ileo- 
 colic variety, as just stated, it increases by the passage of more 
 
 m 
 
 (T\ 
 
 U 
 
 Fig. 362. — Diagram of Intussusception. 
 
 a, Intussusceptum ; b, intussuscipiens ; I., ensheathing layer ; 
 II., returning layer; III., entering layer. 
 
 and more of the ileum through the valve ; after a time this stops, 
 and is replaced by the ordinary form of growth. 
 
 Intussusception is occasionally met with as a post-mortem 
 phenomenon, due to the irregular intestinal movements occurring 
 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 young children, 
 the onset being usually sudden. The child is attacked with 
 severe pain, possibly localized and more or less paroxysmal at 
 first, but rapidly becoming continuous and diffused over the 
 abdomen. This is followed by vomiting, which, however, is less 
 
INTESTINAL OBSTRUCTION 
 
 severe than in acute strangulation, and not so often faeculent. 
 The patient rarely suffers from absolute constipation, diarrhoea 
 and the discharge of blood-stained mucus, perhaps associated 
 with tenesmus, being 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 about half the cases a distinct tumour 
 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, constituting what is known 
 as the ' signe de Dance.' In other cases the tumour may be 
 more limited, and distinctly moveable. 
 
 A natural cure occasionally follows, resulting either from 
 spontaneous 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 very satis- 
 factory, owing to the formation of a fibrous stricture. 
 
 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, 
 the attacks becoming more frequent and prolonged as the case 
 progresses. Vomiting is often but little marked during the in- 
 termissions. 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 examina- 
 tion, 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 termina- 
 tion 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 much can be 
 attempted to prevent a fatal issue. 
 
 In acute intussusception the patient should be at once placed 
 under the influence of opium, in order to still peristalsis and pre- 
 vent the increase of the tumour. Inflation of the bowel with air, 
 
A MANUAL OF SURGERY 
 
 or the injection of copious enemata of warm water or oil, may 
 then be carefully undertaken. No undue force should be em- 
 ployed in this proceeding, 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, laparotomy should 
 be performed without delay, and the condition of the intus- 
 susception 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 bowel, 
 which is steadied by the other hand. In about half the cases 
 reduction is impracticable, owing to the presence of adhesions, 
 and if the general condition of the patient is fairly good, the 
 intussusception should be removed and the divided ends of the 
 bowel united by suture. This is best performed by a modification 
 of Maunsell's method, an incision being made through the anti- 
 mesenteric border of the intussuscipiens, through which the intus- 
 susceptum is drawn out and cut away, and the bowel subsequently 
 sutured as described at p. 934. If, however, the patient is in a 
 condition of profound 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, for F. H. Wiggin* 
 has shown that few children 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. 
 
 Investigation of a Case of Intestinal Obstruction. 
 
 As already indicated, the cause of intestinal obstruction is by 
 no means always a matter of easy diagnosis, whilst the localiza- 
 tion of the lesion with a view to accurate operative treatment is 
 never simple. In every case the surgeon should conduct his 
 examination in a methodical and orderly manner, and it is well 
 to make one's investigation 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 biliary colic, chronic constipation, acute diffuse or localized 
 peritonitis, uterine derangements, syphilis or dysentery, etc. 
 
 2. The History of the Present Attack should then be con- 
 
 * Medical Record, January 18, 1896. 
 
INTESTINAL OBSTRUCTION 
 
 sidered, 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. 
 By this means it is possible to ascertain whether the patient 
 is suffering from acute or chronic obstruction, as also whether 
 the causative lesion has been in existence for some time or not. 
 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 responsible for the exhaustion seen at 
 the end of an acute attack or in the chronic variety. Hence 
 collapse 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 completeness or not of the obstruction. This matter 
 has been especially emphasized by Treves, who has pointed out 
 that when the obstruction is but partial the pain is intermittent, 
 whilst when the block is complete the pain becomes continuous. 
 Hence in acute strangulation 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 inflammation of the peritoneum. 
 
 (d) Vomiting is an almost invariable accompaniment of obstruc- 
 tion. Its cause is still a matter of some doubt, since some 
 authorities claim that it is due to a reverse peristalsis, whilst 
 others maintain that the ordinary onward movements of the 
 bowel are quite sufficient to explain it ; the intestinal contents 
 are urged forwards against the face of the obstruction, and, 
 being unable to pass, an axial regurgitant stream is produced. 
 It is a little difficult to see how this could occur when the lower 
 end of the colon is the part affected. Whatever the mechanical 
 explanation, there is no question as to the influence of the nervous 
 system in its production, or as to its being chiefly reflex in 
 character, which is evident from the fact that it occurs equally 
 when omentum or bowel is strangled. Hence, it is easy to under- 
 stand that it commences early in children and sensitive women, on 
 
1024 A MANUAL OF SURGERY 
 
 account of the greater irritability of their nervous centres, whilst 
 it is also more marked when the small intestine is involved. 
 Anything that increases peristalsis naturally intensifies its occur- 
 rence. When the obstruction is situated in the jejunum or upper 
 part of the ileum, the vomiting is never really faecal in character, 
 although, if it has been temporarily checked by opium, the ejecta 
 may be exceedingly offensive and dark in colour, owing to decom- 
 position ; true faecal vomiting can only come from an obstruction 
 to the lower ileum or colon. 
 
 (e) Constipation, although usually present, is not necessarily 
 absolute, as it is possible for the lower bowel to be emptied in 
 cases of obstruction, whilst the patient sometimes passes a motion 
 as gangrene supervenes or death is approaching. 
 
 4. A most careful Physical Examination must now be instituted. 
 
 (a) An inspection of the uncovered abdomen should first be 
 made. The amount and character of the distension is observed, 
 and whether or not it is situated in the centre, as when small 
 intestine is involved, or in the flanks when the obstruction is 
 in the rectum or sigmoid flexure. The existence of visible peri- 
 stalsis or enlarged coils of intestine should be noted ; such are 
 rarely seen in the acute cases, but may be very evident in the 
 chronic forms. The rise and fall of the abdomen during respira- 
 tion should be watched to ascertain whether the movements are 
 equal on both sides, or if any prominence, such as would be 
 caused by a tumour, is noticeable. The general condition of the 
 patient, whether emaciated or not, as also the appearance of the 
 face and the position in which he lies, should be observed. 
 
 (b) All the normal and abnormal hernial apertures are 
 thoroughly investigated, as also the rectum and vagina. 
 
 (c) 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. 
 
CHAPTER XXXV. 
 RECTUM AND ANUS. 
 
 Congenital Malformations. 
 
 The lowest portion of the intestinal canal, 4 inches in length, 
 which is commonly known as the rectum, 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 early separated ; the posterior segment, which 
 becomes the rectum, extends down into the pelvis, to be joined 
 
 Fig. 
 
 A B 
 
 -Three Varieties of Malformation of Rectum. 
 
 363. — 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. 
 
 by an epiblastic pit or involution growing in from the perineum, 
 known as the ' proctodeum.' Failures in typical development 
 may be due either to the proctodeum being absent or stenosed, to 
 the rectum either being absent (Fig. 363, A) or retaining in 
 measure its cloacal condition and opening into some other viscus 
 — e.g., the bladder, urethra, vagina, or vulva (Fig. 363, B) — or to 
 want of union between the upper and lower segments (Fig. 363, C). 
 The following are the chief clinical varieties of malformation met 
 with ' 
 
 6.5 
 
1026 A MANUAL OF SURGERY 
 
 (i.) Absence of the anus, with or without development of the 
 rectum, which, if present, may open in some abnormal situation. 
 In such cases, the important question to be settled by the 
 practitioner is the existence or not of a rectum, and this, unfor- 
 tunately, cannot always be determined without an open explora- 
 tion through the perineum ; if, however, during crying and 
 straining there is a distinct bulge in the middle line at the 
 spot where the anus should be, there is every likelihood of the 
 viscus being present. If so, it is always expanded in a club-like 
 extremity, usually lined with peritoneum in front, and often below. 
 If the rectum is absent, it usually ends near the pelvic brim, 
 and is merely represented by a fibrous cord below that level 
 (Fig. 363, A), whilst the bony pelvis is often atrophic and its 
 outlet much reduced in size. Thus in a case seen recently an 
 interval of half an 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. 363, 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. 
 
 The Treatment of these cases must be instituted at as early a 
 date after birth as possible, so as to prevent intestinal obstruction. 
 
 Anal stenosis is readily dealt with by regular dilatation with 
 bougies. 
 
 Where a membranous septum persists between the 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. 1039), 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, 
 colotomy must be performed, and by preference the iliac operation, 
 since the space between the crest of the ilium 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 difficulty. 
 
RECTUM AND ANUS 1027 
 
 Various malformations in connection with the post-anal gut 
 have been already described (p. 649). 
 
 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 introduction of foreign bodies, or the presence of a polypus, 
 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. If the inflammation becomes chronic, 
 a simple fibrous stricture may result. Treatment. — Injections of 
 lead and opium or of borax may be used locally, whilst the patient 
 is kept in a recumbent position and on a low diet, the bowels being 
 regularly opened by the administration of laxatives or enemata. 
 
 Thread-worms (Oxyuris vcrmicularis) 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 
 phenomena. 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. 
 
 The Bilharzia hsematobia is occasionally found in the rectum as 
 well as in the urinary passages (p.iogo). 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, diarrhoea 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 coexistent. They occur in children who have been 
 in Africa, and, unfortunately, no satisfactory treatment is known. 
 
 Ischio- Rectal Abscess. 
 
 Suppuration in the ischio-rectal fossa (localized periproctitis) 
 is very frequently met with, and, from the fact that it commonly 
 results in a fistula, is of considerable surgical interest. It may 
 arise from a variety of causes, but for convenience may be 
 described under the three following headings : 
 
 1. Acute Ischio-Rectal Abscess is due to infection of the loose 
 fatty tissue filling the ischio-rectal fossa (Fig. 364, I.R.A.) with 
 some pyogenic organism, reaching it either through the perineum 
 or from the bowel. In the latter case some solution in the 
 continuity of the mucous membrane occurs, such as follows its 
 penetration by a fish-bone or other foreign body, or some form of 
 ulceration ; the Bac. coli is thereby set free, and in consequence 
 the pus has the usual characteristic offensive odour. If the 
 infection is derived from the perineum, the usual cocci of sup- 
 puration are present, and the pus has no objectionable smell. A 
 red, painful swelling is noticed on one side of the anus, which is 
 
1028 
 
 A MANUAL OF SURGERY 
 
 at first hard and brawny, but soon becomes soft and fluctuating. 
 Defalcation is exceedingly 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 forming, a free opening should be made, the 
 cavity washed out, and stuffed with some antiseptic dressing. If 
 taken early enough, rapid recovery may ensue without the bowel 
 becoming involved, but when the mucous membrane has been 
 encroached upon or perforated, the wound will not heal without 
 division of the sphincter. 
 
 Occasionally a more diffuse type of acute suppuration occurs in 
 the ischio-rectal fossa, constituting a cellulitis, and not uncommonly 
 
 Fig. 364. 
 
 -Diagrammatic Section of Lower End of Rectum, Anus and 
 Ischio-Rectal Foss^. 
 
 L.A., Levator ani ; E.S., external sphincter; I.R.A., ischio-rectal abscess; 
 A. A., anal abscess ; F.I. A., fistula-in-ano ; A.F., superficial anal fistula. 
 
 resulting in gangrene (gangrenous periproctitis). It is most likely to 
 be seen in weakly individuals and old people, and the symptoms 
 are very asthenic in type. The suppuration may extend above 
 the levator ani, and lead to deep fistulous tracks. The parts 
 must be freely opened up, the gangrenous tissue scraped away, 
 and the raw surfaces treated with peroxide of hydrogen. The 
 wounds are then stuffed with iodoform gauze, and subsequently 
 well irrigated twice a day. Free stimulation is always required in 
 these cases, but the prognosis is very bad, death being probably 
 caused by acute toxaemia or pyaemia. 
 
 2. Chronic Ischio-Rectal Abscess is usually met with in run- 
 down or tuberculous individuals during young adult life, and is 
 not unfrequently a complication of phthisis. It arises from injuries 
 to the perineum or bowel, and may even be induced by exposure 
 
RECTUM AND ANUS 1029 
 
 to wet or cold, as by sitting on a damp stone. A deposit of tuber- 
 culous 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 inflam- 
 matory 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. The Treatment is as for all 
 tuberculous deposits, viz., in the early stages, and even before 
 suppuration has occurred, incision, removal by a sharp spoon of 
 all tuberculous tissue, the application of pure carbolic acid, and 
 dressing the wound with gauze infiltrated with iodoform. Where 
 extensive sinuses or fistulae exist, treatment as for fistula-in-ano 
 mast be adopted. 
 
 3. Suppuration in the ischio-rectal fossa may occasionally be 
 dependent on disease of neighbouring or distant structures, e.g., 
 the sacro-iliac or hip joints, the pelvic bones, the spine, prostate, 
 pelvic cellular tissue, etc., the pus finding its way down by the 
 side of the rectum and burrowing through the levator ani, to reach 
 the surface. The usual treatment of such condition must be 
 adopted, but if practicable the abscess is opened elsewhere, as, of 
 course, the existence of a sinus near the anus is a fertile source of 
 septic contamination. 
 
 Anal Abscess. — This term is applied to an abscess forming 
 immediately under the anal integument, and superficial to the 
 sphincter (Fig. 364, A. A.); it is usually due to inflammation of 
 one of the numerous sebaceous follicles in that locality. It may 
 be acute or chronic, in the latter case being usually tuberculous, 
 and is one of the most frequent causes of fistula-in-ano. It must 
 be freely opened throughout its whole length, and stuffed. 
 
 Fistula-in-Ano. 
 
 The term fistula-in-ano is somewhat loosely applied to all those 
 conditions in which suppurating tracks are found in the neigh- 
 bourhood 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 usually some suppurative condition, e.g., 
 an ischio-rectal or anal abscess, in the neighbourhood of the 
 bowel ; but it is sometimes the result of a stricture of the gut, the 
 inner opening being either above, in the substance of, or below 
 the cicatricial mass. This is more likely to be the case when 
 multiple fistulae exist. 
 
 Varieties. — 1. The Complete Fistula (Fig. 365) is one in which 
 
1030 A MANUAL OF SURGERY 
 
 there are openings both externally and into the bowel. When 
 following an anal abscess, they are both close to the anus, and 
 the track lies immediately beneath the skin and mucous mem- 
 brane (Fig. 364, A.F.). When following an acute ischio-rectal 
 abscess, the external opening is a variable distance from the anus, 
 and the inner about 1 inch up the bowel, being situated in relation 
 with the so-called internal sphincter (Fig. 364, F.I. A.); occasionally 
 blind extensions are met with branching off from this, but not so 
 frequently as when the fistula follows a chronic abscess. In the 
 latter case the skin may be extensively undermined, looking blue 
 and congested, and the fistulous tracks may burrow widely, open- 
 ing even on the thigh, or in the perineum or buttock. The 
 so-called horseshoe fistula passes round the bowel, usually behind 
 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 
 
 Fig. 365. — Complete Fig. 366. — Incomplete Fig. 367. — Incomplete 
 
 Fistula-in-Ano with External Fistula. or Blind Internal 
 
 External and In- (Tillmanns.) Fistula (Till- 
 
 ternal Openings. manns.) 
 (Tillmanns.) 
 
 the muscular coat for some distance above the internal opening by 
 sinuses or an abscess cavity. 
 
 2. The Blind External Fistula (Fig. 366) is the term applied to a 
 sinus resulting from the opening of an ischio-rectal abscess in 
 which no communication with the bowel can be discovered. A 
 probe passed into the wound can often be felt by a finger in the 
 rectum with only the thickness of the mucous membrane between. 
 In dealing with these external fistulae the possibility of the original 
 cause being at a distance must not be overlooked. 
 
 3. The Blind Internal Fistula (Fig. 367) 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 disturb- 
 ance. The orifice can sometimes be felt by digital exploration, 
 and on the insertion of a speculum may perhaps be seen and care- 
 fully examined by a straight probe or one bent in the form of a 
 hook ; it is often associated with considerable undermining of the 
 mucous membrane, and if chronic with stenosis of the bowel. 
 
 In all these conditions it is very difficult to obtain healing, 
 
RECTUM AND ANUS 1031 
 
 owing to the state of unrest in which the parts are kept by the 
 continuous movements, voluntary and involuntary, of the sphincter ; 
 hence division of this muscle is almost always necessary. It may, 
 however, be advisable to leave the case alone when the fistula 
 complicates the later stages of phthisis, or when a small blind 
 internal fistula exists in elderly people, causing but little incon- 
 venience and no injury to the general health. 
 
 Operation. — The bowels must have been completely evacuated, 
 both by means of castor-oil or some suitable purgative, and about 
 an hour previous to operation by enema, a most important 
 preliminary, not only for the comfort of the operator, but also 
 because it is very desirable that no further action should be 
 required for some days. The patient is placed in the lithotomy 
 position, and the perineal and anal regions shaved and purified. 
 A probe is passed along the fistula into the rectum, and guided 
 by it a grooved director, along which a curved pointed bistoury 
 is introduced, and the intervening structures divided ; this will in 
 most cases include the external sphincter. A careful search is 
 made for pockets or tributary branches of the main track, and 
 such, if found, are opened up and scraped out, undermined and 
 unhealthy skin being snipped away with scissors; bleeding points 
 are, if necessary, tied, and the cavity carefully powdered with 
 iodoform, and lightly stuffed with oiled lint or gauze soaked in 
 iodoform and glycerine. Pressure by a graduated antiseptic wool 
 compress should be applied by means of a T-bandage. The wound 
 is allowed to granulate, and care taken that irregular healing does 
 not lead to a re-formation of the fistula. With this object in view, 
 it is often advisable to pass a moderate-sized bougie from time to 
 time at the end of a fortnight. 
 
 When a sinus extends for some distance under the mucous 
 membrane from the upper end of the original fistula, it may not 
 be always desirable to lay it open to its whole extent, since such 
 might involve serious haemorrhage at a spot where it cannot well 
 be checked. It will often suffice to partly divide and scrape it, 
 and then, if the main fistula has been satisfactorily dealt with, it 
 will probably heal without difficulty, especially if syringed out 
 occasionally with stimulating lotions. 
 
 In the case of a horseshoe fistula, the sphincter need only be 
 divided at one spot, and that usually in the middle of the horse- 
 shoe. The whole track must, however, be opened up, the cavity 
 scraped, loose tags of skin removed by the scissors, and an 
 ordinary dressing applied. 
 
 After -Treatment. — The bowels should, if possible, be prevented 
 from acting for four days, and most scrupulous care taken to keep 
 the parts clean. The deep dressing need not be changed for the 
 first twenty-four or forty-eight hours, provided that the surround- 
 ing skin is well flushed with a warm carbolic solution. When the 
 plugs are removed, fresh small strips of gauze soaked in iodoform 
 
1032 A MANUAL OF SURGERY 
 
 and glycerine are introduced night and morning after the wound 
 has been syringed. On the fourth day a good dose of castor-oil 
 should be given, and subsequently care taken to secure an action 
 of the bowels daily. 
 
 Fissure of the Anus. 
 
 This is a most painful and troublesome complaint, met with 
 most commonly in 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 passage of large 
 scybalous masses in patients suffering from chronic constipation. 
 The fissure is usually single, extending through the posterior border 
 of the anus towards the coccyx ; a ' sentinel ' external pile is often 
 situated immediately over it, and the crack may lead to a definite 
 ulcer just within the external sphincter. According to Ball of 
 Dublin, it is due to one of the valve-like tags, left at the junction 
 of the proctodeum and rectum, being caught by a scybalous mass, 
 and torn from its upper connections. Each time a motion passes 
 the 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 defsecation, which often lasts for some hours. 
 The pain is usually associated with tenesmus, and may radiate down 
 the thighs or up the back, and not uncommonly to the left sacro- 
 iliac joint ; it may be so severe as to lead the patient to refrain from 
 defalcation for prolonged periods. The faeces 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 spas- 
 modically contracted, and the entrance of a finger is forcibly resisted. 
 
 Treatment in the earlier stages is undertaken by regulating the 
 action of the bowels by suitable laxatives, by the use of cocaine 
 suppositories prior to defaecation, and by improving the general 
 health. Sometimes the application of a hamamelis ointment, com- 
 bined with the ung. hydrargyri nitratis dil., is most effective in 
 giving relief. In confirmed cases the sphincter has been forcibly 
 dilated by the thumbs, and the crack or ulcer cauterized ; but 
 by far the most efficient treatment consists in dividing its base 
 with a straight probe-pointed bistoury, the incision at the same 
 time including the external sphincter. The ulcer and the edges 
 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 explored with the finger, especially with a 
 view to the possible existence of a polypus, which, if undetected, 
 
RECTUM AND ANUS 1033 
 
 would cause a recurrence of the mischief. Rest being thus 
 obtained, healing soon follows. 
 
 Fibrous Stricture of the Rectum. 
 
 One of the most important conditions associated with or 
 resulting from inflammatory lesions of the lower gut is stenosis. 
 It is usually met with in advanced life, especially 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 usually due to the cicatrization and con- 
 traction of ulcers following prolonged diarrhoea and dysentery, 
 although occasionally due to tuberculous or syphilitic ulceration. 
 Any form of chronic proctitis, e.g., gonorrhoea, may also lead to 
 it. It occurs sometimes as a sequela of pelvic cellulitis 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 point 
 than in the former. Repeated attacks of inflamed piles may also 
 lead to stenosis at or just above the anus. A stricture sometimes 
 results from traumatism, or follows operations involving the whole 
 or at any rate the greater portion of the circumference of the 
 bowel. As already mentioned, it may be associated with a fistula, 
 especially if the latter has existed for long ; the inner opening 
 may then be found in the substance of the stricture, as pointed 
 out by the late Mr. Henry Smith. 
 
 The earliest Symptoms of stricture are often alternating attacks 
 of diarrhoea and constipation, in which the constipation is primary, 
 and the diarrhoea due to a catarrhal enteritis arising from the 
 irritation of the retained faeces. Gradually the difficulty in 
 passing motions becomes more and more marked, and the 
 faeces themselves become narrowed, flattened, and elongated, 
 something like pipe-stems, or small masses like shrimps may 
 alone succeed in passing. This is associated with pain and un- 
 easiness referred to the lower bowel ; a certain amount of blood 
 and mucus may be mixed with the excreta, and sooner or later 
 marked dyspepsia and abdominal distension supervene. If the 
 case is allowed to run on without treatment, absolute obstruc- 
 tion of a chronic type may result, and lead to a fatal issue ; 
 or the mucous membrane of the bowel 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 fistulae are established, 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 
 like an os uteri. In other cases, the bowel is stenosed for 
 
io 3 4 A MANUAL OF SURGERY 
 
 some distance, and its surface more or less ulcerated ; whilst it 
 due to pelvic cellulitis, it may be drawn up and fixed to the 
 posterior pelvic wall. When the stricture is too high for the 
 finger to reach, the gut may appear normal, though somewhat 
 dilated (ballooning). Sometimes the stricture is smooth, and free 
 from nodular irregularities and excrescences ; often, however, it 
 is ulcerated and irregular, the examination causing great pain. 
 The gut above the contraction is hypertrophied, distended, and 
 if filled with retained faeces, the mucous membrane may show 
 signs of inflammation, 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 from above. 
 
 The Treatment in the early stages consists in keeping the 
 bowels regular and the motions soft by means of laxatives, such 
 as castor-oil or salines, whilst the passage of the excreta is assisted 
 by enemata. The diet is regulated, and the strength maintained, 
 if need be, by tonics. Locally, the stricture, if within reach, 
 should be dilated by means of bougies passed in increasing sizes 
 every two or three days, care being taken that the point of 
 the instrument engages the stricture, and is not caught against 
 folds of mucous membrane or turned backwards. The utmost 
 gentleness must be used, in order, as far as possible, to stretch 
 the mucous membrane, and not tear it. Laminaria or compressed 
 sponge tents are of use in some cases, followed subsequently 
 by bougies. When situated low down, the stricture may be 
 notched posteriorly, or slightly nicked in several places with a 
 probe-pointed bistoury, and bougies then passed. There is 
 always a great tendency in these strictures to contract again, and 
 the patient should be instructed to pass a bougie for himself at 
 short intervals. If the stricture is out of reach, or signs of 
 obstruction manifest themselves in spite of treatment, colotomy is 
 the final resource. 
 
 Syphilitic Disease of the Rectum and Anus. 
 
 The rectum and anus are attacked by syphilitic disease in a 
 variety of ways, the most prominent being as follows : 
 
 (a) The initial lesion or primary chancre is occasionally met 
 with in the neighbourhood of the anus, but presents no features 
 that demand special attention. 
 
 (b) In the secondary stage mucous tubercles or condylomata 
 are frequently seen, being placed either at the anal margin or 
 symmetrically on either side of the gluteal fold, the sores on 
 one side having evidently infected the other. They are of the 
 usual type (p. 128), 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 
 
RECTUM AND ANUS 10.55 
 
 not uncommon, occurring most usually, but not solely, in young 
 married women amongst the poorer classes, and especially in 
 hospital patients. It is a somewhat early tertiary manifestation, 
 and usually commences within easy reach of the finger, about 
 3 inches from the anus. It starts as a diffuse gummatous infil- 
 tration 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 frequently 
 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 
 formation of fistulae, not only between the rectum and neighbour- 
 ing 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 a syphilitic stricture, 
 which may extend for some distance up the bowel. The symptoms 
 consist in pain, increased on defaecation, 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 course of the case, are usually 
 sufficient to determine the diagnosis. The general health re- 
 mains good in the earlier stages of the affection, but later on 
 may be undermined by the pain and constant purulent dis- 
 charge. 
 
 Treatment consists in administering mercury and iodide of 
 potassium, the former perhaps in the shape of suppositories, 
 whilst locally dilatation by bougies is necessary. In advanced 
 cases colotomy is essential in order to secure rest to the parts, 
 and give them a chance of healing. Possibly in a few instances 
 only a temporary opening of the bowel may be required, but 
 where much contraction exists and a considerable tendency to 
 obstruction, the artificial opening must remain permanently. 
 Sometimes the ulceration persists in spite of colotomy, and care 
 must then be taken to prevent the retention of discharges by the 
 occasional passage of bougies. 
 
 Tumours of the Rectum. 
 
 Polypus Recti occurs most frequently in children, and consists 
 usually of an adenoma of Lieberkuhn's follicles, but occasionally 
 of simple fibrous tissue covered with mucous membrane. They 
 are commonly found within easy reach of the anus, and present 
 
1036 A MANUAL OF SURGERY 
 
 an appearance something like a small cherry with a long pedicle, 
 pendulous and freely mobile. The Symptoms caused are irri- 
 tability of the bowel and the passage of blood by the anus, which 
 latter when occurring in a child without symptoms of obstruction 
 is almost pathognomonic of polypus. The tenesmus excited may 
 lead, as mentioned elsewhere, to prolapse or to the occurrence 
 of an intussusception. It is occasionally associated with a fissure 
 of the anus, which probably arises as a secondary result of the 
 irritation caused by the partial extrusion of the polypus during 
 defalcation. A natural cure can be effected by rupture of the 
 attenuated pedicle, which is at first attended by a certain amount 
 of haemorrhage. Treatment. — The polypus is cut away after tying 
 or twisting its pedicle, or the clamp and cautery may be employed. 
 
 Papilloma of the rectum is a rare disease, and gives rise to 
 haemorrhage from and irritability of the bowel, or, if large, even to 
 obstruction. 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 
 in the shape of a large fleshy tumour growing from the submucous 
 tissue, and projecting into the lumen of the gut so as to cause 
 obstruction. It is less painful than cancer, and usually occurs at 
 an earlier age. The symptoms are much as in the latter disease, 
 and the treatment, where feasible, is the same, viz., extirpation of 
 the growth, but it will very probably recur. 
 
 Epithelioma of the Anus (i.e., of the skin covering the anal 
 margin) occurs as a primary development similar to that on the 
 lip, and is then of the squamous type. It presents the usual 
 features, viz., an indurated nodular mass, which readily ulcerates, 
 and runs the typical course of such a disease, infecting the 
 inguinal glands. It is readily dealt with in the earlier stages 
 by an operation somewhat similar to that for excision of the 
 rectum. 
 
 Cancer of the Rectum appears in the form of columnar epithe- 
 lioma, consisting, as described elsewhere (p. 179, Fig. 42), of an 
 overgrowth of Lieberkiihn's follicles, not only into the lumen of 
 the gut (centrifugal or papillomatous type of growth), but also 
 invading the deeper portions of the bowel wall, infiltrating the 
 submucous and muscular layers (centripetal growth). A cer- 
 tain amount of vascular fibro-cellular stroma is found between 
 the glandular elements, and, according to the relative amount of 
 these structures, two types of the disease are described : (a) The 
 nodular variety commences at one spot in the form of a localized 
 malignant wart-like mass, which is hard in consistency, and con- 
 tains an excess of fibrous stroma. This type becomes ulcerated 
 after a time, and does not grow very rapidly, (b) The annular 
 variety is characterized by the mass being more cauliflower-like, 
 
RECTUM AND ANUS 1037 
 
 growing more quickly, and tending early to involve the whole 
 circumference of the gut. This latter form ulcerates early, bleeds 
 freely, and causes greater destruction of tissue, so that obstruc- 
 tion 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. 
 
 Both varieties sooner or later involve neighbouring structures, 
 and hence lead to fixation of the mass, either to the pelvic walls 
 or to the bladder, vagina, or prostate ; sometimes the iliac vessels 
 or sciatic nerves are compressed, causing cedema or neuralgia 
 respectively. Fistulae may develop in connection with the 
 bladder, in which viscus the growth may actually form a con- 
 siderable mass. Secondary deposits, similar in microscopic, struc- 
 ture to the primary growth, are found in the lumbar glands, or, 
 if the anus is affected, in the inguinal region ; they commonly 
 involve the liver, and may even be disseminated throughout the 
 body. The peritoneal cavity may also be invaded. 
 
 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. It then leads to 
 recurring attacks of constipation, alternating with diarrhoea, and 
 to the discharge of large quantities of mucus, often blood-stained. 
 A sense of weight or dragging pain is noticed in the rectum, and 
 the patient after defaecation feels as if there is still something to be 
 passed. This sensation increases until true tenesmus and strain- 
 ing 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, 
 but later it passes independently of the motions. On examina- 
 tion, an ulcerating, crateriform mass is met with, which may either 
 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. 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 in- 
 volved, 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 colotomy has been performed. Marked cachexia supervenes, 
 the digestion becomes impaired, any meal causing pain and flatu- 
 lent distension ; natural sleep is impossible, and if a recto-vesical 
 fistula forms, the patient's troubles are further aggravated by the 
 passage of faeces and flatus by the urethra. 
 
 The case runs a more or less rapid course to the fatal issue, 
 which on an average ensues about seventeen months after the 
 
1038 A MANUAL OF SURGERY 
 
 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 invagina- 
 tion of the mass and occlusion of the tube ; whilst if ulceration is 
 excessive, or the disease situated low down, obstruction is much 
 less common, invagination being here impossible, and peristalsis 
 being expended on the onward passage of the faeces. Exhaus- 
 tion from haemorrhage, pain, sleeplessness, or septic 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 
 colotomy. 
 
 Excision of the Rectum, or proctectomy, is only applicable to 
 those cases in which there is a reasonable prospect of the whole 
 disease being eliminated. When the finger can be passed into 
 healthy bowel beyond the growth, and where the mass is not 
 fixed anteriorly so as to endanger other viscera, e.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 
 where extensive it also contra-indicates operation. If there is 
 any reason to suspect secondary deposits in the lumbar glands or 
 liver, it is needless to put the patient through the very trying 
 ordeal of excision. Formerly it was considered of vital importance 
 to avoid opening the peritoneum ; but at the present day it is 
 frequently done, and with no untoward result, if due precau- 
 tions are taken ; so that, although the growth may be situated 
 high up, if it is freely moveable, and there is no evidence of 
 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 i% 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 peri- 
 toneum 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. 
 
 It is good practice to anticipate the radical operation by a 
 preliminary colotomy, unless the case is a very early one. Where 
 the whole circumference of the bowel has to be removed for 
 3 inches or more, the passage of faeces through the wound is not 
 only a source of septic contamination, but also causes extreme 
 pain, whilst the condition subsequently left is almost certain to 
 err on the side either of patulency or of contraction, and there is 
 total loss of control. An effective anus in the iliac region obviates 
 * British Medical Journal, 1889, ii., p. 407. 
 
RECTUM AND ANUS 1039 
 
 all these difficulties, whilst the preliminary operation gives the 
 surgeon a chance of investigating the condition of the lumbar or 
 sacral glands, and of ascertaining the extent of the growth up the 
 bowel. 
 
 Two forms of operation are described, according to whether 
 the growth is situated high up or low down. The latter, or 
 low operation, sometimes known as Langenbeck's, is performed 
 through the perineum ; the former, for dealing with cancer situ- 
 ated higher up, necessitates partial removal of the sacrum or 
 coccyx, and is known as Kraske's. 
 
 1. Loiv Operation. — The rectum 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, 
 dividing the levator ani on each side, and working gradually 
 upwards and to the front, where greater care must be taken to 
 ensure the vagina, prostate or membranous urethra from harm. 
 In the male, a bougie or catheter may be passed into the urethra 
 with advantage. Bleeding-points can be secured during this 
 process by pressure-forceps. The upper attachments 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 iodoform, and 
 plugged for twenty-four hours with gauze, the posterior incision 
 not being closed by suture, and no attempt made to drag down 
 the mucous membrane. Subsequently the wound may be left 
 without any internal dressing, an external pad of salicylic wool 
 sufficing ; it is thoroughly washed out two or three times a day 
 with some dilute antiseptic, such as sanitas (1 in 10), Condy's 
 solution, or carbolic acid lotion (1 in 60), which may be used 
 alternately ; granulations gradually cover the surface, and, as 
 cicatrization progresses, the mucous membrane is by degrees 
 approximated to the skin margin, and the patulous cavity dimin- 
 ished in size until healing is complete. 
 
 If the growth affects one side of the gut alone, the operation is 
 modified by only removing that half. If fixed posteriorly, the 
 coccyx, and even a part of the sacrum, may be taken away with- 
 out hesitation to facilitate the extirpation of the mass. 
 
 2. Kraske's or the High Operation. — The patient reclining on his 
 ri«^ht 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 liga- 
 ment and gluteus maximus detached from the left side of the 
 
1040 
 
 A MANUAL OF SURGERY 
 
 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 pos- 
 terior sacral foramen to the under border of the third, and then 
 to the left border of the bone at that level (Fig. 368, a b). The 
 loose cellular tissue surrounding the upper part of the rectum is 
 thus exposed, and the gut, together with the tumour, is freed from 
 its connections, and amputated from the sound gut above, the 
 peritoneum being usually encroached on in this stage of the pro- 
 ceedings. If the growth extends to the anus, the whole length of 
 the rectum below is excised ; but if the sphincter and lower inch 
 or two are free from disease, they are left in situ, and not divided 
 posteriorly, whilst the upper end of the gut is in all cases drawn 
 
 Fig. 368. — 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. 
 
 down, and fixed by a few points of suture either to the anal portion 
 along its anterior wall, or to the skin. The wound is carefully 
 washed out, and stuffed with gauze sprinkled with iodoform ; even 
 if the peritoneal sac has been opened, no harm will usually come 
 of it, since a careful packing of the wound will close it off in 
 twenty-four hours. The results which have followed this severe 
 operation are, on the whole, encouraging, always provided that a 
 preliminary colotomy has been performed. 
 
 Various modifications of Kraske's proceeding have been 
 suggested, one of the best being that performed by Bardenheuer. 
 The sacrum is exposed, sawn across just below the third fora- 
 mina (Fig. 368, 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. 
 
RECTUM AND ANUS 1041 
 
 Excision of the rectum is a proceeding only practicable in com- 
 paratively few cases of the disease (Jessop states 15 to 20 per 
 cent.), and fatal results are not uncommon from shock, haemor- 
 rhage, or peritonitis. The tendency to recurrence is considerable, 
 but the disease is not then so painful as before, since the nerve 
 terminals have been removed. In the cases that are cured a 
 certain amount of inconvenience is certain to follow either from a 
 patulous or stenosed condition of the anal orifice, and it is still 
 a moot point whether in many cases a simple colotomy is not as 
 valuable as excision. 
 
 As already stated, if the radical operation is not feasible, 
 Colotomy is the only means whereby the patient's condition can 
 be temporarily ameliorated. The surgeon should not wait until 
 urgent symptoms develop, but should operate at the earliest 
 possible date, and for the following reasons : (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 ; (c) it retards the 
 growth of the disease by eliminating the irritating action of the 
 faeces ; (d) it removes a!) chance of intestinal obstruction from 
 the growth itself; and (e) it diminishes the absolute risk of the 
 operation by doing it when the patient is comparatively well and 
 hearty, and when there is no urgency. Formerly, when under- 
 taken for obstruction alone the death-rate was about 30 or 40 per 
 cent. ; in an early iliac operation it is now practically nil, 01 at 
 most 3 or 4 per cent. 
 
 Should the patient refuse colotomy, or should it be for any 
 reason contra-indicated, treatment consists in limiting the diet 
 to such materials as strong broths, arrowroot, etc., with some 
 stimulant, so as 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 morphia. 
 
 Haemorrhoids, or Piles. 
 
 By the term Piles is meant 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 lowest 
 portion of the colon is similar to that in the intestine generally, 
 the vessels being distributed transversely around the gut ; but in 
 the rectum they run in longitudinal series along the bowel, being 
 connected by transverse branches, which form a plexus around 
 and just above the anus. Their situation in the loose submucous 
 tissue, where there is but little support, necessarily exposes them 
 to great and sudden variations of pressure before and after 
 
 66 
 
I04 2 A MANUAL OF SURGERY 
 
 defecation. 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 portal trunk — all these reasons may be looked 
 on as Predisposing Causes of the condition. In addition to these 
 we must also mention a sedentary occupation, alcoholic 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 
 arise which favour their development. Young women are re- 
 markably exempt from piles, owing probably to the regularity of 
 the menstrual discharge ; but uterine conditions, such as preg- 
 nancy, displacements, or tumours, which cause obstruction to the 
 venous return, are liable to be associated with them. Many forms 
 of abdominal tumour, e.g., aneurisms, may also determine their 
 existence. 
 
 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 
 prominence 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 congestion of the liver, as by alcoholic excess, or a chill. 
 
 Two chief varieties of piles are described, viz., the external and 
 internal ; but frequently a combination of the two conditions is 
 present. 
 
 External Piles are found at the margin of the anus, and are 
 covered with skin. They consist of a small central vein in a vari- 
 cose 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 they give rise to no Symptoms beyond a little 
 pruritus, and perhaps a sense of fulness and irritation imme- 
 diately before and after defalcation. They are 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 distended with blood-clot. Under suitable treatment the 
 swelling subsides in a few days, usually leaving the fleshy fold 
 more bulky and harder than previously, owing to the partial or 
 complete organization of the thrombus. 
 
 The Treatment of external piles, when uninflamed, is very 
 
RECTUM AND ANUS 
 
 1043 
 
 simple. Constipation must be relieved ; the parts should be kept 
 clean and well washed ; a hamamelis ointment or extract may be 
 occasionally applied, and great care taken not to irritate the anus 
 after defalcation by the use of hard paper (e.g., newspaper). Very 
 soft curl paper, well crumpled, should be employed, or preferably 
 absorbent wool. It is but rarely that operative measures are re- 
 quired in a simple case of external piles ; where, however, ex- 
 ternal and internal piles coexist, it is advisable to complete any 
 operation undertaken for the latter condition by the removal of 
 the more prominent fleshy folds surrounding the anus. This is 
 accomplished by grasping them with forceps, and snipping them 
 away by scissors in a direction radiating from the centre of the 
 anus. We would warn the practitioner, however, against a too 
 free use of the scissors, whereby a subsequent contraction of the 
 anus may be induced. For inflamed external piles the patient 
 should be kept in bed, the bowels opened by a copious warm 
 enema, and fomentations applied. 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 with iodoform and salicylic wool. 
 
 Internal Piles consist of dilated veins held together by a certain 
 amount of connective tissue, and covered 
 by mucous membrane. At first they are 
 quite soft and compressible, and easily 
 emptied on pressure ; but when they 
 have existed for some time the connec- 
 tive tissue may be increased in amount, 
 and arterial twigs are often found run- 
 ning into the mass. 
 
 The condition is limited to the lower 
 2 inches of the bowel, and may present 
 very varied appearances in different 
 cases. Thus, there may be a general 
 varicosity of the veins in the submucous 
 tissue without the formation of any dis- 
 tinct tumours. The mucous membrane 
 is then of a deep claret colour, somewhat thickened, and liable 
 to protrude during defalcation. There is a certain amount of 
 mucous glairy discharge, and the faeces may be streaked with 
 blood ; but, as a rule, the haemorrhage is not great. Such a 
 condition is usually followed by a definite formation of haemor- 
 rhoidal tumours, and not unfrequently runs on to prolapse. 
 
 When distinct haemorrhoidal masses form, they may be of two 
 types : (a) The longitudinal or fleshy pile (Fig. 369), consisting of 
 broad sessile masses, dusky in colour, soft and compressible in 
 consistency, and usually 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 
 
 
 ' 1 MIA1\I 
 
 369. — Internal 
 
 i'lLES. 
 
1044 A MANUAL OF SURGERY 
 
 found, in which small portions of faeces may lodge and produce 
 irritation. This form usually bleeds but little, (b) The globular 
 or bleeding pile is single or multiple, and usually somewhat pedun- 
 culated ; the surface of the tumour is roughened and granular, 
 like a strawberry, due to the existence of dilated capillaries. 
 When, however, a portion of it has been repeatedly protruded, 
 the exposed mucous membrane becomes hard, and practically 
 converted into skin. The haemorrhage is often abundant, and 
 comes either from the dilated superficial capillaries, or occasion- 
 ally from a central arterial twig. 
 
 The Symptoms arising from internal piles are often not very 
 marked until haemorrhage occurs ; but there is usually a sense 
 of weight or fulness about the anus, with sometimes pain, which 
 is increased before and after defaecation. The patient feels as 
 if a foreign body were present in the bowel, and the mass not 
 unfrequently protrudes, giving rise to much pain and incon- 
 venience until replaced by the patient, owing to the grip of the 
 sphincter. Sooner or later haemorrhage is almost certain to be 
 noticed, coming on at first after defaecation, and only a few drops 
 being lost. After a time, however, the flow increases, and may 
 continue to such an extent as to cause marked anaemia. If the 
 case remains untreated, the pain and inconvenience increase ; a 
 blood-stained mucous discharge from the rectum is noticed, soiling 
 the linen ; reflex irritation of neighbouring organs is produced, 
 and a condition of nerve prostration from pain and haemorrhage 
 may result. In cases where the piles are due to portal obstruc- 
 tion, as in cirrhosis of the liver, the bleeding may be beneficial, 
 and must not always be checked. Moreover, when the menstrual 
 flow is diminished, a vicarious discharge of blood from the piles is 
 sometimes observed. 
 
 Complications of Piles. — Inflammation of the venous ampullae 
 contained in piles leads to what is popularly termed an ' attack 
 of piles,' although this is much less common with the internal 
 than the external variety, and the fleshy form is that usually 
 affected. Evidences of a localized phlebitis manifest them- 
 selves in the shape of a painful distension and swelling of the 
 parts, which become blue in colour and exquisitely sensitive. 
 They subside with or without suppuration ; in the latter case a 
 spontaneous cure may result, whilst in the former general blood 
 contamination may follow, death from pyaemia having even 
 occurred. Strangulation of the piles by the sphincter ani may 
 follow protrusion where reposition is not effected, the mass then 
 becoming painful, tense, swollen, and livid in colour ; inflamma- 
 tion running on to ulceration and even sloughing follows, the 
 patient suffering meanwhile from sickness, pain, and toxaemia. 
 Pyaemia is likely to ensue unless the case is effectively treated, 
 preceded by pylephlebitis (i.e., septic inflammation of the branches 
 of the portal vein in the liver). On the other hand, a spontaneous 
 
RECTUM AND ANUS 
 
 1045 
 
 cure may be effected. Prolapse may become chronic, and fissure 
 of the anus develop. 
 
 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, 
 however, often associated. From polypus piles are distinguished 
 by being multiple rather than single, by being softer and more 
 compressible, 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 anum from many other conditions besides piles. In the 
 latter case the blood is of a bright red, florid colour, and often 
 coats the fasces, whereas if it originates higher in the intes- 
 tinal canal it is dark or tarry in colour (melecna), and is more 
 intimately mixed with the excreta. A digital examination of 
 the rectum will also in the latter case eliminate the presence of 
 piles. 
 
 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. These may 
 be given daily, whilst at the same time the food and drink of the 
 individual are regulated, all excess of alcohol being avoided, and 
 suitable exercise enjoined. In weakly and debilitated individuals 
 it is advisable to adopt a more stimulating and tonic plan of 
 treatment. Aloes should generally be avoided. 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 defalcation ; 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 
 (1 in 8) is also advisable, and bleeding from piles can often be 
 arrested by this means. The ung. gallae c. opio of the Pharma- 
 copoeia is recommended, but is not so efficacious. 
 
1046 A MANUAL OF SURGERY 
 
 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 the condition 
 of the liver, as the bleeding may be beneficial in relieving hepatic 
 congestion, and an operation is then 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, 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 Smith. The mucous membrane having been everted, as 
 just described, each of the haemorrhoidal tumours is grasped by a 
 pair of ring-ended catch forceps, and thus temporarily secured ; 
 by this means the scope of the operation required can be readily 
 gauged. The clamp is then applied to each mass successively in 
 a direction corresponding to the long axis of the gut, great care 
 being taken not to include the external skin. The clamp is 
 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. 1043), the mucous membrane re-inverted, the parts 
 dusted with iodoform, and a carefully graduated compress of anti- 
 septic 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 day, 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. From a 
 very large experience of this operation, gained both at hospital 
 and in private, we have no hesitation in maintaining that, if 
 efficiently carried out, and combined with the use of a powerful 
 and properly constructed screw-clamp, it is absolutely safe and 
 free from danger ; that any complications from sepsis, haemorrhage, 
 etc., are due to the carelessness of the surgeon, and not to the 
 character of the operation ; and that for all practical purposes it 
 is the best means of dealing with internal piles. 
 
 2. Ligature is also an operation much in vogue for the treatment 
 of piles, and as now carried out with due antiseptic precautions, 
 
RECTUM AND ANUS 1047 
 
 a large amount of success attends its use, although it is doubtful 
 whether recovery is as speedy or painless as after the cautery. 
 The hemorrhoidal 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 ligature cut short, the knot 
 being allowed to separate by subsequent ulceration. 
 
 3. Crushing by means of a powerful clamp has also been 
 recommended by Benham, Allingham, and others, the base of 
 the mass being thoroughly compressed, and the pile then cut 
 away. We think it safer to combine such treatment with the 
 styptic and antiseptic qualities of the cautery. 
 
 4. Where the veins of the lower inch or two of the mucous 
 membrane are in a varicose condition, but no definite haemor- 
 rhoidal tumours are present, Whitehead's operation may be em- 
 ployed. It consists in the 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, and the latter dissected up from the 
 muscular coat of the bowel by successive snips of the scissors ; it 
 is then cut away, all bleeding-points are secured, and the lower 
 end of the divided mucous membrane united by suture to the skin, 
 the stitches passing deeply under the surface of the wound and 
 not merely through the margins. Excellent results have followed 
 such treatment 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 
 defalcation ; 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 only 
 the mucous membrane is protruded, and this is known as an 
 incomplete prolapse ; if, however, the condition persists, the whole 
 thickness of the bowel may become involved, mucous membrane, 
 submucosa, and even the muscular and serous coats, giving rise 
 to the complete variety (Fig. 369). The former condition (some- 
 times badly termed a prolapsus ani) is more commonly 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 by 
 an incomplete stage, limited to the mucous membrane, and that 
 in adults complete prolapse is occasionally observed. 
 
 Causes. — 1. It may be produced by a simple relaxation of the 
 tissues, as met with in weakly 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 accompanied by 
 straining: efforts. 2. Conditions which have led to chronic tenesmus 
 
1048 
 
 A MANUAL OF SURGERY 
 
 or violent expulsive efforts, e.g., piles, chronic constipation, diar- 
 rhoea, rectal irritation, as from worms in children, or diseases of 
 neighbouring organs, such as vesical calculus, stricture, enlarged 
 prostate, may also determine prolapse. 
 
 Symptoms and Diagnosis. — The anal orifice is occupied by a 
 smooth rounded swelling, red or purplish in colour, covered by 
 mucous membrane ; this protrusion in the early stages can be 
 easily replaced by a little pressure, but returns if the patient 
 strains or coughs. When the swelling is of large size, reduc- 
 tion is increasingly difficult and painful from infiltration and 
 fibrous overgrowth of the submucosa, and it is very liable to 
 become inflamed and ulcerated from friction. Incontinence of 
 faeces is also a common result. When 
 the whole thickness of the gut is 
 protruded, the serous lining may 
 accompany the tumour, but is usually 
 limited to the anterior surface, and 
 into the sac thus formed small intes- 
 tine may pass, and even become 
 strangulated (Fig. 370, X). The 
 prolapse itself may also be con- 
 stricted if allowed to remain for 
 long unreduced ; the mass is then 
 livid, swollen, and intensely painful, 
 and if left to itself may slough away, 
 and thus lead to a spontaneous cure, 
 although severe septic symptoms 
 may supervene, and even perforative 
 peritonitis. 
 
 There should be but little difficulty 
 in recognising a prolapse ; the only x j nd icates the serous sac in the 
 condition for which it can be mistaken anterior wall due to protrusion 
 is an intussusception protruding from of the peritoneum, 
 the anus ; in such, however, the finger 
 
 or a probe can be inserted into the rectum by the side of the pro- 
 truding gut, which is impossible with a prolapse. 
 
 Treatment. — In the earlier stages, all that is needed "is the 
 removal, if possible, of the cause of the tenesmus, e.g., dilata- 
 tion of a urethral stricture, removal of a vesical calculus, or the 
 regulation of the bowels so as to check either chronic diarrhoea 
 or constipation. When piles are present, they should be treated 
 as described above, and the prolapse will, as a rule, subsequently 
 disappear. Thread -worms must be dealt with by suitable means 
 (q.v.). Beyond this, cold or astringent injections may be employed, 
 e.g., sulphate of iron (1 to 3 grains to 1 ounce), and it is advisable 
 for the individual to acquire the habit of having the daily motion 
 at bedtime, whilst children are made to defalcate lying on the 
 side, one buttock being pulled up for the purpose. The prolapse 
 
 Fig. 370. — Longitudinal Sec- 
 tion of Complete Prolapsus 
 Recti. (Tillmanns.) 
 
RECTUM AND ANUS 1049 
 
 is carefully washed, reduced by pressure with the fingers, and 
 retained by strapping the nates together, particularly in children, 
 or by applying some suitable pad and a T-bandage. The great 
 hope of obtaining a cure in this way consists, in never allowing 
 the prolapse to remain unreduced for any length of time. 
 
 When such palliative measures fail, Operative Treatment must 
 be undertaken. 
 
 In the slighter cases of incomplete prolapse, it will suffice to 
 diminish the size of the anal orifice by snipping away ladiating 
 folds of skin and mucous membrane, and allowing the wounds 
 thus produced to cicatrize. In the worse cases it may be neces- 
 sary, in addition, to remove strips of the mucous membrane in a 
 longitudinal direction by means of the clamp and cautery ; or a 
 larger area of the posterior wall of the prolapse may be denuded 
 of its mucous covering, and the edges brought together by deep 
 stitches. Where such has failed, or is thought undesirable, the 
 prolapse may be dissected away by incising the circumference of 
 the anal orifice at the junction of the skin and mucous membrane, 
 and turning down the outer layer of the mucous coat like a cuff. 
 A finger inserted in the bowel suffices to draw down all the slack 
 inner lining, and to ascertain that nothing is present but the 
 mucous membrane. The whole of the prolapsed portion is re- 
 moved by scissors, all bleeding-points being secured as divided ; 
 the upper edge of the mucous membrane is then united by suture 
 to the cutaneous margin of the anal orifice. 
 
 In cases of total prolapse of the bowel in children, nothing 
 but palliative treatment is generally necessary ; but in adults a 
 modification of the above described operation is required. The 
 patient's buttocks are well raised, so as to prevent any protrusion 
 of intestine if the peritoneal cavity is opened. The base of the 
 prolapse is divided anteriorly on a level with the anus, the open- 
 ing in the peritoneum plugged with a sponge, and the remainder 
 of the mass removed by scissors, bleeding-points being secured as 
 divided. 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 the anal orifice and 
 lower gut should be thoroughly washed out twice or thrice daily 
 to prevent accumulation of septic material. Control over the 
 bowel is usually regained, though often somewhat slowly, and the 
 after-treatment is likely to be prolonged. 
 
 In obstinate cases where the prolapse recurs again and again 
 after operation, the sigmoid flexure should be cut down upon 
 from the groin and anchored by sutures to the abdominal wall 
 (colopcxy), or even a temporary colotomy performed. 
 
CHAPTER XXXVI. 
 SURGICAL AFFECTIONS OF THE KIDNEYS. 
 
 Congenital Affections of the Kidney. — Many different malformations and dis- 
 placements are met with affecting these organs. 
 
 The chief Malformations are as follow : (a) Complete absence of one organ, 
 a very rare condition, and (b) congenital atrophy of one kidney, it being repre- 
 sented by a mass of fatty tissue : in both cases the other organ is correspond- 
 ingly enlarged and hypertrophied. (c) The kidneys may be fused together, 
 either constituting one large organ in the median line, and more or less 
 normal in shape, or sometimes constituting the so-called horseshoe-shaped 
 variety, the convexity being directed downwards, (d) Deep lobulation of 
 the kidney, as in some animals, is sometimes seen, especially if the organ 
 is displaced ; occasionally this is carried to such an extent as to divide it 
 into two or more portions, (e) The ureter and pelvis may be double, this 
 malformation affecting the pelvis alone, or extending as far as the bladder. 
 (/) The renal artery may arise from the aorta in two or more main branches. 
 
 The majority of these malformations are of very little clinical importance, 
 except in the operation of nephrectomy, when they may necessitate a slight 
 modification of the usual proceedings. 
 
 Congenital Displacement of the Kidney occurs about once in every thousand 
 individuals, the organ being either depressed, so as to lie over the sacro-iliac 
 synchondrosis or sacral promontory, or raised above its normal position. The 
 left kidney is more frequently affected in this way than the right, and, when 
 lying in the iliac fossa, the descending colon is usually displaced inwards, so 
 that the rectum starts to the right of the middle line. The adrenal bodies 
 retain their normal position, and do not move with the kidney. 
 
 Cystic disease, sarcoma, and hydronephrosis may also occur congenitally, 
 and will in turn be described below. 
 
 Floating and Moveable Kidney. — The term Floating Kidney has 
 been applied to a supposed congenital condition in which the organ 
 is attached to the posterior abdominal wall by a meso-nephron or 
 peritoneal ligament ; it is, however, more than doubtful whether 
 such an abnormality really exists. By Moveable Kidney is 
 meant an acquired condition in which the kidney moves within 
 the perinephric fatty tissue, which forms a loose capsule around 
 it. It occurs more frequently in women than in men, and more 
 often on the right than on the left side, partly because the renal 
 vessels are longer on this side than on the other, and partly 
 because the descending colon is more fixed than the ascending. 
 
 Causes. — Parturition accounts for many cases ; firstly, because 
 of the sudden diminution of the intra-abdominal pressure, and 
 
SURGICAL AFFECTIONS OF THE KIDNEYS 1051 
 
 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 or rapid emaciation, whilst tight-lacing or 
 traumatic influences may be responsible for some cases. It is 
 frequently associated with that form of displacement downwards 
 of the abdominal viscera which is known as Glenard's disease, 
 or enteroptosis. This is perhaps due to accumulation of faeces 
 in the transverse colon, whereby the lesser omentum and other 
 peritoneal ligaments become stretched, and in consequence the 
 intestines, stomach, and even the liver may slip downwards and 
 become moveable. The right kidney participates freely in this 
 displacement. 
 
 The Symptoms arising from a moveable kidney consist chiefly 
 in pain referred to the back, or perhaps shooting along the ureter 
 to the groin, testis or labium majus ; it is increased by pressure on 
 or manipulation of the abdomen. 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 exacer- 
 bations of these symptoms, with a temporary diminution in the 
 amount of urine, result from kinking of the ureter ; sudden relief, 
 followed by an increased flow of urine possibly containing some 
 muco-pir , indicates that the organ has returned to its normal 
 situation. 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. If the patient is lying in the prone position on a flat 
 couch, a distinct loss of resistance is noticed external to the 
 erector spinas on the affected side. 
 
 Treatment consists in wearing an abdominal belt, suitably 
 padded, or in the operation of nephrorrhaphy (p. 1071). 
 
 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 haemor- 
 rhage follows, both into the substance of the kidney or its pelvis, 
 and into the perinephric fatty tissue, and this even when the 
 capsule has not been torn. The integrity of this structure is a 
 point of great importance, since it limits to some extent the 
 bleeding and prevents urinary extravasation ; the kidney may 
 be crushed to a pulp without any external haemorrhage, and 
 under these circumstances clots are likely to pass down the 
 ureter, and may obstruct it and lead to its subsequent occlusion. 
 When the anterior portion of the capsule is torn, the peritoneum 
 may also be involved, and then evidences of intraperitoneal 
 bleeding may manifest themselves, and, indeed, if the kidney is 
 
1052 A MANUAL OF SURGERY 
 
 extensively lacerated, fatal haemorrhage may result, though this 
 is unusual. Rupture of the posterior surface of the kidney opens 
 up the retroperitoneal 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. 
 
 The Symptoms produced consist in severe shock, combined 
 with pain in the loin, shooting down into the testis or thigh, and 
 increased frequency of micturition, the urine voided being usually 
 mixed with blood. 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 secretion 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 shown by distension of the abdomen and the existence 
 of fluid within it. The development of a perinephritic abscess is 
 recognised by fever, rigors, increased pain in the loin, and the 
 usual phenomena of deep suppuration. 
 
 The Treatment usually required is to keep the patient quiet in 
 bed, with an icebag applied to the loin ; pain may be relieved by 
 strapping the side or by applying a firm bandage. Persistent 
 haemorrhage necessitates the administration of ergot, tannic acid, or 
 turpentine ; but if it is threatening the patient's life, an exploratory 
 incision is required, and, if need be, removal of the organ, although 
 it is sometimes possible to stitch up a limited rent. Any disten- 
 sion of the bladder must be relieved, the clots being washed out 
 through a large-eyed catheter. The occurrence of peritonitis or 
 of a perinephritic abscess will call for suitable surgical measures, 
 the injured viscus being dealt with according to circumstances. 
 
 Rupture of the Ureter is a rare accident, usually due to direct 
 violence, but occasionally happening during pelvic operations, 
 such as removal of the uterus. When due to a subcutaneous 
 injury, it cannot be recognised at once, but extravasation of urine 
 takes place, resulting in the formation of a perinephritic abscess. 
 This is incised sooner or later, and on exploring the cavity it may 
 be possible to detect the rent in the ureter, but more frequently its 
 situation cannot be found, and then a doubt will necessarily exist 
 as to whether the lesion involves the ureter or the pelvis of the 
 kidney. In either case a urinary fistula in the loin results, which 
 may possibly close after a time ; if the fistula persists, nephrectomy 
 will be required, and then the sooner such an operation is under- 
 taken the better. In a few favourable cases it has been possible 
 to suture the rent in the ureter by the following plan : the lower 
 
SURGICAL AFFECTIONS OF THE KIDNEYS 1053 
 
 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 into a longitudinal opening made in 
 the side of the lower segment, and accurately stitched in position. 
 
 We have recently had two cases probably of this nature under treatment at 
 hospital. Both occurred in young boys, and both were due to cab accidents. 
 In the first, after 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 illustra'ion of the fact that 
 healthy urine does comparatively 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, nephrectomy being subsequently required. 
 Both cases 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, though very rarely, 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 
 following headings : (a) Blocks within the urinary passages from 
 the presence of stenes, parasites, foreign bodies, or even blood-clot ; 
 (b) 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. 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 
 
io54 
 
 A MANUAL OF SURGERY 
 
 never leads to hydronephrosis. Should it occur as the result of 
 impaction of a calculus in one of the ureters, the secretion on that 
 side is totally suppressed as soon as the tension within the pelvis 
 and calyces is sufficiently high. Should, however, the obstruction 
 he intermittent or incomplete, so that some of the urine escapes, 
 thereby relieving the pressure, hydronephrosis develops. Sudden 
 and complete occlusion of the urethra likewise 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. The pyramids 
 are flattened, and the cortex expanded and thinned, so that the 
 whole kidney looks larger 
 than usual. A certain amount 
 of interstitial infiltration of 
 the cortex is always present ; 
 the urine secreted in the 
 early stages is usually abun- 
 dant and of a low specific 
 gravity. 
 
 If the obstruction con- 
 tinues, 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 
 considerably with the method 
 of onset and the cause of the 
 trouble. Frequently all that 
 happens is a painless en- 
 largement of the affected organ ; if both are involved, 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 uraemia 
 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 compen- 
 satory hypertrophy of its fellow. Not unfrequently a fluctuating 
 swelling of considerable size is produced by hydronephrosis ; 
 it presents all the physical signs of a renal tumour (p. 1065), 
 and its formation is often associated with pain, vomiting, 
 
 Fig. 371. — Hydronephrosis. (From 
 Specimen in Bristol Hospital 
 
 Museum.) 
 
SURGICAL AFFECTIONS OF THE KIDNEYS 1055 
 
 and increased frequency of micturition. Finally, a perinephritic 
 abscess may develop, owing to ulceration of the pelvis or ureter, 
 and the cyst may thus discharge through the loin. Occasionally 
 the size of the tumour varies considerably from time to time, 
 owing to the obstruction being temporarily overcome by the 
 pressure of retained urine behind it. 
 
 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 
 malformation of the upper end of the ureter, it is possible to 
 transplant it and thereby relieve the obstruction. Unilateral 
 hydronephrosis must 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. In the majority, however, the block is situated 
 so low down that it cannot be reached, and nephrectomy must 
 then be undertaken. 
 
 Inflammation of the Kidney and its Surroundings. — It is un- 
 necessary to discuss the many varieties of inflammation of the 
 kidney ; they are dealt with in medical text-books. The following 
 conditions are, however, of surgical importance : 
 
 1. 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) occasionally in floating or moveable kidney ; 
 (/) the ingestion of irritating drugs, e.g., cantharides, turpentine, 
 and occasionally cubebs or copaiba ; (g) the presence of foreign 
 bodies, such as needles, bullets, and parasites, e.g., the Bilharzia 
 hamatobia or the Stvongylns gigas ; (h) a pyaemic embolus ; and 
 (i) possibly cold. 
 
 Whatever the cause, the pathological phenomena are the same, 
 consisting in the lining membrane becoming congested and 
 thickened, and secreting a muco-purulent, or even purulent, dis- 
 charge. 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-organisms are present, as in cases due to extension 
 from the bladder, the kidney is likely to be involved in the process 
 (pyelonephritis), or the condition may be followed by a urinary 
 abscess in the loin or suppurative perinephritis. 
 
 The Symptoms of pyelitis consist of pain and tenderness over 
 
1056 A MANUAL OF SURGERY 
 
 the affected kidney, increased frequency of micturition, and the 
 intermittent discharge of pus in acid urine. The intermissions are 
 due to the inflammatory swelling of the mucous membrane, which 
 temporarily blocks the upper entrance to the ureter, and necessi- 
 tates a certain degree of pressure of the urine and pus accumulated 
 in the pelvis of the kidney in order to overcome the obstruction. 
 Necessarily, where pyelitis follows chronic cystitis, the acid re- 
 action of the urine is neutralized by the changes occurring in the 
 bladder ; in such cases a nocturnal elevation of temperature is 
 usually noted. 
 
 The Treatment of pyelitis is mainly directed to the cause. 
 Where such is removable, e.g., calculus or foreign bodies, an 
 operation is advisable. In septic cases originating in the bladder, 
 treatment should first be directed towards the latter viscus. If 
 no cause is evident, the patient is kept warm, his diet restricted 
 to the simplest solids and bland fluids, ana salol, alkalies, and 
 sedatives prescribed. If these measures fail, the affected kidney 
 should be explored. 
 
 2. Pyelonephritis, or inflammation of the pelvis of the kidney 
 together with the renal parenchyma, is almost invariably suppura- 
 tive in type and commonly due to extension upwards from the 
 lower urinary organs, constituting the chief element in the more 
 serious cases of what used to be badly termed ' surgical kidney.' 
 
 This condition may supervene suddenly and with acute symp- 
 toms, and then probably results from some surgical operation or 
 simply from catheterism in a patient whose bladder is in a highly 
 septic condition. The organisms find their way upwards along 
 the lymphatics in the mucous lining of the ureters, and soon infect 
 the pelvis, giving rise to a suppurative pyelitis ; the walls of the 
 ureters may in such cases be studded with miliary abscesses. 
 The presence of septic matter in the pelvis always lights up a 
 certain amount of irritation in the renal substance, constituting a 
 subacute interstitial nephritis ; but in addition to this bacteria 
 invade the pyramids and travel upwards along the lymphatics or 
 the renal tubules, giving rise to abscesses, either scattered through 
 the connective tissue of the organ or within its tubules, in either 
 case seriously damaging its excretory function. In both in- 
 stances it is possible for many of these minute foci of pus to run 
 together and form a large collection, which in time becomes 
 recognisable from outside ; but more usually the patient dies of 
 toxaemia or uraemia before that stage is reached. Sometimes the 
 condition develops more chronically, and then the phenomena of 
 pyonephrosis are more prominent. 
 
 The Clinical History of pyelonephritis is a little vague. In 
 acute cases the symptoms probably commence with a severe rigor 
 shortly after the operation which has called the trouble into 
 existence. This is associated with pain in the loins or back, 
 headache, vomiting, and probably some amount of drowsiness, 
 
SURGICAL AFFECTIONS OF THE KIDNEYS 1057 
 
 perhaps passing into a condition of coma. The rigor may be 
 repeated, or the fever may remain high without exacerbations. 
 The urine is usually diminished in amount, and, indeed, may be 
 suppressed entirely ; if any passes, it is high-coloured and contains 
 albumen and perhaps blood, together with some amount of pus, 
 which is probably derived largely from the lower portion of the 
 urinary track. The prognosis in these cases is nearly hopeless, 
 the patient being almost certain to die of uraemia, especially as 
 both kidneys are generally affected, although in the more chronic 
 type, if the cause of obstruction is removed, he may recover. 
 
 Treatment. — The cause of the affection in the lower urinary 
 passages must be attended to ; septic urine is drawn off, and if 
 need be the bladder washed out ; all causes of obstruction must 
 also be removed, if practicable. The patient is, of course, kept in 
 bed ; the loins are cupped or fomented ; the patient is encouraged 
 to drink plenty of bland fluid, whilst stimulants are, if possible, 
 avoided entirely, as also opium. When the temperature remains 
 high, quinine is administered. 
 
 3. Pyonephrosis is the name applied to a distension of the pelvis 
 of the kidney when associated with suppurative pyelitis. It is 
 always secondary, either to pyelitis or to hydronephrosis. In the 
 former case, the inflammation of the ureter causes partial obstruc- 
 tion to the flow of urine, and hence leads to dilatation ; in the 
 latter, suppuration extends to the previously dilated pelvis from 
 the bladder, or as a result of the local cause. It is always asso- 
 ciated with a certain amount of pyelonephritis, from which indeed 
 it is only distinguished by the greater degree of dilatation. 
 
 Pathological Conditions. — The lining membrane of the pelvis 
 is inflamed, thickened, and perhaps ulcerated. A considerable 
 quantity of decomposing urine, mixed with muco-pus, is always 
 present in the dilated pelvis and calyces, and rugged calculi or 
 tuberculous masses may also be found, giving rise to a chronic or 
 subacute interstitial nephritis, which may run on to suppuration. 
 A certain amount of perinephritis is always associated with this 
 condition. 
 
 Clinical Signs. — The kidney is found to be enlarged and tender 
 on palpation, whilst more or less constant pain is present in the 
 loin. The temperature is usually somewhat raised, especially 
 at night, from the absorption of septic products ; the patient 
 steadily loses ground, and becomes emaciated ; the tongue is 
 dry, the appetite diminished, and nausea is sometimes present. 
 The urine is usually scanty in amount, and loaded with muco-pus, 
 which may be constant or intermittent. If both kidneys are 
 involved, the excretion of urine gradually diminishes, leading to 
 a fatal issue from uraemia, unless the patient dies previously from 
 toxaemia or pyaemia. 
 
 Treatment. — Where both kidneys are involved as a result of 
 some urethral or prostatic affection, no special treatment directed 
 
 67 
 
1058 A MANUAL OF SURGERY 
 
 to the kidneys is feasible ; but if the condition is unilateral, and 
 not secondary to disease of the lower urinary organs, nephrotomy 
 should be undertaken, and any removable cause dealt with. 
 Failing this, the cavity may be drained, or even nephrectomy 
 performed. 
 
 4. Abscess in the Kidney may follow any of the conditions 
 already alluded to, in which bacteria gain access to the organ from 
 below. It also occurs in connection with pyaemia and after the 
 general infective fevers, being then more or less of a pyaemic type. 
 In acute interstitial nephritis the abscesses are multiple and at 
 first small, being located between the tubules or sometimes within 
 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 
 abscesses are preceded by infarcts which appear immediately 
 beneath the capsule as wedge-shaped areas of a chocolate colour, 
 which turns to yellowish white as suppuration occurs. Symptoms 
 are not produced unless the abscess is large enough to be detected 
 from outside ; the mere presence of pus in the urine associated 
 with an enlarged and tender kidney is not sufficient evidence of 
 abscess formation. When the collection is large enough, the 
 organ can be distinctly felt, and perhaps fluctuation detected. 
 Possibly pyuria is absent, but a perinephritic abscess is very 
 likely to form. Treatment of an abscess of the kidney consists 
 in nephrotomy for drainage purposes, or perhaps nephrectomy. 
 
 The more chronic varieties are probably tuberculous in origin, 
 and may then attain considerable dimensions, all that is noted 
 being the lumbar swelling, whilst pyuria is not necessarily 
 present. 
 
 5. Perinephritis cannot be recognised unless suppurative in 
 nature, resulting either from septic wounds or from ulceration 
 involving the walls of the pelvis and calyces, or from the trans- 
 mission of micro-organisms from the interior of a suppurating 
 kidney or pelvis without any breach of surface. A perinephritic 
 abscess may also arise from inflammation spreading from the 
 intestine, pleural cavity, ribs, or elsewhere. 
 
 The Symptoms may be acute or chronic in nature. In acute 
 perinephritis, signs of deep suppuration in the loin are produced, 
 viz., an indurated painful swelling, associated with fever, and 
 perhaps preceded by rigors. Fluctuation may sometimes be 
 detected when pus has formed, but the abscess is often so deeply 
 placed that it is difficult to recognise it at first ; it tends to point 
 at the side of the erector spinae, or may burrow forwards between 
 the abdominal muscles, and find an exit on the anterior abdominal 
 wall. Occasionally it bursts into the peritoneal or pleural cavities, 
 or into the intestine. If it comes to the surface, it is preceded by 
 congestion and cedema of the skin. Chronic perinephritis gives rise 
 
SURGICAL AFFECTIONS OF THE KIDNEYS 
 
 1059 
 
 to no characteristic symptoms until an abscess forms which is 
 large enough to be felt. 
 
 Treatment in each case consists in giving exit to the pus through 
 an incision at the outer border of the erector spinae ; 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 tuber- 
 culosis, when miliary tubercles are found studding the organs, 
 but giving rise to no special symptoms. Treatment, of course, is 
 impracticable. 
 
 (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 into (Edema- 
 tous granulation tissue 
 containing tubercles, and 
 that of the pelvis and 
 calyces is similarly 
 affected ; finally, the renal 
 parenchyma itself be- 
 comes infiltrated with 
 tuberculous tissue spread- 
 ing from the pyramids. 
 Clinically, enlargement of 
 both kidneys is noticed, 
 arising partly from the 
 deposit of tubercle within 
 the organ and partly from 
 the obstruction within the 
 ureter. The symptoms 
 caused by the renal mis- 
 chief cannot at first be 
 distinguished from those 
 due to the vesical trouble. 
 Fig. 372. — Tuberculous Kidney, showing p e rinephritic abscess 
 
 Thickening of Mucous Membrane of ,, r n j 
 
 Pelvis and Ureter. (From Specimen in occasionally follows, and 
 College of Surgeons' Museum.) the patient dies from ex- 
 
 haustion, septic absorp- 
 tion, 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. A caseous mass forms, which may 
 extend widely, causing disintegration of the kidney substance, or 
 may burst into the pelvis and infect that cavity. A tuberculous 
 
A MANUAL OF SURGERY 
 
 pyonephrosis follows, and the process spreads for some distance 
 down the ureter, and even infects the bladder (Fig. 372). Sup- 
 purative perinephritis may also supervene, and give rise to an 
 abscess which bursts externally. 
 
 The Symptoms are at first indefinite, the patient complaining 
 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. The pain is generally of an 
 aching character, and more or less constant, although exacerba- 
 tions may occur. The urine usually contains a certain propor- 
 tion of pus, in which on examination the Bac. tuberculosis can often 
 be detected. Hematuria is not marked, even if present at all. 
 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, and may contain a large quantity 
 of pus. 
 
 The Diagnosis of primary renal tuberculosis is usually a matter 
 of doubt, if the presence of bacilli in the urine cannot be demon- 
 strated, since the symptoms are very similar to those of renal 
 calculus. The history of the patient and of his family may be 
 of importance, but the chief points of distinction are that the 
 symptoms are less influenced by exercise or rest, and there is less 
 hematuria 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. In doubtful 
 cases the final distinction is made by exploring the organ through 
 an incision in the loin. The tuberculous kidney is usually mottled 
 in colour and pallid -looking, whilst hard, scattered, caseous 
 nodules may be felt, which become fluid on pressure, or on in- 
 cision give exit to caseous pus. The upper part of the ureter is 
 often somewhat thickened and indurated. In calculus the surface 
 is uniformly even and dark red, or 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 distonded. 
 
 Treatment. — If on exploration of the kidney the disease is found 
 to be strictly limited and the pelvis unaffected, it may be possible 
 to treat it in the same way as tuberculous affections elsewhere, 
 viz., by scraping away the diseased tissue, careful purification of 
 the cavity by liquefied carbolic acid, and plugging the wound 
 thus formed. 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 for such conservative treatment, the kidney 
 practically consisting of a series of cysts filled with offensive 
 pus. If the surgeon is tolerably certain that the other kidney 
 is healthy, nephrectomy should be performed, care being taken to 
 divide the ureter below the farthest limit of the disease. The 
 occurrence of a perinephritic abscess necessitates an incision in 
 
SURGICAL AFFECTIONS OF THE KIDNEYS 
 
 1061 
 
 the loin, and through this opening the kidney can be explored 
 and, if necessary, removed. 
 
 Renal Calculus. — Renal Calculi are usually met with in indi- 
 viduals suffering from lithiasis, as indicated by the passage of 
 sand or gravel in the urine. The general causes of this con- 
 dition are detailed elsewhere (p. 1088). All renal concretions are 
 primarily excreted in a crystalline form from the renal tubules, 
 but under ordinary circumstances are sufficiently small to find 
 their way into the pelvis 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 
 
 Fig. 373. — Calculous Kidney. (College of Surgeons' Museum.) 
 
 substance or in one of the calyces, and by the gradual deposit of 
 the same material increase in size until large enough to give rise 
 to symptoms (Fig. 373). Renal calculi are not often of great 
 bulk, rarely exceeding that of a Barcelona nut ; occasionally, 
 however, the whole of the pelvis, and some of the calyces, may be 
 occupied by a concretion, which takes the shape of the cavity in 
 which it lies. When many calculi are present in the pelvis of the 
 same kidney, they are usually faceted. Chemically they consist 
 either of uric acid or urate of ammonium ; sometimes, however, 
 they are composed of oxalate or acid phosphate of lime. 
 
 The Pathological Phenomena connected with renal calculi vary 
 with their size, shape, number, and position. If situated in the 
 
1062 A MANUAL OF SURGERY 
 
 substance of the renal parenchyma, they give rise to but little 
 change, being more or less encapsuled in a cavity lined by 
 granulation tissue. When occupying the pelvis of the kidney, 
 they set up pyelitis, and from the obstruction to the flow 
 of urine, caused partly by the thickening of the mucous 
 membrane, and partly by the calculus engaging the orifice of 
 the ureter, produce dilatation of the pelvis of the kidney, and 
 the phenomena of hydro- or pyo-nephrosis. If on account of 
 their shape or size they become imprisoned in one of the calyces, 
 ulceration of the wall and suppurative perinephritis may follow ; 
 the calculus may even find its way into the abscess cavity, and be 
 discharged spontaneously or removed through the loin, a urinary 
 fistula often resulting. If the calculus passes down the ureter, 
 it gives rise to the symptoms of renal colic. When small and 
 smooth, it usually reaches the bladder without much difficulty, 
 and is then voided with the urine, or remains as a vesical calculus. 
 Occasionally, owing to its size or irregular shape, it becomes 
 impacted in the ureter, usually at its upper end, giving rise to 
 acute obstruction and the cessation of the urinary secretion on 
 that side, followed by disorganization. If the kidney thus affected 
 is the only one available for excretory purposes, the patient, if 
 unrelieved, dies in a few days from suppression of urine [calculous 
 anuria). In other cases the stone ulcerates through the wall of 
 the ureter, giving rise to a retroperitoneal urinary abscess, or 
 possibly to suppurative peritonitis. If the ureter is only partially 
 obstructed by the calculus, the changes which take place in the 
 kidney are more gradual, and result in hydro- or pyo-nephrosis. 
 
 The typical 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 in- 
 creased on exercise or jolting ; it is frequently referred to distant 
 regions, but most commonly follows the course of the genito- 
 crural nerve, giving rise to pain in the front of the thigh, accom- 
 panied by retraction of the testicle ; in the female it is also 
 experienced in the labium majus. Sometimes it extends down 
 the back of the thigh, and it has even been said that pain in the 
 heel is pathognomonic ! It is almost invariably associated with 
 hematuria, and often with pyuria, the amount of blood or pus 
 being increased on exertion. Frequency of micturition is a pro- 
 minent symptom, whilst if the pelvis is enlarged the kidney may be 
 tender, and distinctly felt on palpation. If the calculus is lodged 
 in the renal parenchyma, the urinary secretion may be but little 
 influenced, although the characteristic pain is well marked ; the 
 patient also finds that at night he can only gain relief by lying 
 on the affected side, and on manual examination the kidney, 
 though somewhat tender, is not much enlarged. When the 
 calculus lies in the pelvis or one of the calyces, the typical 
 phenomena described above are produced ; but it is then noticed 
 
SURGICAL AFFECTIONS OF THE KIDNEYS 1063 
 
 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 passage 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 
 suddenly, and is referred both to the loin and along the course 
 of the genito-crural nerve. It is always associated with vomiting 
 and severe shock, the patient often lying on the floor writhing in 
 agony, with cold perspiration standing in beads on his forehead. 
 The 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 evacuat- 
 ing a small amount, and that generally blood-stained. After 
 lasting for a variable period, the pain suddenly ceases, as a result 
 of the passage of the calculus into the bladder, or of its slipping 
 back into the pelvis of the kidney. 
 
 Calculous anuria is the term applied to a cessation of the 
 urinary secretion which results from blocking of one or both 
 ureters with calculi, the opposite kidney in the former case being 
 absent, atrophied or diseased. The condition is usually lighted 
 up by some physical effort, which presumably dislodges the 
 calculus. It is ushered in by sudden pain in the loin, which 
 often passes away in the course of two or three days. The 
 anuria is rarely complete at first, a few ounces of pale limpid 
 urine being passed at intervals, whilst occasionally distinct poly- 
 uria is present. Sooner or later definite uraemic phenomena 
 supervene ; the most usual period is seven or eight days after the 
 onset, but incomplete obstruction or a pre-existing condition of 
 hydronephrosis may delay matters. The onset of uraemia is 
 indicated by vomiting, a slow, full pulse becoming irregular, 
 contraction of the pupils and muscular tremors. Coma and con- 
 vulsions are rarely seen, and there is no dyspnoea ; the tempera- 
 ture is subnormal. Possibly the calculus can be detected through 
 the rectum or vagina if it is impacted low down. 
 
 The Diagnosis of renal calculus is often a matter of uncertainty 
 in the absence of a history of the passage of gravel or of the 
 occurrence of renal colic. It is most likely to be mistaken for 
 tuberculous disease ; the differential diagnosis between the two 
 conditions has already been considered (p. 1060). Some assist- 
 ance may perhaps be obtained by the use of the X rays, and 
 Mr. Henry Morris has pointed out that too long an exposure is 
 undesirable, since the calculi are not very opaque, owing to their 
 containing so much organic material. Phosphatic calculi are 
 more easily detected than those consisting of oxalate of lime, 
 whilst the uric acid stones are only seen with difficulty. 
 
 Treatment. — In the early stages treatment is directed to the cure 
 
1064 A MANUAL OF SURGERY 
 
 of lithiasis (see p. 1088). The patient's diet and general habits 
 of life must be suitably regulated, and he is instructed to make 
 use of alkaline purgatives, such as Carlsbad or Vichy waters, or 
 citrate of lithia 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 dissolving the stone or assisting 
 its onward passage to the bladder. Sometimes it may become 
 encysted, if the patient is kept absolutely at rest ; the symptoms 
 will then gradually ameliorate, and finally disappear. 
 
 Attacks of renal colic are treated by the use of hot hip baths, 
 warm drinks, and hypodermic injections of morphia ; in the more 
 severe cases chloroform must be administered. 
 
 If, in spite of the above-mentioned measures, the pain persists 
 or increases in amount, or if one kidney is considerably enlarged 
 and very tender, an exploratory operation is required, especially if 
 a considerable amount of blood or pus is being passed in the 
 urine, and the patient's temperature raised. It must also be 
 undertaken if a perinephritic abscess forms or a calculus becomes 
 impacted in the ureter. Pain in both kidneys is no contra- 
 indication to operation, since there is no objection to exposing 
 and even removing calculi from both organs ; it must not be 
 forgotten, however, that sympathetic pain in a sound kidney may 
 be induced by calculi on the opposite side. Naturally, the organ 
 in which most pain is complained of is dealt with first, unless the 
 existence of a calculus in the opposite kidney is indicated by the 
 X rays. The constant passage of gravel, moreover, need not 
 deter one from operating, since when once the kidney has been 
 relieved by removal of the larger masses, the tendency to 
 recurrence may be checked by suitable diet or drugs. The 
 amount of urea excreted daily should always be estimated in 
 these cases, and if it is much diminished no operation should be 
 undertaken. For details of the technique of nephrolithotomy, 
 see p. 1069. 
 
 Where the organ is totally disorganized nephrectomy may be 
 required, but such treatment is not always advisable, especially 
 when sinuses have resulted from a suppurative perinephritis. In 
 such cases the renal tissue has often entirely disappeared, and 
 disintegrating calculous material may occupy the pelvis, which is 
 surrounded by a mass of dense fibro-cicatricial tissue, the removal 
 of which is impracticable and even dangerous. All that should 
 be attempted is the extraction of the stone and the purification of 
 the cavity ; the patient must resign himself to the inconvenience 
 of a suppurating sinus in the loin. 
 
 A diagnosis of calculous anuria should always determine an 
 operation, as such is the only means of saving life. After explor- 
 ing the kidney and its pelvis in the usual way, the ureter is 
 exposed by prolonging the incision downwards and forwards in 
 front of the anterior superior iliac spine, and parallel to the outer 
 
SURGICAL AFFECTIONS OF THE KIDNEYS 1065 
 
 end of Poupart's ligament. The peritoneum and its contents are 
 displaced forwards, and the ureter can then be explored from end to 
 end, except at its lower portion in females. An impacted stone is 
 cut down on and removed through a longitudinal incision in the 
 ureteral wall, which is subsequently closed by a Lembert's suture. 
 When the lower end of the female ureter is blocked, the calculus can 
 often be detected pev vaginam, and may be removed by that route. 
 
 Tumours of the Kidney. — The General Characters of renal 
 tumours are as follows : A swelling is noticed in the loin, which is 
 
 Fig. 374. — Cystic Disease of Kidney. (King's College Museum.) 
 
 shaped more or less like the kidney, a notch being occasionally 
 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 by the growth 
 of the tumour. On the right side it is not unusual for the renal 
 
io66 A MANUAL OF SURGERY 
 
 dulness to be continuous with that due to the liver. The mass 
 moves slightly on respiration, though less distinctly than the 
 liver or spleen ; and no pedicle can be felt passing down towards 
 the pelvis. 
 
 The different varieties of tumour which may originate in the 
 kidney may be classified as the simple and the malignant. Several 
 cystic conditions also occur. 
 
 The Simple tumours of the kidney are : 
 
 i. Cystic Disease (or, as it has been termed, adenoma of the 
 kidney), which may be congenital or acquired. It is not unfre- 
 quently bilateral, especially when congenital. The kidney is en- 
 larged and occupied by cysts, varying in size, but rarely exceed- 
 ing 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 numerous, 
 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. 374). Generally the whole kidney is involved, 
 and may attain enormous dimensions ; but 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 per- 
 sistence of the mesonephros (or Wolffian body) in the substance 
 of the true kidney (or metanephros), and its development into 
 cysts. The early symptoms are simply those of pressure, but at 
 a later stage the secretion of urine is interfered with to such an 
 extent as to produce 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 observed in elderly people, and the chief, if not the only, 
 symptom is excessive hematuria. It cannot be diagnosed with 
 certainty, but if found in an exploratory operation, it can be 
 removed with success. 
 
 3. Occasionally tumours of a considerable size are found growing 
 from the kidney, similar in structure to the zona fasciculata of the 
 adrenal bodies. They are looked on as adenomata growing from 
 accessory and misplaced adrenals ; the renal parenchyma is normal 
 in texture, though stretched over the new growth. When 
 diagnosed, they may be removed together with the kidney, and 
 the results are usually satisfactory. 
 
 Malignant tumours of the kidney may be divided into : 
 1. The Sarcomata of Infants, which are often congenital, but 
 may be acquired within the first few years of life. They are 
 encapsuled, the kidney substance being sometimes spread over 
 them, and consist of round or spindle cells, the latter often show- 
 ing a cross-striation, resembling that of muscular fibres (myo-sar- 
 comata). They grow to a great size, and may affect both organs, 
 
SURGICAL AFFECTIONS OF THE KIDNEYS 1067 
 
 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 detachment of a sarco- 
 matous embolus, which travels upwards and blocks the pulmonary 
 vessels. Treatment by nephrectomy has given most unsatisfac- 
 tory results, recurrence within a short period occurring even in 
 those few cases which escape death from shock. When both 
 kidneys are affected, nothing can be done. 
 
 2. The Sarcomata of Adults occur between the thirtieth and 
 fiftieth years, and are of the spindle-celled variety. Only one 
 kidney is generally involved, giving rise to a rapidly growing 
 swelling, associated with pain and haematuria. Calculi are often 
 found in the pelvis of such organs. Secondary deposits form 
 in the viscera, and death is usually due to exhaustion. The 
 results of nephrectomy have not been very encouraging. 
 
 3. Carcinoma is an uncommon form of tumour in the kidney. 
 It presents the same clinical features as a sarcoma, and can only 
 be recognised on microscopic examination. One symptom, how- 
 ever, 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 roots of the spermatic veins, and hence, whenever an 
 elderly person develops a varicocele, a careful examination of the 
 kidney on the affected side should always be instituted. 
 
 Various Cystic Conditions of the kidney must be noted in addi- 
 tion to the general cystic disease, already 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 may be 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 complicate matters, but, unless the 
 cyst has ruptured into the pelvis, diagnosis is scarcely feasible 
 apart from an exploratory incision. 
 
 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. Rounded swellings, 
 single 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. 
 
 (d) Not unfrequently a number of small cysts develop in con- 
 
io68 
 
 A MANUAL OF SURGERY 
 
 nection with chronic granular nephritis, but they are of no clinical 
 importance. 
 
 Operations on the Kidney. 
 
 The kidneys are placed on either side of the middle line, and 
 extend from the nth rib above, to midway between the last rib 
 and the iliac crest below, the right kidney being somewhat lower 
 than the left, owing to the presence of the liver. The hilus 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 kidneys may be exposed by two chief routes, viz., the 
 lumbar and the abdominal. 
 
 The Lumbar incision (Fig. 375, B) commences at a point cor- 
 
 Fig. 375. — Diagram to Illustrate Lumbar Incisions. 
 A, For lumbar colotomy ; B, for exposing tbe kidney. 
 
 responding to the outer border of the erector spinse, and \ inch 
 below the last rib, extending downwards and outwards in the 
 direction of the fibres of the external oblique for about 4 or 5 
 inches 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. 
 
 The Abdominal incision is made along the linea semilunaris, 
 which is divided, and the peritoneal cavity opened. If the colon 
 lies over the kidney it 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. 
 
 A third method has been advocated by some surgeons, known 
 as the Lateral or Lumbo-abdominal. The incision extends verti- 
 
SURGICAL AFFECTIONS OF THE KIDNEYS 1069 
 
 cally from the tip of the last rib to the iliac crest, and, if necessary, 
 a cross-cut is made backwards at right angles to it. The peri- 
 toneum is stripped forwards from the kidney, the operation being 
 thus retroperitoneal. The advantage over the ordinary lumbar 
 incision has, however, yet to be demonstrated. 
 
 The following are the chief operations undertaken upon the 
 kidney : 
 
 1. Nephrotomy consists in exposure of the kidney, exploration 
 of its substance, and, if need be, incision into it for the removal 
 of some abnormal condition. It should generally be undertaken 
 through the loin. When exposed, the kidney is partially freed 
 from its connections, and drawn up into the wound. Its sub- 
 stance is then carefully palpated between the fingers, any abnormal 
 softening or hardening being noted. It may next be explored 
 with a fine round needle, such as is used for knitting. Care 
 must be taken not to mistake the sensation imparted to the 
 fingers by striking the pyramids with the needle for a stone. 
 If nothing abnormal is detected, an incision should be made 
 through the convex border of the kidney substance, a little pos- 
 terior to the mesial plane of the organ and at the junction of its 
 inferior and middle thirds. Free haemorrhage follows such a pro- 
 ceeding, but soon stops when the finger is inserted. This incision 
 through the renal parenchyma must always be undertaken in 
 preference to one through the pelvis, since the latter heals with 
 difficulty, and is liable to leave a fistula. One of the lower calyces 
 is opened by this means, and the pelvic cavity is then carefully 
 explored by the finger or probe. The upper part of the ureter is 
 best examined by making a tiny hole in the pelvis through which 
 a probe is introduced, the opening being subsequently sutured 
 without difficulty. Should a stone be detected, it may be removed 
 by dressing forceps or a scoop through the renal parenchyma, as 
 also any foreign body ; a papillomatous growth can be scraped 
 away, and the base carefully cauterized, whilst if the operation is 
 performed in order to drain a suppurating pelvis, a drainage-tube 
 is inserted into its interior. The wound in the cortex is usually 
 secured by one or more catgut sutures passed through its sub- 
 stance, unless the condition of the lining membrane of the pelvis 
 renders such a step inadvisable, or unless permanent drainage is 
 required. The external wound may then be closed, the muscular 
 planes being carefully united by a series of buried sutures. 
 
 2. Nephrectomy, or total removal of the kidney, is performed for 
 the following conditions : (a) For tuberculous disease, when con- 
 servative measures are impracticable, or when the pelvis and 
 ureter are involved ; (b) 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 disintegra- 
 tion or rupture, especially if complicated by laceration of the 
 peritoneum ; and (/) for some cases of ruptured ureter. 
 
1070 A MANUAL OF SURGERY 
 
 Before undertaking the excision of any kidney, however diseased, 
 it is essential that the surgeon should satisfy himself as to the 
 existence of another, and also, if possible, ascertain that it is 
 capable of undertaking the increased duties which will subse- 
 quently fall upon it. Many different plans of doing this have 
 been suggested, but it is often difficult to be absolutely certain. 
 In doubtful cases the best course is to perform an exploratory 
 laparotomy, by means of which not only can the existence of a 
 second kidney be determined, but also its condition investigated, 
 and the size of the renal artery ascertained. An examination of 
 the diseased organ can also be made ; if it is of large size, the 
 operation may be at once completed from the front ; but if it is 
 small enough to be dealt with from the loin, the abdomen is 
 closed, and the nephrectomy put off for a week or ten days, 
 until the first incision has healed. It is sometimes possible to 
 prove the existence of a second kidney by means of the cysto- 
 scope, little gushes of urine being seen to escape from the ureter ; 
 in females catheterism of the ureter is practicable. Another 
 method suggested is to compress the orifice of one ureter and 
 collect the urine from the other ; but these plans are difficult to 
 accomplish and cannot be depended on. 
 
 Nephrectomy may be undertaken through the abdomen or 
 through the loin ; but sundry combinations or modifications of 
 these operations have been recommended by various authorities. 
 
 The Abdominal Operation is chiefly utilized when the organ is 
 much enlarged, on account of the readier access obtained, espe- 
 cially to the pedicle. The main objection lies in the fact that the 
 peritoneum is opened, and thereby exposed to septic contamina- 
 tion, especially when the pelvis and the upper part of the ureter 
 are distended with decomposing pus, as is frequently the case. 
 Moreover, no satisfactory drainage is obtained for the cavity left 
 by the removal of the organ, unless a counter-opening is made 
 through the loin. Of course, a great advantage, as before stated, 
 is that the other kidney can be first examined, and its condition 
 ascertained. As to the technique : after exposing the kidney in 
 the manner already described, the organ is freed from its adhesions 
 to surrounding tissues, the surgeon being careful to keep outside its 
 true capsule, but inside the layer of condensed perinephric tissue. 
 Special precautions must be adopted in dealing with the posterior 
 aspect of the tumour, particularly on the right side, where it is 
 occasionally adherent to the inferior vena cava. The mass is now 
 lifted from its bed, and its pedicle, consisting of the ureter and 
 renal vessels, isolated. These latter are secured separately by 
 ligature and divided, a clamp being applied to the distal ends. 
 The ureter is dealt with in the same way, small pieces of sponge 
 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 
 
SURGICAL AFFECTIONS OF THE KIDNEYS 1071 
 
 kidney thus freed is removed, and the wound in the posterior 
 parietal layer of the peritoneum brought together, if possible, by 
 sutures, provision for drainage having been previously made 
 either through the loin or by the insertion of a gauze drain from 
 the front. The abdominal cavity is carefully cleansed from all 
 blood-clot, and closed in the usual way. Considerable shock is 
 always experienced from this operation, and the death-rate from 
 this cause is somewhat high. 
 
 The Lumbar Method can only be employed when the kidney is 
 not much 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 by laparotomy, 
 Kocher recommends that the peritoneum 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. 
 
 3. Nephrorrhaphy is the title given to the operation for fixing a 
 moveable kidney. The usual lumbar incision is adopted, and 
 if the organ is found to move freely within its fatty capsule, this 
 latter should be always drawn into the wound, and a considerable 
 portion excised. Two or three silk stitches of medium thickness 
 are then passed through the muscles, and also through the 
 cortical portion of the kidney, securing a good hold of it. By 
 tying these the kidney is fixed to the posterior abdominal wall, 
 and the wound is then closed. The results of this operation have 
 not always been satisfactory, the symptoms returning. It appears 
 from experiments that sutures passed through the renal paren- 
 chyma are very quickly disintegrated and removed ; and hence, 
 although the kidney may seem to be efficiently immobilized at the 
 completion of the operation, it readily becomes loose again. To 
 obviate this it has been suggested to leave the parietal incision 
 open, merely stuffing it with gauze, so that a firm mass of cica- 
 tricial tissue may develop, extending from the kidney to the sur- 
 face, and thus anchoring it. Some, again, have recommended 
 that the true capsule should be partially stripped off and stitched 
 to the abdominal parietes, the raw surfaces thus formed uniting 
 securely, and fixing the organ ; whilst others advise the isolation 
 of one of the tendons of the spinalis dorsi, which is passed from 
 above downwards under the capsule, as a support on which the 
 kidney is slung. (See report in Clinical Journal, February 5, 
 1896.) 
 
CHAPTER XXXVII. 
 
 BLADDER AND PROSTATE. 
 
 Congenital Affections of the Bladder. 
 
 I. Ectopia Vesica, or Extroversion of the Bladder, is the term given 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 prominent 
 by the pressure from behind of the abdominal contents (Fig. 376, B). This 
 surface is usually irregular, and covered with papilliform processes ; the 
 
 // 
 
 // 
 
 Fig. 376. — Ectopia Vesica. (Tillmanns.) 
 
 B, Exposed mucous membrane of bladder ; U, U, orifices of ureters; 
 H, H, projections of pubic rami on either side. 
 
 orifices of the ureters (U, U) are easily recognised below, urine being occa- 
 sionally emitted from them in forcible jets. The condition is necessarily one ol 
 the greatest discomfort, not only from the constant dribbling of urine causing 
 excoriation and eczema of the thighs and surrounding parts, but also from the 
 pain and irritation due to friction of the clothes against the exposed mucous 
 membrane. The symphysis pubis is always absent, and the horizontal ramus 
 
BLADDER AND PROSTATE 1073 
 
 of the pubic arch terminates on either side in the inguinal region (H, H). The 
 innominate bones are usually rotated outwards, 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 con- 
 siderably impaired. The penis is cleft, and in a condition of complete 
 epispadias ; it is drawn upwards and backwards over the trigone, so that it 
 requires pulling down (as seen in the illustration) to expose the ureteral 
 orifices. The testes are often found in the inguinal canal, or, if in the 
 scrotum, are accompanied by congenital herniae. 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 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 unsatisfactory. 
 The majority of the cases are treated by the application of a urinal, but, 
 unfortunately, the instruments hitherto devised are not particularly efficient. 
 Various operative measures have also been practised with the object of 
 covering the exposed surface, and forming, if possible, a reservoir in which 
 the urine may be retained, (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 granulate, and, if successful, the bladder wall finally 
 lies at the bottom of a sulcus, 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 (b) Plastic operations without interfering 
 with the pelvis have been introduced and practised 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 con- 
 stitutes the anterior wall of the newly-formed bladder, if such it can be 
 called, whilst its raw outer surface is covered in either by flaps derived from 
 either side, or by undercutting the neighbouring skin and sliding it upwards 
 to the middle line, 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. 
 
 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 
 Cloacal Condition may in part persist (see p. 1025). 
 
 Traumatic Affections of the Bladder. 
 
 Rupture of the Bladder may be produced in several ways : 
 (1) It may be due to direct violence applied to the lower part of 
 the abdomen, especially when the viscus is distended. (2) It 
 may complicate 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 simple 
 over-distension, especially if destructive ulceration of its walls is 
 
 68 
 
to74 A MANUAL OF SURGERY 
 
 present ; or it may follow ulceration of a saccule if it contains a 
 phosphatic concretion. 
 
 Rupture of the bladder is divided into two main classes, accord- 
 ing 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 ob- 
 literated hypogastric arteries, and posteriorly on to the rectum. 
 
 Intraperitoneal Rupture involves the posterior or superior por- 
 tions of the viscus, and is the variety most frequently met with. 
 The symptoms produced are severe shock, associated with hypo- 
 gastric pain of a burning nature. The patient experiences a con- 
 stant 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 is 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. 
 
 The Treatment of these cases consists in immediate laparotomy ; 
 the fluid within the peritoneal sac is removed by sponges, and 
 the wound in the bladder clearly demonstrated, preferably with 
 the patient in the Trendelenburg position (p. 1105), which must 
 not, however, be adopted until the urine and inflammatory effusions 
 have been removed. The rent is carefully closed by means of a 
 row of Lembert's sutures, which should always extend a little 
 beyond each extremity 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 cathether 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 cellular 
 tissue, and, if unhealthy, at once gives rise to a most virulent 
 form of suppurative pelvic cellulitis, which is usually fatal from 
 toxaemia or pyaemia. Abscesses tend to 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. 
 If the urine is healthy and uncontaminated with bacteria, and is 
 not allowed to remain long in contact with the tissues, the pros- 
 pects of recovery are good. 
 
BLADDER AND PROSTATE 1075 
 
 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 cystitis 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 cystotomy. In the female digital dilatation of the 
 urethra is the best means of gaining access to the interior of the 
 viscus. 
 
 Methods of Examining the Bladder. 
 
 When a patient presents himself complaining 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. At the first interview 
 it is advisable to ask the patient to void his urine, after which, providing no 
 tight stricture exists, a medium-sized catheter-a-boule, or one of rubber, should 
 be gently introduced, and the amount, if any, of the residual urine estimated 
 
 d 
 
 Fig. 377. — Leiter's Electric Cystoscope. (Tillmanns.) 
 
 a, Electric lamp in beak ; b, glass window for illumination purposes ; 
 c d, switch for opening or closing current. 
 
 and tested. Having gained all the information possible from this source, an 
 examination of the bladder should then be made, or perhaps at a subsequent 
 visit. (1) 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. 1097, 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) As mentioned 
 elsewhere, 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. (5) Of recent years a new means of examining the interior of the 
 bladder has been introduced in the shape of the cystoscope (Fig. 377). 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 eyepiece placed at the end of the instrument, he is able to see the portion cf 
 the vesical wall illuminated by the electric lamp. To use it the bladder must 
 
io?6 A MANUAL OF SURGERY 
 
 be previously washed out, and the patient anaesthetized. About six ounces of 
 boric acid lotion 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. Different ends are supplied to enable 
 the anterior and posterior walls to be examined. Considerable practice is 
 needed for any useful information 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. (6) 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. 
 
 Inflammation of the Bladder. 
 
 Acute Cystitis, or. inflammation of the bladder wall, results 
 from : (i.) Cold in gouty subjects ; in fact, there are certain 
 individuals who often ' take cold ' in their bladders, instead of 
 developing a bronchial or nasal catarrh, (ii.) It is sometimes 
 due to traumatic causes, e.g., the presence of foreign bodies, or 
 injury to the viscus during operation, (iii.) It occurs most fre- 
 quently as a complication of gonorrhoea, owing to an upward 
 extension of the inflammation, and in such cases the symptoms 
 are often very severe, (iv.) It may result from the absorption of 
 irritating poisons, such as cantharides. (v.) Septic cystitis may 
 supervene if a dirty instrument is introduced, and there can be 
 but little doubt that this was a most prolific source of the mis- 
 chief in times past ; it is very likely to occur when the bladder 
 is paralyzed in cases of spinal injury. Under these circum- 
 stances infection may supervene even when sterilized instru- 
 ments are employed, owing to the presence of mucus in the 
 urethra, along which cocci are able to find their way. The im- 
 portance of sterilizing the penis and urethra, and guarding the 
 external meatus by an antiseptic dressing in these cases has 
 already been referred to (p. 634). 
 
 The Bacteriology of cystitis has not been very satisfactorily worked out, but 
 that bacteria are present and play an important part in its production cannot 
 for a moment be doubted. The Bacillus colt is one of the most common 
 microbes found, and may be unaccompanied by other organisms, the urine 
 remaining acid, though stale and objectionable to the smell. How it reaches 
 the bladder is somewhat uncertain, but probably in girls — in whom this 
 variety of cystitis is not unfrequent — it may reach the urinary organs by 
 direct infection from the rectum to the vulva, a vulvo-vaginitis being some- 
 times associated with it. It has also been shown that any wound of the 
 rectal mucosa is liaHe to be followed by migration of bacilli into neighbouring 
 organs. 
 
 More commonly the urine is alkaline and ammoniacal ; in such cases 
 organisms which have the property of decomposing urea are fo.md, such as 
 the Proteus Hauseri, the Diplococcus urea liquefaciens, ordinary pyogenic cocci, 
 etc., with or without the Bacillus coli. 
 
 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 
 irritability of the bladder, frequent efforts of a painful and spas- 
 
BLADDER AND PROSTATE 1077 
 
 modic 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 usually 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 exhaustion, peritonitis, suppurative pyonephrosis, or 
 even acute toxaemia ; occasionally the whole mucous lining of the 
 viscus may slough. In some patients, however, when the inflam- 
 mation is concentrated at the neck of the bladder, retention, dis- 
 tension, 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 use- 
 ful to allay the pain and irritability. As 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. In the worst cases urotropine (5 to 10 grains) 
 salol (10 to 20 grains), and boric acid (15 to 20 grains), adminis- 
 tered by mouth, may do good. 
 
 Chronic Cystitis is much more common than the acute variety. 
 The usual cause is 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, whilst impairment of the nervous 
 mechanism, as in various forms of injury or disease of the spinal 
 cord, may induce trophic changes and predispose to its occurrence. 
 
 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 phos- 
 phate, and a granular sediment of phosphate of lime. It is 
 usually alkaline, perhaps foul-smelling and ammoniacal, con- 
 taining 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 symptom. The 
 patient's general health is not at first affected, but if the symptoms 
 
1078 A MANUAL OF SURGERY 
 
 persist it soon becomes impaired, partly from the absorption of 
 septic products from the bladder, and partly from the 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. 1056). 
 
 Pathological Anatomy. — The mucous membrane is thickened and 
 congested, the superficial veins dilated and even varicose, whilst 
 ulceration is not uncommon. The continued repetition of the 
 acts 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 
 outflow 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 
 retained urine undergoes decomposition. Perforative ulceration 
 occasionally follows, originating a fatal peritonitis or pelvic cellu- 
 litis 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 septic mischief to the kidney. 
 
 The Diagnosis of chronic cystitis is readily made from the 
 characteristic symptoms of irritation of the bladder and the 
 condition of the urine ; but considerable difficulty may be ex- 
 perienced 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. The passage of a catheter or sound 
 will generally detect any obstruction located in the urethra, whilst 
 the bladder is also examined by the different methods described 
 at p. 1075. 
 
 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 strictures dilated. In most cases, even 
 where the cause is not apparent, great benefit will be derived 
 from washing out the bladder. Catheters and other instruments 
 should always be sterilized before use, and lubricated with some 
 antiseptic preparation, such as carbolic oil (1 in 20) ; for it is all- 
 important to remember that sepsis, if not already existent, is 
 easily induced, and that its presence renders the case much more 
 difficult to cure. 
 
 The bladder is best irrigated by passing a soft rubber instru- 
 ment, 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 
 
BLADDER AND PROSTATE 1079 
 
 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 sensa- 
 tions 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 (1 in 10), boric acid (20 grains to 1 ounce), perchloride of 
 mercury (1 in 2,000), or a neutral solution of quinine (2 grains to 
 1 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 ur twice a day. 
 
 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 a milk 
 diet is perhaps the best which can be employed. 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 
 may be of some assistance. Urotropine is useful, acting by setting 
 free formalin 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 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, whilst injections of dilute 
 astringents have been advised, but must be used with caution. 
 
 In cases which do not improve, and if the patient is becoming 
 exhausted from the constant interference with his rest, etc., the 
 only means of treatment left is that of opening the bladder through 
 a perineal incision. Perineal Cystotomy is undertaken not only for 
 the draining of 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 n\ inches in front of the anus 
 to about 1 inch from that opening. The knife divides the deeper 
 structures of the perineum, and, guided by the left index-finger in 
 the wound, 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. The knife is carefully 
 withdrawn, the finger gently inserted into the bladder, and 
 
ioSo A MANUAL OF SURGERY 
 
 the staff removed. After digital exploration of the bladder, a 
 full-sized gum-elastic catheter (No. 16 or 18) 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 irrigation. The catheter is removed and changed 
 at the end of forty-eight hours, and in favourable cases may be 
 discontinued altogether at the end of a week ; in severer cases a 
 permanent opening may have to be maintained. 
 
 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 com- 
 mences in the submucous tissue as a deposit of miliary tubercle, 
 which caseates and suppurates, breaking down, and giving rise to 
 ulcers with undermined edges ; these are rarely of large size at 
 first, are usually multiple, and situated in or near the trigone. 
 The Symptoms are those of chronic cystitis and hsematuria, the 
 irritability of the viscus being very marked. The diagnosis is 
 made by demonstrating the bacillus of tubercle in the urine, and 
 by the cystoscope. The course of the case is unfavourable, the 
 ulcers increasing in size, and death resulting from exhaustion, 
 general infection, phthisis, or extension to the kidneys. 
 
 Treatment. — The case is usually treated for some time as one 
 of chronic cystitis before its nature as a tuberculous affection is 
 ascertained. In the milder cases it may suffice to attend to the 
 general health and hygiene of the individual, and to wash out the 
 bladder with some antiseptic two or three times a week, leaving 
 a drachm or two of a 10 per cent, solution of iodoform in olive 
 oil or glycerine within the viscus. In more advanced cases 
 cystotomy has been undertaken by the suprapubic method, and 
 the ulcerated surfaces scraped and disinfected by applying the 
 galvano-cautery or pure carbolic acid. To effect this the method 
 suggested by Mr. Hurry Fenwick, of using a suitable speculum 
 as a caisson through which to work, is especially to be recom- 
 mended. 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. 
 
 Very similar Symptoms may be induced by the presence of a 
 Simple Ulcer of the Bladder, which, according to Fenwick, occurs 
 not unfrequently. It is usually single, and situated near the neck 
 or trigone, giving rise to great irritability of the viscus and haema- 
 turia, although the urine remains clear. The diagnosis is best 
 made by the cystoscope. Phosphatic deposits sometimes form 
 over the ulcerated surface, and may suggest the existence of a 
 stone. Treatment consists in washing out the bladder with lactic 
 acid (^ to 3 per cent.), or in scraping and cauterizing the base of 
 the sore through a suprapubic incision. 
 
BLADDER AND PROSTATE 
 
 ioSr 
 
 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 and myxoma, but 
 that most often seen is the Papillomatous or Villous Tumour, 
 which appears as a soft flocculent mass, usually situated near the 
 
 trigone, and close to the open- 
 ing of one of the ureters 
 (Fig. 378). The floating tufts 
 or villous processes consist of 
 an extremely delicate con- 
 nective tissue, covered with 
 a layer or two of epithelium 
 similar to that lining the 
 bladder, and traversed by 
 bloodvessels. Occasionally the 
 growths 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 in- 
 fection from the primary 
 growth. 
 
 The Symptoms are those 
 of recurrent haemorrhage, the 
 blood being of a bright red 
 colour, followed later on by irritability of the bladder. At first 
 the haemorrhage is intermittent, considerable intervals occurring 
 between the attacks ; but subsequently it becomes more con- 
 tinuous. 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 mic- 
 turition, leading in some cases to strangury. On standing, this 
 deposit becomes so tenacious and jelly-like as to be poured with 
 difficulty from one vessel to another. The urine may also contain 
 portions of the tumour 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 hydronephrosis. On examina- 
 tion of the bladder with a sound, nothing definite can be detected, 
 unless the surface of the growth becomes encrusted with phos- 
 phates, and no abnormality is noticed on rectal examination. 
 Occasionally a small portion of the growth may be caught in the 
 eye of a catheter. 
 
 Fig. 378. — Villous Tumour of the 
 Bladder. (From King's College 
 Museum.) 
 
1082 
 
 A MANUAL OF SURGERY 
 
 The Prognosis of the case is unsatisfactory, since, although the 
 growth is not at first malignant, it often becomes so, and leads to 
 a fatal termination through exhaustion, haemorrhage, or septic 
 complications. 
 
 Sarcoma of the bladder is an unusual disease, more often seen 
 in children than in adults. In the former it gives rise to multiple 
 polypoid growths, in the latter it is usually single and sessile. 
 The tumour grows rapidly and may attain considerable dimensions, 
 spreading outside the bladder and even invading the pelvic bones. 
 Lymphatic glands are often implicated at an early date. 
 
 Cancer of the bladder may originate in that viscus, or may 
 
 Fig. 379. — Cancer of Bladder. (Royal College of Surgeons' Museum.) 
 
 spread to it from the rectum or neighbouring organs. In the 
 former case, a squamous epithelioma is the usual type ; in the 
 latter, the nature of the growth 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 frequently the neoplasm extends into 
 and infiltrates the walls, whilst marked ulceration is also present 
 
BLADDER AND PROSTATE 1083 
 
 (Fig. 379), 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 pain- 
 less 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 growing 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 tumour involves the internal 
 meatus, micturition may be considerably impaired, whilst if the 
 orifices of the ureters are obstructed, hydronephrosis 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 per rectum to be hard and resistant ; its ulcerated 
 surface may also be seen with the cystoscope. 
 
 The course of the case is similar to that of a somewhat rapidly 
 growing carcinoma, leading to early and marked cachexia, in- 
 creased by the sleeplessness resulting from the vesical irritation ; 
 secondary deposits are found in the viscera and lumbar glands, 
 whilst perforation of the wall may occasionally follow, causing 
 urinary extravasation, septic cellulitis, and death. Another most 
 distressing complication is the establishment of a recto-vesical 
 fistula, through which the urine makes its way into the rectum, 
 thus intensifying the sufferings of the patient. 
 
 The Diagnosis of a vesical tumour can only be made with 
 certainty by the cystoscope, 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 irritability, and 
 cannot otherwise be explained, a tumour of the bladder may be 
 suspected. The question as to whether or not it is malignant 
 can only be determined by a careful examination of the symptoms. 
 In simple papilloma, and the superficial type of epithelioma, 
 haemorrhage precedes the irritability ; but whilst it is usually im- 
 possible to detect the villous growth either by examination with 
 
1084 A MANUAL OF SURGERY 
 
 the sound or from the rectum, a fungating malignant growth may 
 sometimes be recognised by the sound. In the infiltrating type 
 of malignant disease, on the other hand, pain and 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 appearance 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 of the Bladder. — In the early stages, 
 when the diagnosis of a tumour has not been confirmed, the 
 haematuria may be treated with ordinary haemostatic remedies, 
 such as a mixture containing dilute sulphuric acid and ergot, or 
 turpentine administered in capsules (10 minims three times a day). 
 When once a diagnosis has been established, removal by operation 
 is the only plan which holds out any hope to the patient, and such 
 can only be undertaken with any prospect of success in benign 
 growths, or in the very earliest stages of the superficial form of 
 malignant disease. The bladder is laid open either by perineal 
 or suprapubic cystotomy, and the growth removed by the curette. 
 The suprapubic operation is certainly preferable, in that it gives 
 one the opportunity of definitely seeing the interior of the bladder. 
 The plan already mentioned of employing an expanding speculum 
 as a caisson will be found useful ; when all moisture has been 
 sponged away or sucked up, the vesical wall is seen at the bottom 
 of this tube by means of an electric lamp fitted to the surgeon's 
 head. In default of a better instrument, a Fergusson's speculum 
 can be utilized. Growths may be removed by means of long- 
 handled instruments specially adapted for the purpose, and the 
 base from which they spring must be carefully cauterized. 
 
 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 irritability is very great, a 
 permanent suprapubic or perineal opening may be established. 
 
 Functional Derangements of the Bladder. 
 
 Incontinence of Urine. — -A patient is said to be suffering from 
 incontinence when the urine escapes involuntarily, dribbling away 
 either constantly or intermittently from the urethra. 
 
 i. Active Incontinence is often present in young children, mostly 
 boys. It results from some condition of increased excitability of 
 the urinary apparatus, and is looked on by some as of a choreic 
 nature ; in other instances, it is probably due to weakness of the 
 sphincter vesicae, which is unable to resist the pressure induced 
 by even a small amount of urine. The chief sources of irritation 
 are phimosis, ascarides in the rectum, a rectal polypus, or urine 
 
BLADDER AND PROSTATE 1085 
 
 of high specific gravity, containing uric acid crystals in suspen- 
 sion. The affection is most obvious at night, and, indeed, may 
 only occur during sleep ; it has been known to persist till adult 
 life is reached. Somewhat similar in nature to this is the irrita- 
 bility of the bladder induced by calculus, inflammation, or ulcera- 
 tion, where frequent calls to micturition are experienced ; to this, 
 however, the term ' irritability of the bladder ' is applied, ' incon- 
 tinence ' being only used where no active disease of the viscus is 
 present. 
 
 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 of the bad habit. Tonics, e.g., iron, 
 arsenic, and quinine, may be administered, and tincture of bella- 
 donna should also be given in full doses. Instruments have been 
 used for compressing the urethra at night, and are stated in some 
 cases to have effected a cure. 
 
 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 
 distended. 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 either temporarily or permanently impair 
 its function. Thus, in severe shock, the bladder is unconsciously 
 evacuated from relaxation of the sphincter ; but if the lumbar 
 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 overflow supervenes. Paralytic incontinence 
 occasionally follows overdistension 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 Incontinence 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, 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 detected 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 
 
io86 A MANUAL OF SURGERY 
 
 bladder may be so distended as to contain several pints of urine. 
 Very much the same state of things obtains in paralysis due to 
 spinal mischief (p. 643). Treatment must be directed to keeping 
 the bladder emptied by the regular use of the catheter, but it 
 often remains in an atonic state for some time. 
 
 Atony of the Bladder is the term applied to a condition in which 
 the patient is unable to expel its contents, not in consequence of 
 any true paralysis of the muscular walls, but simply from loss of 
 tone. The most usual causes are: (1) Chronic overdistension, the 
 result of obstruction to the outflow, owing to enlarged prostate or 
 stricture, as just described : (2) a single prolonged voluntary or 
 involuntary overdistension ; for instance, owing to the oversight 
 of a house-surgeon, a patient suffering from retention after an 
 operation for varicocele was left unrelieved for more than twenty- 
 four hours, whereby atony was induced. (3) It occasionally 
 follows cystitis, especially that associated with gonorrhoea. (4) In 
 old age atony is sometimes due to simple loss of nerve tone, a 
 condition very similar to that which occurs after or in the course 
 of infective fevers, such as typhus, and is even met with after 
 influenza. 
 
 In the slighter cases all that is noticed is some hesitation or 
 difficulty in commencing the act of micturition, whilst the flow 
 of urine is weak, and cannot be efficiently completed, a few drops 
 dribbling away afterwards. In worse cases a considerable amount 
 of residual urine may be left in the bladder, and this may lead 
 to chronic distension with overflow, and by its decomposition to 
 chronic cystitis. In other cases actual retention may be induced. 
 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 distension of the bladder, and the 
 administration of strychnine, phosphoric 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 muscular fibres ; one elec- 
 trode is inserted into the bladder, and the other placed over the 
 hypogastrium. 
 
 Retention of Urine. — When a person is unable to expel the 
 contents of the bladder, so that it becomes distended, retention 
 is said to be present. It results from a variety of conditions, 
 classified as follows : (1) Penile and urethral causes, e.g., phimosis, 
 or congenital occlusion of the urethra, a ligature or ring placed 
 around the penis, impacted calculus, the so-called congestive or 
 spasmodic stricture, organic stricture, urethral or perineal abscess, 
 ruptured urethra, etc. : (2) Prostatic causes, e.g., inflammation, 
 abscess, tumour, hypertrophy, calculus : (3) Vesical causes, e.g., 
 atony, paralysis, calculus, tumours, etc. : (4) Reflex irritation, 
 such as occurs after operations on the rectum and anus, or in- 
 volving the spermatic cord : (5) Hysteria : (6) Pressure from 
 
BLADDER AND PROSTATE 10S7 
 
 neighbouring organs or external tumours, e.g., uterine fibroids, 
 or retroversion of the gravid uterus. In investigating any 
 particular case, the age and condition of the patient must be 
 taken into consideration, and also the character of any preceding 
 urinary symptoms, whilst a careful examination should be made. 
 Speaking generally, one may state that the most common cause 
 of retention in infants is phimosis ; in children, impacted calculus, 
 or a ligature around the penis : in young men, gonorrhoea or 
 one "of its complications; in young women, hysteria, or foreign 
 bodies in the bladder ; in adult men, stricture ; in adult women 
 some uterine condition ; and, in old men, hypertrophy of the 
 prostate. 
 
 If left unrelieved, the urine accumulates and the bladder 
 becomes distended, giving rise to much pain and discomfort. One 
 of two conditions is certain to follow : (a) In cases of retention 
 from stricture the dilated urethra behind the seat of obstruction 
 gives way, resulting in extravasation of urine. If, however, the 
 bladder wall is weakened by the presence of sacculation, rupture 
 of a saccule may follow, causing pelvic extravasation, (b) When 
 the retention arises from atony or paralysis, or from some ob- 
 struction which can be to some extent overcome, distension with 
 overflow is produced. 
 
 Inasmuch as retention is merely a symptom, the treatment 
 necessarily varies with the cause. 
 
 Abnormal Conditions of the Urine. 
 
 1. Urinary Deposits. — Uric or lithic acid is eliminated in the 
 form of ' cayenne-pepper ' granules, usually known as gravel. 
 On microscopic examination, the granules are found to consist 
 of flat rhomboidal, lozenge-shaped plates, or masses of acicular 
 crystals (Fig. 380). They are of a dusky brownish-red colour, due 
 to' the absorption of urobilin, the normal pigment of the urine. 
 The secretion 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 reacidulating such a solu- 
 tion, the uric acid is precipitated in the shape of white needle- 
 shaped crystals. 
 
 Urates or lithates of potassium, sodium, or ammonium are of 
 frequent occurrence in the urine, appearing as a deposit of 
 amorphous granules of variable colour, according to the amount 
 of urinary pigment present, and this is often known as a ' lateri- 
 tious,' or brick-dust sediment. The ammonium salt is sometimes 
 found in the shape of spiculated globular bodies (Fig. 381). 
 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 precipitated. The muvexide test 
 may be applied either for uric acid or its salts ; it consists in 
 
A MANUAL OF SURGERY 
 
 mixing the substance to be tested with a little nitric acid, and 
 evaporating to dryness, when an orange-red discoloration is pro- 
 duced, which on the addition of liquor ammonia? changes to a deep 
 purple-red. 
 
 A deposit of uric acid or urates is either a temporary condition 
 dependent on some trivial derangement of the system, or is a 
 phenomenon constantly recurring and due to too great an in- 
 dulgence in nitrogenous food, too little fresh air and exercise, or 
 imperfect digestion, the result of some hepatic disturbance. It 
 is also noted in conditions where great tissue change is occurring, 
 as after violent exercise or in fevers. Under these circumstances 
 the materials which should be changed into urea are transformed 
 into uric acid or its salts. When such a tendency is continually 
 
 i£*>.to 
 
 r 
 
 ' j p '-' 
 
 j# 
 
 Fig. 380 — Uric Aciu Crystals. 
 
 Fig. 381. — Urate of Ammonium 
 in Amorphous Granules and 
 Hedgehog-shaped Bodies. 
 
 present, the patient is often said to be suffering from Lithiasis or 
 Lithsemia. Should the individual be incapable of eliminating the 
 material thus formed, an attack of gout or rheumatism is likely 
 to supervene, whilst it must always be borne in mind that the 
 formation of a uric acid calculus is merely a manifestation of the 
 same diathesis, which needs careful treatment after the removal 
 of the stone, if a recurrence of this painful affection is to be 
 prevented. 
 
 The Treatment of lithsemia or lithiasis consists mainly in atten- 
 tion 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. Regular habits are enforced, and plenty 
 of outdoor exercise recommended. The hepatic secretion is 
 stimulated, and the bowels regulated by the administration of 
 saline purgatives, especially natural mineral waters, e.g., Fried- 
 richshall, 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. 
 
 Oxalate of lime usually occurs in the urine of dyspeptic and 
 hypochondriacal patients, who are pale, nervous, and irritable. 
 
BLADDER AND PROSTATE 
 
 1089 
 
 It is supposed to arise from the incomplete oxidation of carbo- 
 hydrate 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. On microscopic examination they 
 are found to be regular octahedra, or in the shape of dumb-bells 
 (Fig. 382). The tve.atment of oxaluria consists in regulation of 
 
 Fig 382. — Oxalate of Lime in Octahedral Crystals and Dumb-bell- 
 shaped Masses. 
 
 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 dis- 
 tilled water. Tonics, such as mineral acids, iron, and quinine, 
 may be ordered, but the best treatment consists in change of air 
 and removal, if possible, from causes of anxiety and worry. 
 
 Phosphatic deposits in the urine occur in three forms : (i.) The 
 triple phosphate, or ammonio-magnesic, is found in alkaline or 
 
 4^ 
 
 Fig. 383. — Crystals of Triple Phosphate in Urine. 
 
 decomposing urine, and is always 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 appear- 
 ance of a ' knife-rest ' is produced (Fig. 383). (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 unfrequently 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 an alkaline saline purgative has been taken before 
 breakfast. The phosphatic material is voided at the end of the 
 act of micturition, and may give rise to considerable anxiety 
 
 69 
 
logo A MANUAL OF SURGERY 
 
 on the part of the patient, who mistakes it for seminal fluid, 
 (iii.) The most usual condition in which phosphates are met with 
 in urine is a mixture of the two varieties described above. Which- 
 ever form is present, the deposit becomes more evident on boiling, 
 disappearing, however, on the addition of a few drops of acid. 
 The treatment of phosphaturia is always directed to the vesical 
 condition, except in those unusual cases where it is due to some 
 constitutional error. 
 
 2. Hematuria, or the admixture of blood with the urine, is 
 best described according to the source from which the blood 
 is derived. 
 
 (a) Renal hematuria results from acute inflammation, conges- 
 tion, 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 haematuria 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 luematobia. 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 lower bowel (p. 1027). 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, pyonephrosis may be induced. No specific treatment 
 has at present been discovered, but in most cases the disease 
 after a time disappears spontaneously. 
 
 (c) Prostatic haematuria may be caused by congestion, calculus, 
 ulceration, or malignant disease ; the blood passes back into the 
 bladder, and hence the phenomena simulate the vesical condition. 
 Examination of the prostate from the rectum 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 in- 
 dependently of micturition, whilst the first few drops of the stream 
 are also coloured. 
 
 (e) Haematuria is occasionally of constitutional origin, arising 
 from purpura, scurvy, or haemophilia ; other evidences of these 
 diseases will be observed, and render the diagnosis evident. 
 
 Microscopical 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 
 haemoglobinuria,' in which corpuscles are absent. The latter 
 
BLADDER AND PROSTATE 109 1 
 
 condition is supposed to be due to vaso-motor spasm of the renal 
 vessels, 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 suspected urine is subsequently added, and sinks to the 
 bottom of the test-glass ; a copious precipitate forms at the line 
 of junction of the two fluids, which on standing becomes a bright 
 blue colour if blood is present. 
 
 The investigation of a case of haematuria 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 micturi- 
 tion 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 dis- 
 coloured, 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 ex- 
 amination of the urine may lead to the discovery of shreds of 
 tumour, epithelial cells, or blood-casts, which could be alone 
 derived from some special part of the urinary 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. 
 
 3. Pyuria is the term applied to the admixture of pus or muco- 
 pus with the urine. It always results from inflammatory affec- 
 tions 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 haematuria. 
 
 Pus in urine is mainly recognised by the microscope, whilst on 
 the addition of liquor potassae it becomes ropy. 
 
 4. Chyluria arises from distension or rupture of the lymphatic 
 vessels in the vesical mucous membrane, and is usually due to 
 the presence of the Filavia sanguinis hominis (p. 316). The urine 
 is milky in colour, and on microscopical examination this is found 
 to be due to the presence of an emulsion of fat. 
 
 5. 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 attempting any operative proceedings ; and this is 
 the more essential because it is well known that this condition 
 often exists quite unexpectedly and entirely apart from symptoms. 
 
1092 A MANUAL OF SURGERY 
 
 Tests. — Many different methods have been adopted for detect- 
 ing 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. (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 pouring the cold urine into a test-tube, and carefully 
 adding the acid, so as to form a stratum below the urine ; at the 
 line of junction of the two, a white film is formed, if albumen is 
 present. (3) With picric acid a yellowish-white precipitate is 
 thrown down, increased by boiling. If the urine is neutral or 
 alkaline, it must first be rendered slightly acid by the addition of 
 a few drops of acetic acid. 
 
 When once the existence of albumen in the urine has been 
 ascertained, its source and its significance must be investigated. 
 A careful microscopical examination of the sediment is made, so 
 as to determine whether casts or pus cells are present. The con- 
 dition 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. (1) When it 
 occurs in the course of some disease involving long-standing sup- 
 puration, such as septic affections 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) Albu- 
 minuria may be intermittent, 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 
 
BLADDER AND PROSTATE 1093 
 
 diet so to diminish it as to warrant the performance of slight 
 operations ; but where the condition is at all advanced, all 
 operations de complaisance are absolutely contra-indicated, and only 
 the chief surgical emergencies should be knowingly dealt with, 
 viz., haemorrhage, asphyxia, intestinal obstruction or strangula- 
 tion and retention of urine. In cases of 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 express wish of 
 the patient, if the increased risks associated with it have been ex- 
 plained to him. The importance of not operating on these patients 
 depends on the facts that they tolerate an anaesthetic badly, that 
 the tissues are in a condition of lowered vitality, and hence the 
 process of repair is hindered, septic inflammations and erysipelas 
 are very prone to develop, whilst secondary haemorrhage is likely 
 to follow, owing to the high pulse tension. Again, boils and 
 carbuncles 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 inflammation to the kidneys from surgical affections 
 of the lower urinary organs, and a fatal result from shock or sup- 
 pression of urine may be induced by operations under these con- 
 ditions. (5) It is occasionally 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 digitalis has been administered in sufficient doses to alleviate 
 the urgent symptoms. 
 
 6. Diabetes. — The presence of sugar in the urine is also a matter 
 of the greatest importance from a surgical standpoint, and its 
 existence or not should always be carefully ascertained. The 
 chief tests employed are as follows : (1) 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 admixture 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. 
 
 The effect of diabetes is very similar to that of albuminuria, in 
 that it leads to diminished vitality of the tissues, and consequently 
 predisposes to the occurrence of sepsis, and of such infective 
 inflammations as boils and carbuncles. Peripheral neuritis and 
 
ICQ4 
 
 A MANUAL OF SURGERY 
 
 sclerosis of the smaller vessels are also induced by this disease 
 in the later stages, and hence gangrene of the extremities is likely 
 to occur, especially in chronic cases and in elderly people. The 
 essential cause of trouble, however, is sepsis, and hence if the 
 most rigid aseptic precautions are taken there is no reason why 
 operative proceedings should not be undertaken in conditions of 
 danger and urgency. Thus several cases have been reported 
 lately in which such serious proceedings as total removal of the 
 breast and axillary contents for scirrhus, or appendicectomy, have 
 been safely undertaken in confirmed diabetics. 
 
 Stone in the Bladder. 
 
 Varieties. — A vesical calculus may be formed of almost any of 
 the urinary deposits commonly met with, and each has its own 
 special characteristics. 
 
 (a) The uric add calculus (Fig. 384) is usually an oval, flattened 
 
 J£<I- ■-■■ 
 
 Fig. 36 
 
 . — Uric Acid Calculus in 
 Section. 
 
 Fig. 385. — Oxalate of Lime 
 Calculus from Outside and 
 on Section. 
 
 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. 
 
 (b) 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 mulberry calculus (Fig. 385, A and B) 
 is a rough, irregular body, sometimes evenly nodular, but not 
 unfrequently tuberculated, or even spiculated. It is extremely 
 hard and dense, laminated, and of a dark red-brown colour, or 
 
BLADDER AND PROSTATE 1095 
 
 sometimes black, owing to admixture with blood. It is rarely of 
 great size, on account of the irritation caused by its presence, and 
 its slowness of growth. 
 
 (d) A pure phosphatic calculus is very uncommon, but any stone 
 or foreign body is certain to become coated with a phosphatic 
 deposit when chronic cystitis has resulted in alkaline decomposition 
 of the urine. Occasionally concretions of a similar nature form 
 spontaneously in saccules of the bladder ; such bodies are white 
 and chalky 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 some- 
 what denser calculus is produced, which is sometimes termed a 
 fusible calculus, owing to the fact that it fuses to a bead under the 
 blowpipe flame. Occasionally a phosphate of lime 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. 
 
 (/) Xanthine, or xanthic oxide, occurs very exceptionally as a 
 calculus of a reddish colour. 
 
 Structure of a Calculus. — A calculus usually consists of the 
 following parts : 1. 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 lime, or of whatever 
 substance the stone is composed ; not unfrequently the composi- 
 tion of adjacent laminae differs, leading to what is known as an 
 alternating calculus. Each lamina consists of myriads of minute 
 crystals, held together by vesical mucus, with wdiich 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. 
 Sometimes there is only one, but 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 
 
IC96 A MANUAL OF SURGERY 
 
 gradually increases until it is fairly common in elderly men. 
 The condition is comparatively rare in women, owing 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 be explained by the large amount of fluid withdrawn 
 from the body by perspiration. 
 
 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 symptoms, whilst old men often tolerate a 
 large stone without much inconvenience ; ceteris paribus, an oxalate 
 of lime calculus is always more irritating than one composed of 
 uric acid. The classical symptoms of a vesical calculus may be 
 preceded by a history of the patient having passed ' gravel ' for 
 a long time, on the cessation of which the calculous symptoms 
 commenced. 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 
 haematuria of a vesical type, though this is not a prominent 
 feature. All these phenomena are increased in severity by jolting, 
 jumping, 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 depending on the straining induced by the calculus. Thus, 
 tenesmus, followed by piles or prolapsus ani, may be produced 
 by sympathetic 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 Ihe bladder of a child after 
 circumcision for phimosis. 
 
BLADDER AND PROSTATE 1097 
 
 The actual Diagnosis of vesical calculus can only be made by 
 sounding. In order to accomplish this, the patient 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 
 ounces of fluid, so as to obliterate any folds produced by laxity 
 of the mucous membrane, as well as to facilitate the introduction 
 of the instrument. A sound of suitable size, warmed and lubri- 
 cated by some antiseptic oil or ointment, is then gently passed 
 along the urethra, and depressed between the separated legs so as 
 to enable it to enter the bladder. The handle of the instrument, 
 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 instrument 
 13 drawn forwards or backwards in the urethra. Each side of 
 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 alternately 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 medium-sized tube of a Bigelow's 
 evacuator, and washing out the bladder. The calculi may by 
 this means be washed out even from sacculi, 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 cal- 
 culus, especially 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. 
 
 Course of the Case. — A patient suffering from vesical calculus is 
 certain, sooner or later, to develop symptoms of chronic cystitis, 
 and septic changes in the urine are equally sure to follow- 
 possibly as a natural sequence, but more probably as the result 
 of the introduction of septic instruments. The bladder is hyper- 
 trophied, and if the stone is not removed, the mucous mem- 
 brane becomes ulcerated, and the inflammation extends to the 
 kidneys ; the patient's life is thus destroyed partly by exhaustion, 
 and partly by septic or uraemic poisoning. Occasionally a calculus 
 
iog8 
 
 A MANUAL OF SURGERY 
 
 becomes encysted in the saccule of a dilated bladder ; it increases 
 in size only on that part of the stone which is exposed at the 
 mouth of the saccule, and hence may become ( — 
 more or less mushroom-shaped. It is recog- 
 nised by the sound always striking it in the 
 same situation. 
 
 The Treatment of vesical calculus is a matter 
 which has exercised the judgment and manipu- 
 lative dexterity of surgeons for many generations. 
 A large number of operations have been made 
 use of, but at the present day only three are 
 employed, viz., lithotrity, lateral lithotomy, and 
 suprapubic cystotomy. 
 
 Lithotrity was formerly conducted at several 
 sittings, the stone being crushed, and the patient 
 allowed to pass the debris subsequently ; 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 opera- 
 tion, and enables it to be completed at one 
 sitting, constituting 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 to slightly raise the pelvis. The 
 bladder is carefully washed out with some bland 
 antiseptic, such as a solution of boric acid, and 
 about 6 ounces of lotion left within it, in order 
 not only to obliterate all folds of mucous mem- 
 brane, but also to facilitate the seizure of the 
 stone, and to prevent injury of the walls during 
 the operation. 
 
 The lithotrite is then introduced. The best instrument to 
 employ is Thompson's modification of Civiale's (Fig. 386), the 
 male blade of which is solid, and the female fenestrated. Other 
 
 "CSSS?"'"' 
 
BLADDER AND PROSTATE 
 
 io<59 
 
 forms are sometimes used in which the female blade is solid, and 
 is either the same size or larger than the male, in order to protect 
 the walls of the bladder from injury. 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 instrument 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 position of the stone is next ascertained by 
 
 Fig. 387. — Evacuator in Position in the Bladder 
 
 rotating the instrument ; the blades are opened, and the stone 
 caused to roll between them by a slight 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 subsequently 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 away, and the 
 manoeuvre must then be carefully repeated. When the surgeon 
 is satisfied that the fragments are sufficiently small, the largest 
 evacuator-tube that can be safely introduced is passed into the 
 bladder. To effect this, it is sometimes necessary to incise the 
 urethral orifice with a bistoury in a downward direction. The 
 evacuator is attached to the tube, and the bladder thoroughly 
 washed out by alternate pressure upon, and relaxation of, the 
 rubber bottle. By this means the fragments of the stone are 
 
A MANUAL OF SURGERY 
 
 collected in the glass receptacle which forms part of the appar- 
 atus. The washing is continued until no more fragments are 
 heard or felt to rattle against the end of the tube. It is often 
 necessary to reintroduce the lithotrite in order to crush some 
 larger portions of the calculus still remaining ; the old practice 
 of withdrawing small fragments within 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 bladder is likely to become subsequently dis- 
 tended with 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 
 relieved by a little morphia. If all goes well, he may be allowed 
 to get up at the end of the week. 
 
 Various Secruelse may follow this operation. Cystitis results 
 partly from mechanical causes, but more frequently from imper- 
 fect asepsis. The symptoms are usually subacute in character, 
 and may pass away after a few days ; but if due to sepsis, 
 considerable constitutional disturbance arises, and a large amount 
 of viscid muco-pus is excreted, whilst the urine frecomes alkaline 
 and ammoniacal. In such a case it is absolutely essential to 
 wash out the bladder once or twice a day, as if left to itself 
 the condition is very liable to spread up to the ureters, and may 
 destroy the patient's life by suppurative pyelonephritis. Atony of 
 the bladder is occasionally induced, either by the operation or by 
 a consequent cystitis, and is especially common in elderly indi- 
 viduals. It must be treated by regular and aseptic catheterism. 
 When the patient's kidneys are already affected prior to the 
 operation, any of the conditions described under urinary fever 
 (p. 1126) may be originated by it, even including suppression of 
 urine. 
 
 Lateral Lithotomy is an operation which has always been of 
 great interest to the surgeon, although at the present day it is 
 comparatively seldom performed. The patient, having been suit- 
 ably prepared, is anaesthetized, and the perineum shaved. A 
 sound is passed so as to make certain of the presence of the 
 calculus, and the bladder washed out, about 6 or 7 ounces of an 
 antiseptic solution being left in. A fully curved staff, grooved 
 on the left side, is introduced and handed over to the care of a 
 trustworthy assistant. The patient is then, and not till then, 
 placed in the lithotomy position, i.e., his hands and ankles are 
 approximated and held together by bandages or suitable shackles ; 
 a Clover's crutch is useful when the surgeon has not plenr.y 
 
BLADDER AND PROSTATE 
 
 of help. The staff is held in the assistant's right hand, the left 
 hand being used to support the scrotum ; the operator usually 
 prefers the staff to be held well up under the arch of the pubes. 
 As a final preparation before commencing, the left index-finger is 
 inserted into the rectum, partly in order to ascertain the depth 
 of the perineum, and partly to see that the bowel is empty, and 
 to induce contraction of its walls, and thus minimize the risk 
 of injury by the knife. Of course the finger is afterwards care- 
 fully purified before placing it in the wound. 
 
 The superficial incision (Fig. 389) commences at a point iA 
 
 Fig. 
 
 . — Knife, Staff and Forceps used in Lateral Lithotomy. 
 (Down Brothers.) 
 
 inches in front of the anus, a little to the left of the central raphe, 
 and extends downwards and outwards to a spot just external to 
 the middle of a line from the anus to the tuber ischii, being 
 deeper behind than in front, and dividing the skin, subcutaneous 
 tissue, and inferior haemorrhoidal vessels and nerves. The in- 
 cision is carefully deepened by the section of any resisting bands 
 until the transverse perineal nerves and vessels are cut through, 
 as also the deeper layer of superficial fascia and anterior layer of 
 the triangular ligament, which are continuous around the trans- 
 versa perinei muscle. The left index-finger is then pushed on 
 into the wound, so as to ascertain the position of the staff, and 
 the knife is carried on towards it, and made to enter the groove 
 at a point corresponding to the membranous portion of the 
 urethra (Fig. 390). When once the knife is felt to be well in 
 
A MANUAL OF SURGERY 
 
 the groove it is pushed on into the bladder, the handle being 
 depressed, and the blade somewhat lateralized. It is most 
 important that the point and back of the knife should never leave 
 the groove in the staff, or the rectum is likely to be wounded ; 
 
 Fig. 389. — Superficial Incision in Lateral Lithotomy. (Fergusson ) 
 
 as it is passed onwards, the membranous portion of the urethra, 
 together with the deep constrictor, is divided, as also the capsule 
 of the prostate, whilst the left lateral lobe of that organ is freely 
 notched. The knife is then carefully withdrawn. The left 
 
 Fig. 390. — Deep Incision in Lateral Lithotomy. (Fergusson.) 
 
 index-finger may now be inserted along the urethra into the 
 bladder, keeping the finger-nail in the groove. The opening in 
 the prostate is enlarged by twisting the finger once or twice as 
 it lies in the wound. If possible, the surgeon feels the calculus 
 
BLADDER AND PROSTATE iioj 
 
 with the tip of the finger, or, at any rate, satisfies himself that 
 he has entered the bladder before the staff is withdrawn. After 
 its removal the wound is still further dilated by rotation of the 
 finger, so as to facilitate the entrance of the lithotomy forceps, 
 which is the next step in the proceeding. These are inserted by 
 sliding them along the back of the index-finger, and when once 
 introduced the finger may be withdrawn, being usually followed 
 by a gush of lotion, which may carry the calculus into the grasp 
 of the forceps. As a rale, however, it is necessary to feel for 
 the stone, and grasp it by opening and closing the blades. The 
 surgeon must then endeavour to manipulate the calculus, so as 
 to have its shortest diameter presenting. The forceps, with the 
 stone in its grasp, is then gently withdrawn by pulling well 
 down along the axis of the pelvic outlet. Great care must be 
 exercised not to use any undue violence, for fear of bruising and 
 lacerating the neck of the bladder ; gentle side-to-side move- 
 ment is perhaps the best to employ. Should the calculus be 
 larger than was at first expected, the urethra and prostate may 
 be notched with a probe-pointed bistoury on the right side, so 
 
 zjswms^ 
 
 Fig. 391; — Lithotomy Scoop, and Position of Finger in 
 extracting stone. 
 
 as to enlarge the aperture, or the tissues may be gently pushed 
 back with the index-finger, whilst steady traction is exercised. 
 If the calculus breaks into several pieces or if many calculi are 
 present, the fragments may be removed by means of the finger 
 and lithotomy scoop (Fig. 391). The bladder is now once more 
 thoroughly searched, washed out with an antiseptic, and all evident 
 haemorrhage stopped. In most cases it is advisable to introduce 
 through the wound a gum-elastic vaginal tube or a large catheter, 
 which is left in position for a few days. 
 
 The After-Treatment consists in keeping the patient quiet, with 
 his legs tied together, a pad of wool being placed against the 
 perineal wound, which is syringed out once or twice a day 
 through the tube. When the wound begins to granulate, the 
 tube may be removed ; the urine escapes for a time through the 
 perineal opening, which, however, contracts gradually, and closes 
 in most instances in the course of two or three weeks. The 
 patient should be kept on a light non-stimulating diet, with plenty 
 of diluent drinks, such as barley-water. 
 
 Complications and Dangers of Lateral Lithotomy. — (1) Hamor- 
 rliage may arise from three sources : the superficial arteries of the 
 
1 104 A MANUAL OF SURGERY 
 
 perineum, the deep branches of the pudic, especially that which 
 passes to the bulb, and the veins of the prostatic plexus. The first 
 of these are divided in the superficial incision, and may be readily 
 secured, if necessary, by forceps and ligature. The artery to the 
 bulb is not likely to be wounded if the incision is limited anteriorly 
 according to the directions given above ; if, however, this trunk 
 or its branches in the bulb are cut, free arterial haemorrhage 
 follows, which is usually stopped without difficulty by opening 
 up the wound and seizing the bleeding-points with forceps. The 
 internal pudic artery runs but little risk of injury except in those 
 cases where it follows an abnormal course ; it is readily treated 
 on general principles. Venous haemorrhage from the prostate is 
 a more serious matter, and is especially prone to occur in elderly 
 persons with prostatic hypertrophy. It is recognised by venous 
 blood welling up from the depths of the wound, or possibly, if 
 not evident at the time of the operation, by the bladder becoming 
 distended with clot, considerable pain being thereby induced. If 
 noticed during the operation, it is treated by syringing out the 
 wound with iced lotion, and the insertion of an air tampon or 
 a petticoated tube. The former contrivance consists of a gum- 
 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 latter is not 
 obtainable or fails to act ; it is made by tying a petticoat of lint or 
 gauze around the distal end of a vaginal tube ; this is 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 superficial incision too far backwards, or 
 by keeping it too near the middle line behind ; or it may occur 
 later in the operation by not maintaining the point of the knife 
 strictly in the groove. It is more liable to happen, however, whilst 
 withdrawing the knife, the point being swept backwards, thus 
 opening the bowel ; it most frequently happens to boys. 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 by cicatrization without special treat- 
 ment ; but when high up and more extensive, a recto-vesical 
 fistula is likely to follow. The treatment usually recommended 
 in such a case is to divide the sphincter, and thus lay the lower 
 end of the rectum and the lithotomy wound into one cavity, the 
 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 
 
BLADDER AND PROSTATE 1105 
 
 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 
 iikely 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) Septic Cystitis, 
 and extension of the inflammation to the kidneys, occasionally 
 supervenes, whilst life may be also destroyed by shock, suppres- 
 sion of urine, or pyaemia. 
 
 Lateral Lithotomy in Boys was formerly considered one of the 
 most successful major operations in surgery, but at the present 
 time it has been proved that lithotrity can be equally well prac- 
 tised, provided suitable instruments are employed and the external 
 meatus is incised. Should a cutting operation be required, the 
 high position of the bladder lends itself most favourably to the 
 suprapubic method, which is now extensively practised. The 
 chief peculiarities of lateral lithotomy in boys consist in the rudi- 
 mentary nature of the parts involved, and in the fact that the 
 bladder is an abdominal rather than a pelvic viscus. Hence the 
 deep incision always travels beyond the limits of the prostate, 
 whilst the knife has to pass relatively higher than usual in order 
 to reach the bladder. Considerable difficulty is also experienced 
 in touching the stone with the finger, and if much force is used, 
 the neck of the bladder may be torn through, and fatal cellulitis 
 ensue. Atrophy of the left testis has happened as a sequela of 
 this operation owing to section of the ejaculatory duct in the 
 prostate. 
 
 Suprapubic Cystotomy is an operation which has been exten- 
 sively practised of recent years, and with considerable success. 
 The chief difficulty consists in displacing the anterior reflection 
 of the peritoneum, so as to expose the bladder without injuring 
 it. This is, however, readily accomplished by the use of Trendelen- 
 burg's position. The bladder is washed out, and 8 or 10 ounces of 
 lotion left within it ; the patient is then placed with the pelvis 
 raised well above the head, the intestines being thus allowed to 
 gravitate to the postero-superior part of the abdomen ; as soon as 
 the abdominal parietes are opened, air rushes into the connective 
 tissue behind the symphysis (cavum 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 
 reaching 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 entrance of atmo- 
 
 70 
 
no6 A MANUAL OF SURGERY 
 
 spheric air into this cavity further assists in the depression of the 
 peritoneum. The tense rounded outline of the bladder can now 
 be readily detected with the finger, and a couple of lateral silk 
 sutures or slings 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, through which the index-finger is passed 
 and the stone examined. Suitably curved lithotomy forceps are 
 introduced, and the stone grasped and withdrawn. The after- 
 treatment of the wound is a point on which much difference of 
 opinion has been expressed. Some leave it open, allowing it to 
 heal by granulation ; this is especially advisable if much cystitis 
 is present. When, however, the bladder is tolerably healthy, it 
 may be closed by sutures, which only pass through the muscular 
 and 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 become extravasated. 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. 
 
 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-indication is present, all cases of vesical 
 calculus should be treated by lithotrity. 
 
 The Contra-indications to Lithotrity are as follow : (i) Conditions 
 of the Stone. If the calculus exceeds i^ inches in diameter, it is 
 not advisable to attempt lithotrity on account of the damage 
 which may be inflicted on the vesical wall. Moreover, some 
 stones, especially those consisting of oxalate of lime, are so hard 
 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 encysted stone will also pre- 
 clude 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 
 difficult. Excessive irritability of the urethra, as evidenced by 
 the occurrence of severe rigors after instrumentation, may alsG 
 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 lithotomy ; whilst a contracted bladder, which will only hold a 
 
BLADDER AND PROSTATE 1107 
 
 few ounces of urine, materially increases the dangers and diffi- 
 culties of lithotrity. 
 
 Having thus described the conditions which contra-indicate 
 lithotrity, a choice must be made between entering the bladder 
 from the perineum or above the pubes. 
 
 Indications for Lateral Lithotomy. — (1) Where cystitis and 
 great irritability of the bladder are present, the incision facilitating 
 the process of draining and washing it out ; (2) the presence of a 
 phosphatic concretion ; (3) a contracted and hypertrophied con- 
 dition of the bladder. 
 
 Suprapubic Lithotomy should be undertaken under the following 
 conditions : (1) Where the stone is too large to be dealt with by 
 crushing ; (2) where the stone is encysted ; (3) where a stricture 
 or enlarged prostate is present ; (4) where lateral lithotomy is 
 rendered impracticable on account of pelvic conditions, such as 
 rachitic contraction or the existence of a tumour, or where the 
 left hip-joint is ankylosed, preventing the patient from assuming 
 the lithotomy position. Suprapubic cystotomy is only absolutely 
 contra-indicated by two conditions, viz., severe septic cystitis and 
 contraction of the bladder. 
 
 Calculus in the Female. — As already mentioned, vesical calculus 
 is very rare amongst women, owing to th« shortness and greater 
 size of the urethra, so that small stones passing downwards from 
 the kidneys are easily voided. Phosphatic concretions are not 
 uncommon, and are then formed around a foreign body usually 
 introduced by the patient. Many of the symptoms are very 
 similar to those in the male. 
 
 Treatment. — If the calculus does not exceed ^ to f inch in 
 diameter, it can usually be extracted by dilating the urethra with 
 the finger, the sphincter being also nicked in two or three places 
 if necessary. It is never wise to totally divide the sphincter, 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. 
 
 Affections of the Prostate. 
 
 Acute Prostatitis arises most usually as a sequela of gonorrhcea, 
 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 
 decomposing urine, or from the passage of instruments. It is 
 also 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 
 
noS A MANUAL OF SURGERY 
 
 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 follicles with pyogenic organisms. 
 Sometimes merely one or two follicles are enlarged, 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. Micturition becomes frequent and painful, and 
 defalcation may cause considerable 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 organ can be felt enlarged, 
 hot, and tender. Suppuration is likely to follow, and retention of 
 urine may be thereby induced. A follicular abscess bursts into the 
 urethra spontaneously, or is ruptured by the passage of a catheter 
 for the relief of retention ; the opening, however, is often of a 
 valvular nature, and only a small portion of the pus escapes. 
 The process may then continue to spread, and the pus may find 
 its way into the rectum, or come to the surface through the 
 perineum. In either of the latter conditions, a rectal or perineal 
 fistula is liable to result. Considerable constitutional disturbance 
 is usually associated with this affection, whether suppuration 
 occurs or not. The formation of a parenchymatous abscess is 
 always attended with much more acute symptoms, both general 
 and local. The organ is larger and produces more rectal irrita- 
 tion ; 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. 
 
BLADDER AND PROSTATE 1109 
 
 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 hyperaemic 
 and sensitive organ. A glairy discharge of viscid material, 
 similar in appearance to uncooked white of egg (prostatorrhaa), 
 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 rectum, the 
 organ can be felt enlarged and tender, and the vesiculae 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 suppuration, a cure may occasionally be brought 
 about by the administration of iodide of potassium, or of the liq. 
 ferri perchloridi (IT^xv. or more, t.d.s.), combined with sulphate 
 of magnesia. The local application of a solution of nitrate of 
 silver by a porte-caustique is also sometimes recommended, but 
 we are not much in favour of such a proceeding. Probably the 
 best treatment consists in forcible dilatation of the prostatic 
 urethra, as suggested by Oberlander, the follicles being thereby 
 emptied of their secretion ; massage of the prostate per vecium 
 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 ulcera- 
 tion, and sometimes the organ is riddled with ragged cavities. 
 The symptoms are those of irritability of the neck of the bladder, 
 combined with pain referred, perhaps, to the end of the penis, 
 or mainly noticed in the back or perineum, Hematuria is occa- 
 sionally produced, whilst pyuria is almost constant The urine 
 
A MANUAL OF SURGERY 
 
 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. Possibly, if the disease is not too 
 extensive, benefit may be derived from scraping the tuberculous 
 tissue away 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. They develop primarily in the glandular 
 crypts, and may remain embedded in the organ, giving rise to 
 
 but little inconveni- 
 ence. When large and 
 protruding from the 
 gland into the urethra, 
 symptoms of obstruc- 
 tion 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 in- 
 duced. Sometimes a 
 number of them are 
 found in a pouch or 
 pocket, formed by the 
 amalgamation of 
 several of the crypts. 
 It is in some instances 
 possible to remove the 
 calculi through the 
 
 _ _ _ „ urethra, but more fre- 
 
 Fig. 392. — Enlarged Prostate ; Middle Lobe . .... 
 
 replaced by Enormous Fibro-myoma. (From quently a perineal mci- 
 College of Surgeons' Museum.) sion is required. 
 
 Hypertrophy of the Prostate is a condition rarely met with, 
 except in patients over fifty years of age. There is a general 
 enlargement of the tissues of the part, involving either the 
 glandular and the muscular elements equally, or especially limit- 
 ing itself to one or other of these tissues ; more frequently the 
 glandular element is considerably in excess. Another variety is 
 due to the development of localized tumours in, or outgrowths 
 
BLADDER AND PROSTATE 
 
 from, the organ, which are usually fibro-myomatous in nature, 
 particularly if embedded in the prostatic substance ; when of this 
 type they are almost exactly analogous to the so-called fibroid 
 tumours of the uterus, since they originate in the walls of the 
 sinus pocularis, the male analogue of that organ. These tumours 
 are rather denser than ordinary prostatic tissue, and are often 
 completely encapsuled. They are primarily developed in the 
 substance of the prostate, but may project backwards, when 
 large, towards the rectum, or grow upwards into the bladder 
 (Fig. 392), or may even become pedunculated, constituting a 
 polypus in the dilated urethra. Not uncommonly these new 
 growths consist mainly of glandular tissue with distinct ducts, and 
 possibly concretions may be found in the tubules. There are thus, 
 
 Fig. 393.— Effect of Enlargement of the Middle Lobe of the 
 Prostate on the course of the Urethra. (Diagrammatic.) 
 
 The left-hand figure represents the normal curve of the urethra ; that on the 
 right side the barrier caused by an enlarged middle lobe. 
 
 pathologically speaking, three main forms of the so-called 'chronic 
 hypertrophy of the prostate ': the diffuse enlargement, the fibro- 
 myomata, and the adenomata, but they are often combined one 
 with the other. 
 
 The changes produced in the prostatic urethra and neck of the 
 bladder vary considerably according to the character of the out- 
 growth in any particular case. A certain amount of obstruction 
 is always present, except in a few instances in which the internal 
 meatus becomes unduly patent, possibly from a tumour in the 
 median portion being wedged in between the two lateral lobes. 
 The prostatic urethra is increased in length in all cases of 
 this disease. When the lateral lobes are enlarged, the lumen 
 of the urethra is diminished from side to side, being narrow 
 or chink-like instead of circular ; its vertical measurements are, 
 however, increased. The urethra is, moreover, rendered more 
 or less tortuous, owing to irregular enlargement of the various 
 
A MANUAL OF SURGERY 
 
 portions. Thus, if the median lobe is especially prominent, 
 a rounded barrier extends across the urethra, which becomes 
 almost S-shaped (Fig. 393, B). If one lateral lobe is enlarged 
 more than the other, the urethra is pushed over towards the 
 unaffected side. The shape of the internal meatus is also considerably 
 modified : when the median lobe is enlarged, it becomes crescentic, 
 the convexity looking upwards and forwards ; when one lateral 
 lobe is of larger size than the other, the orifice is also crescentic, 
 the convexity being directed towards the smaller lobe; when all 
 three lobes are affected, the entrance to the bladder may be 
 Y-shaped, the limbs of the Y passing on either side of the median 
 lobe. Not unfrequently the prostate may project into the bladder 
 as a rounded, collar-like elevation, encircling the meatus. There 
 is an abundant blood supply to the organ, the veins in the capsule 
 being notably enlarged. 
 
 The Symptoms vary somewhat with the nature and position 
 of the enlargement. The patient at first finds some difficulty in 
 micturition, especially at the commencement of the act ; straining 
 often hinders rather than assists. The stream is not necessarily 
 smaller than formerly, but is projected with less force. Gradu- 
 ally irritability of the bladder ensues, and the patient has to pass 
 water very frequently, a trouble especially noticed during the 
 night. Some degree of pain and a sense of weight and fulness 
 about the perineum are also experienced, whilst tenesmus, and 
 even hernia, may be subsequently induced by the straining. 
 Intermittent attacks of increased pain and difficulty in micturition 
 occur from time to time, being generally induced by exposure to 
 cold and wet, and presumably due to congestion of the prostate. 
 After lasting for a few days the more acute symptoms slowly 
 disappear, if judiciously treated. 
 
 As the obstruction increases, a certain amount of residual urine 
 remains within the bladder after each act of micturition, the 
 vesical muscles gradually losing power and becoming atonic. 
 Gradually well-marked distension and atony of the bladder ensue 
 in neglected cases, the urine dribbling away and wetting the 
 clothes, whilst decomposition of the retained fluid follows, and 
 causes cystitis with increasing vesical irritation and muscular 
 spasm. The urine becomes alkaline after a time, containing 
 muco-pus and phosphates, the result of chronic cystitis. This, if 
 neglected, is certain to lead to hydronephrosis and pyelonephritis. 
 The general health of the patient is slowly undermined by the 
 constant irritation produced by this process, as also by septic 
 absorption, and the final chapter may be ushered in by symptoms 
 of uraemia from the mischief inflicted on the kidneys. 
 
 Occasionally the early symptoms may pass unnoticed for a 
 considerable time, the patient imagining that the frequent calls to 
 pass water are good signs rather than evidences of disease. In 
 such cases the bladder may become over-distended, and the con- 
 dition unsuspected until, owing possibly to some exposure to cold 
 
BLADDER AND PROSTATE 1113 
 
 or over-indulgence in alcohol, complete retention is induced, and 
 then, to the surprise of the patient, an enormous amount of urine 
 is withdrawn on the passage of a catheter. Priapism is some- 
 times a troublesome condition, and the effect of this on the moral 
 sense may be very serious, and leads in some cases to acts of 
 gross indecency. 
 
 The Diagnosis of enlarged prostate is made partly by a con- 
 sideration of the symptoms complained of, but mainly by an 
 examination of the urethra and rectum. The age of -the patient, 
 the increasing irritability of the bladder, by night and day, the 
 fact that straining hinders rather than helps the expulsive act, 
 together with evidence of vesical distension — all these facts indi- 
 cate that the seat of obstruction lies in the prostate. A rectal 
 examination is then instituted, and some idea gained of the size 
 and condition of the organ ; it must not be forgotten, however, 
 that the size, as recognised by a finger in the rectum, cannot 
 measure in any way the amount of obstruction to the passage of 
 the urine, and, in fact, it often happens that where the gland does 
 not feel especially large from the rectum, the obstruction is the 
 
 Fig. 394. — Catheter Coude and Bicoude. 
 
 greatest. The careful introduction of a catheter will assist in 
 making the diagnosis, inasmuch as the barrier at the neck of the 
 bladder is easily detected, and sometimes with difficulty passed. 
 
 Treatment. — All that is required at first is regular catheterism, 
 in order to prevent the bladder from becoming over-distended, 
 and this the patient may sometimes be taught to do for himself. 
 To pass a catheter in a case of enlarged prostate is not always 
 easy, owing to the fact that the middle lobe (Fig. 393, B) projects 
 across the urethra, and bars the onward progress of an instrument 
 of the ordinary shape. The surgeon should therefore use either 
 a catheter coude or bicoude (Fig. 394), which consists of a soft, 
 straight instrument of the usual French type, the end of which 
 is bent or doubly bent at an angle, so as to enable it to ride 
 over the obstruction ; or he may employ an English gum-elastic 
 catheter, the stilette of which is drawn out a little so as to increase 
 its curve ; or he may utilize the silver prostatic catheter, which 
 is longer and more curved than usual, depressing it well between 
 the thighs after clearing the pubic arch. Whichever method is 
 adopted, no force is required, since with a little skill the point 
 of the instrument will pass round the obstruction and enter the 
 bladder. Every precaution must be taken to ensure the efficient 
 sterilization of all instruments employed, and it should be remem- 
 
1 1 14 A MANUAL OF SURGERY 
 
 bered that as a general rule large rather than small instruments 
 will pass most easily. 
 
 During the first fortnight of catheter life the patient must be 
 carefully guarded from cold and exposure, to avoid the occurrence 
 of constitutional disturbance. Not unfrequently a certain amount 
 of fever (to which the name of Catheter Fever was given by the 
 late Sir Andrew Clark) is produced, which either passes off in the 
 course of a few days, or may increase, together with symptoms 
 of chronic cystitis, running on to a fatal issue at the end of three 
 or four weeks. The origin of this condition is still somewhat 
 doubtful ; it may certainly arise from the absorption of micro- 
 organisms or their products from the urethra, or from the use of 
 impure instruments, but possibly reflex nervous disturbance plays 
 some part in its production. The only treatment required in the 
 simpler cases is to keep the patient warm in bed, to limit his diet, 
 to administer quinine and opium, and to keep the bowels well open. 
 
 During the continuance of catheter life, the patient must be 
 warned to live quietly, and abstain from all excesses, especially 
 as regards eating and drinking ; sexual excitement should be 
 avoided, and horse-exercise forbidden ; precautions must also be 
 taken to ensure protection from cold and damp. The adminis- 
 tration of alkalies is desirable if the urine is highly acid, so as to 
 diminish the irritability of the bladder. 
 
 Under such a regime, it is possible that the patient may live 
 in comparative comfort perhaps for years, the progress of the 
 affection being entirely checked in some instances. In others, 
 the patient suffers from intermittent attacks of congestion of the 
 prostate, with increased pain and irritability of the bladder, and 
 augmented difficulty in micturition. The introduction of a catheter 
 is then very likely to cause bleeding, but a few days' rest in bed 
 usually brings about considerable improvement. The progress of 
 the case depends, to a large extent, upon the bladder remaining 
 free from septic contamination, and the surgeon must realize and 
 impress upon his patient that such is generally due to infection 
 from without, and hence the most scrupulous care must be taken 
 to sterilize all instruments before and after use. In cases where 
 the relief given by regular catheterism is but temporary, and the 
 irritability of the bladder increases seriously, further measures 
 are absolutely imperative. 
 
 Two chief plans of operative treatment have been adopted in 
 this affection, both directed to reducing the size of the organ, and 
 thus removing the obstruction to the passage of urine ; in the 
 one, the gland itself is attacked, and portions of it removed or 
 divided (prostatotomy or prostatectomy) ; in the other, the diminu- 
 tion in size is attained by indirect measures. 
 
 Prostatotomy, or incision of the prostate, is usually undertaken 
 from the perineum. The ordinary incision for median cystotomy 
 is made after the passage of a staff with a median groove. The 
 
BLADDER AND PROSTATE 1115 
 
 membranous urethra and prostate are divided in the middle line 
 to a sufficient extent to allow of the introduction of the finger 
 into the bladder, and an elastic tube is then inserted for drainage. 
 Any projecting nodules or masses of prostatic substance that 
 can be detected are removed. The drainage is maintained for 
 a week or ten days, and considerable improvement is said to 
 follow in some cases. The chief objection to this plan is that the 
 perineum in these patients is often so deep that it is impossible 
 to insert the finger into the bladder ; considerable haemorrhage 
 may also take place, whilst it is difficult to remove tumour masses 
 that might be easily enucleated by other means. The chief 
 indication for its use is when cystitis is present to such a degree 
 as to necessitate continuous drainage. 
 
 It has also been proposed to divide the obstruction at the neck 
 of the bladder by a concealed knife, to destroy it by a galvano- 
 cautery (Bottini's method), or snare it when pedunculated; such 
 proceedings are uncertain, and not free from risk. 
 
 Prostatectomy, or removal of the prostatic enlargement, has 
 been introduced as a means of treatment during the last few years. 
 It is usually conducted through a suprapubic incision into the 
 bladder, the patient being previously placed in the Trendelenburg 
 position. The enlargement at the neck of the bladder can be felt, 
 and, by the use of suitable illuminating apparatus, seen. Pro- 
 jecting growths may be incised and shelled out without much 
 difficulty or haemorrhage ; whilst if the whole organ is enlarged, 
 the mucous membrane over it may be divided by a circular in- 
 cision, and the gland substance enucleated from its fascial capsule 
 by the use of a suitable scoop, or with the fingers. The passage 
 of a catheter along the urethra enables the surgeon to ascertain 
 that the whole of the projecting growth has been removed, whilst 
 a finger in the rectum pushes the gland forwards and makes it 
 more prominent. Most satisfactory results have followed this 
 operation, although sometimes severe haemorrhage has occurred. 
 It is most suitable in cases where a pedunculated or encapsuled 
 tumour exists in the middle lobe, but the whole gland can be 
 removed without much difficulty, and without seriously damaging 
 the urethra. 
 
 When there are no projecting intra-vesical growths, it is pos- 
 sible that a perineal prostatectomy (partial or complete) is a 
 better operation. 
 
 The chief measures which have been employed for reducing the 
 size of the prostate by indirect means are as follows : 
 
 (a) Double Castration. — This plan was first suggested by White 
 of Philadelphia, in 1894, and has now been followed to a sufficient 
 extent to enable us to come to some decision as to its utility. 
 It has long been known that uterine fibroids diminish in size 
 after removal of the ovaries, and the similarity between such 
 growths and an enlarged prostate would lead one to anticipate that 
 
im6 A MANUAL OF SURGERY 
 
 if the testes are excised a similar shrinking of the prostate might 
 follow ; such, in certain instances, has been found to be the case. 
 The conditions most favourable to double castration are those in 
 which the whole gland is enlarged, soft and vascular, bleeding 
 readily on the introduction of a catheter ; on the other hand, hard 
 prostates, or those in which fibroid tumours are present, are not 
 likely to be much improved by this proceeding. It is also 
 interesting to note that the tone of the muscular wall of the 
 bladder can be largely regained, even after considerable distension 
 and atony have occurred. 
 
 (b) In order to overcome the natural objection of patients to 
 the removal of their testes, vasectomy, or the excision of a portion 
 of the vas deferens on each side, has been practised. In suitable 
 cases the results have been good, but are attained more slowly 
 than after castration. 
 
 (c) Ligature of the internal iliac arteries has also been employed 
 in order to starve the gland, and certainly in a few instances with 
 success. 
 
 The actual treatment to be adopted in any particular case must 
 be determined by its special features. Catheterism will suffice 
 for a time, but when this fails operation should be undertaken. 
 For localized outgrowths projecting into the bladder, and recog- 
 nised by the cystoscope, suprapubic prostatectomy is to be recom- 
 mended, but for general enlargement of the organ, especially if 
 it is soft and succulent, vasectomy should first be performed, and 
 may be followed up by double castration, or even by perineal 
 prostatectomy, if necessary. 
 
 Finally, if the patient refuses these operations, or if his general 
 condition prevents them from being undertaken with safety, and 
 catheterism is insufficient to give relief to his symptoms, a per- 
 manent fistula either above the pubes or through the perineum must 
 be established, necessitating the use of a portable urinal. This 
 is effected by introducing a trocar and cannula into the bladder, 
 and leaving it there until a sufficient track has been formed. 
 
 Cancer of the Prostate occurs in elderly men, but is not com- 
 mon ; it is usually of a scirrhous type, though sometimes it is of a 
 soft nature ; in either form it early progresses beyond the limits of 
 the capsule. The symptoms produced are those of obstruction to 
 the flow of urine, together with pain, which may be very severe, 
 and at a later date haemorrhage. The progress of the disease is 
 much more rapid than in senile hypertrophy. On rectal examina- 
 tion the hard mass is readily detected, whilst secondary deposits 
 may be found in the lumbar and abdominal glands on palpating 
 the abdomen. Occasionally phenomena referable to pressure on 
 the abdominal vessels and nerves arise, and the symptoms of 
 general cachexia soon manifest themselves. Palliative treatment 
 alone can be adopted. 
 
CHAPTER XXXVIII. 
 AFFECTIONS OF THE URETHRA AND PENIS. 
 
 Affections of the Urethra. 
 
 Congenital Malformations. — Total Absence, or Occlusion, of the 
 urethra has been met with, the urine under such circumstances 
 being sometimes retained, and leading to dilatation of the bladder, 
 ureters, and kidneys, a condition rapidly fatal, even if the child 
 be born alive. In a few cases the urachus remains patent, and 
 a congenital urinary fistula is established at the umbilicus, whilst 
 in others the cloacal condition persists, the urine passing into 
 the rectum. 
 
 Epispadias is a deformity in which the urethra is partially or 
 wholly exposed along the upper surface of the penis. According 
 to Mr. Henry Morris, it is not, properly speaking, a division or 
 deficiency in the upper wall of the urethra, but in its floor, which 
 has been transposed to the dorsum by torsion of the penis. ' It 
 is thus, in fact, a hypospadias reversed, i.e., upside down.' In 
 rare instances, the external meatus is situated just above the 
 glans, which is cleft and deeply grooved superiorly. More 
 commonly the urethra opens at the root of the penis, just in 
 front of the symphysis, and in such patients the organ is always 
 rudimentary and stunted. Complete epispadias is only present 
 when associated with extroversion of the bladder (p. 1072). The 
 incomplete form has been treated with success by the use of 
 reversed flaps dissected up from the side of the penis. For details 
 of the operations on this and the following conditions, see larger 
 text-books on operative surgery. 
 
 Hypospadias, or defective development of the lower wall of the 
 urethra, is a much more common malformation than the fore- 
 going. Three varieties are described. In (a) hypospadia gland is 
 the opening of the urethra corresponds to the position usually 
 occupied by the fraenum, and is thus directed downwards instead 
 of forwards. The prepuce in these cases is always voluminous, 
 and hangs like a hood over the glans, which is bent down over 
 the orifice, (b) Hypospadia penis is characterized by the urethra 
 opening somewhere along the under surface of the body of the 
 penis, which is often small and stunted. Considerable discom- 
 fort may arise in the act of micturition owing to the urethral 
 
mS A MANUAL OF SURGERY 
 
 orifice looking downwards ; it is also sometimes so small as to 
 require incision and dilatation. (c) Complete hypospadias, or 
 hypospadia pevincalis, is a somewhat complicated condition, in 
 which the lower wall of the urethra is defective as far back as 
 the perineum, the scrotum being cleft, and thus resembling the 
 vulva. The penis is always small, imperfectly developed, and 
 bound down by adhesions between the scrotal segments, looking 
 not unlike a hypertrophied clitoris. Under such circumstances 
 it is not surprising that the sex of the child has been mistaken, 
 and not a few cases are on record where it has been educated as 
 a female until the age of eighteen or twenty. Non-descent of the 
 testes is often associated with this malformation. 
 
 In the incomplete varieties, where the deformity is slight and 
 the urethral opening well in front of the scrotum, no interference 
 is necessary ; but where it encroaches on the scrotum, causing 
 inconvenience and discomfort, and threatening to prevent effective 
 sexual intercourse in the future, the restoration of the urethra 
 may be attempted by the use of reversed flaps obtained from 
 either side, or from the redundant prepuce. In the complete form 
 the penis must first be liberated from its adhesions and set free ; 
 the integument lining the scrotal cleft is then dissected up and 
 turned inwards to form the posterior part of the urethra, whilst the 
 lateral halves of the scrotum are brought together with sutures ; 
 the anterior portion of the urethra may then be dealt with as for 
 the incomplete variety. 
 
 Traumatic Laceration of the Urethra usually results from 
 violence applied directly to the perineum, as by falling astride a 
 stile, fence, or beam ; it has also been caused by severe jolting in 
 the saddle, or by a kick in the perineum. In fractures of the 
 pelvis it may be produced by a spicule of bone puncturing the 
 canal, and the membranous portion is that generally affected. 
 The whole circumference of the urethra may be involved, the 
 two segments being entirely disconnected, or only a portion may 
 be ruptured, and that most frequently the floor. 
 
 The Symptoms consist of pain in the perineum and shock, 
 followed by great distension of the scrotum from haemorrhage, 
 whilst blood trickles from the urethral orifice. If the patient is 
 able to restrain himself from passing water, and is successfully 
 treated, no extravasation of urine results, since the lesion is below 
 the sphincter vesicas ; if, however, he attempts to micturate, the 
 urine finds its way into the perineal and scrotal tissues. Whether 
 the rupture is complete or not, an organic stricture of considerable 
 density is almost certain to follow, and great difficulty is sub- 
 sequently experienced in keeping it dilated. 
 
 Treatment. — In the slighter cases, where it is probable that the 
 mucous membrane has alone been torn and there is no perineal 
 swelling, the patient should be kept quiet in bed, and no attempts 
 made at instrumentation. If urinary infection of the wound 
 
AFFECTIONS OF THE URETHRA AND PENIS 1119 
 
 occurs and an abscess forms, it can be dealt with by incision at a 
 later date. 
 
 Where, however, it is thought that the urethra is partially or 
 wholly divided, no temporizing measures such as tying in a 
 catheter, even if that be possible, should be adopted. An incision 
 ought to be made at once into the perineum so as to expose the 
 divided ends of the urethra, which it is the surgeon's aim to unite. 
 The blood-clot is removed, bleeding points are secured, and if the 
 ends of the urethra can be identified, a soft catheter is introduced 
 into the bladder, and they are sutured together around it with 
 fine catgut. When the ends are much torn, it is wise to cut 
 away the bruised extremities so as to have clean, smooth surfaces 
 to deal with. Under all circumstances the catheter must be kept 
 in for five or six days, if possible, and subsequently an instrument 
 must be passed every day for some time. 
 
 If a catheter cannot be introduced, or if extravasation has oc- 
 curred, free incisions must be made into the scrotum and perineum 
 to give exit to the blood and urine, and to expose the seat of injury. 
 A catheter is passed as far as possible, and its point felt for, cut 
 down on, and guided into the bladder ; a prolonged attempt under 
 anaesthesia may be necessary to accomplish this, and even then 
 it is useless to attempt to stitch up the urethra, as the sutures are 
 certain to cut out. Occasionally, and especially if treatment has 
 been delayed, the swelling of the parts is so great as to render 
 the passage of a catheter impossible. The patient must then be 
 put to bed for a few days until the blood-clot has disappeared, the 
 urine in the meantime escaping through the perineal wound ; but 
 as soon as possible another attempt must be made. When once 
 the catheter is passed, it must be retained for several days, so as 
 to establish the continuity of the tube. 
 
 Foreign Bodies are sometimes found in the urethra, usually 
 consisting of a portion of a catheter, pipe-stem, or in children a 
 piece of slate-pencil. Their presence gives rise to partial or com- 
 plete obstruction to the flow of urine, followed by ulceration of 
 the mucous membrane, the formation of a peri-urethral abscess, 
 or even extravasation. They are readily detected on the passage 
 of a sound or catheter, and may be removed by suitable forceps 
 if situated near the orifice. Should this fail, the urethra may be 
 incised and the body extracted ; a troublesome urinary fistula is 
 apt to follow this proceeding, even when the wound in the urethra 
 has been carefully sutured. 
 
 A pin is sometimes introduced voluntarily into the urethra, and 
 is not easily removed, since it has usually been pushed in head- 
 foremost. The following manoeuvre is necessary in order to remove 
 it : The point is made to penetrate the floor of the urethra and skin 
 by a sharp push on the head from behind. The body is pulled 
 out until the head catches against the mucous membrane, and 
 then the direction of the pin can be changed, so that the head 
 presents at or towards the meatus. 
 
A MANUAL OF SURGERY 
 
 Impacted Calculus is a not unfrequent cause of retention in 
 children. It can usually be felt through the walls of the canal. 
 The symptoms and treatment are much the same as for foreign 
 bodies. When near the neck of the bladder, it should be pushed 
 back into that viscus, if possible, and treated by lithotrity. 
 
 Simple Urethritis may arise from a variety of causes apart from 
 gonorrhoea, e.g., the presence in the female of an irritating vaginal 
 discharge, such as leucorrhcea, and possibly due to the Bac. coli. 
 It also occurs after the passage of an instrument or of a calculus, 
 and is occasionally excited in gouty individuals by highly acid 
 urine, charged presumably with spiculated crystals of uric acid. 
 The symptoms are much the same as those of gonorrhoea, but the 
 discharge is thinner in character, and on microscopical examina- 
 tion no gonococci are detected. The treatment consists in the 
 administration of alkalies and saline purgatives, all forms of 
 alcohol being interdicted. In more severe cases oleo-balsams 
 may be prescribed, and even mild injections. 
 
 Polypoid Tumours, similar in character to the caruncle met 
 with in the urethra of women, have been observed at the orifice 
 of the male urethra. They are red, vascular, and sometimes 
 exceedingly painful, and are best dealt with by excision, followed 
 by the application of the galvano-cautery, so as to stop the 
 bleeding, which is always copious. If of large size, the base 
 may be ligatured, and the growth cut away. 
 
 Stricture of the Urethra. — By stricture of the urethra is meant 
 a condition in which the onward passage of urine is hindered, 
 owing to some change in the walls of the urethra, which prevents 
 them from dilating. When at rest, the urethra is merely a 
 potential canal, the walls of which are in complete apposition, 
 and it is only converted into a tube when urine is passing along 
 it. When, owing to some change in the structure of its walls, 
 this functional dilatation is impracticable, the patient is said to 
 suffer from stricture. Three forms of stricture are described, viz., 
 the spasmodic, congestive, and organic. 
 
 Spasmodic and Congestive Strictures frequently coexist, although 
 either congestion or spasm may be the predominant feature in any 
 particular case. Thus, in acute gonorrhoea the mucous membrane 
 often becomes engorged and thickened to such an extent as to 
 interfere with the act of micturition. Spasm is the chief element 
 under the following conditions : (i) When a patient, suffering 
 from slight organic stricture, is exposed to wet or cold, especially 
 after heavy drinking ; (2) after operations on the rectum or sper- 
 matic cord ; (3) as a result of catheterism ; and (4) from perineal 
 irritation of the urethra, as by a blow or kick in this region, or 
 from prolonged riding on a bicycle with a badly-fitting saddle or 
 on horseback. Temporary retention is the usual result of any of 
 these conditions, and, as a rule, no treatment is required beyond 
 placing the patient in a hot bath, and unloading the lower bowel 
 
AFFECTIONS OF THE URETHRA AND PENIS 
 
 by the use of a large warm enema. If such fails, catheterism 
 will be necessary, and must be conducted with the greatest 
 gentleness, owing to the congested and lacerable condition of the 
 mucous membrane. Full-sized soft instruments should first be 
 used, and will usually succeed ; if not, a silver instrument must 
 be substituted. 
 
 Organic Stricture is the term applied to an undilatable condition 
 of the uretha, resulting from the development of cicatricial tissue 
 within its walls. 
 
 The Causes of organic stricture are : (a) the long continuance 
 of a urethral discharge, following gonorrhoea, or the frequent re- 
 currence of this affection. Chronic inflammations are always 
 characterized by a tendency to sclerosis of the tissues involved, 
 and the urethra is no exception to this rule, its walls under these 
 circumstances becoming thickened, indurated, and contracted. 
 (b) The cicatrization of a urethral chancre, or of an ulcer caused 
 by the impaction of a stone, or the contraction produced by the 
 healing of a urethral abscess, may also lead to stenosis, (c) The 
 most intractable forms of stricture are those due to cicatrization 
 after rupture or laceration of the urethral wall. 
 
 The usual Situation is within the bulb, i.e., just in front of the 
 triangular ligament ; but the orifice and body are not unfrequently 
 affected. It occurs in the membranous portion only as a result 
 of traumatism, and never in the prostatic. To find more than 
 two strictures in any particular case is unusual, although three or 
 four have been met with. 
 
 Various terms are applied to a stricture according to the 
 physical conditions present ; thus, it is termed annular, if it 
 involves the whole lumen of the urethra ; bridled, if it affects 
 only a portion of the circumference of the tube. A ribbon-shaped 
 stricture is one in which a considerable extent of the wall is con- 
 tracted (i.e., as if a ribbon had been tied around the urethra). It 
 is termed tortuous, if the resulting passage is not straight ; indurated, 
 if the walls are very hard and thickened ; and resilient, when the 
 stricture, though readily dilated, rapidly re-contracts. The terms 
 impassable and impermeable are applied to strictures through which, 
 on the one hand, a surgeon is unable to pass an instrument, or 
 along which, on the other hand, urine cannot find its way ; it is 
 doubtful whether the latter condition ever occurs, whilst the 
 number of impassable strictures met with by the surgeon 
 diminishes with his experience and ability in passing instru- 
 ments. 
 
 The Symptoms of urethral stricture vary according to the case. 
 The patient generally complains of difficulty in the act of micturi- 
 tion, the stream becoming small, and perhaps forked or twisted. 
 It takes a longer time than usual to empty the bladder, and even 
 when apparently successful a few drops of urine may trickle away, 
 wetting the patient's clothes. Irritability of the viscus follows, 
 leading to frequent attempts to pass water at short intervals 
 
 7' 
 
A MANUAL OF SURGERY 
 
 during the day and night. The urine under these circumstances 
 often becomes alkaline, and loaded with muco-pus and phosphates. 
 As the obstruction increases, more and more residual urine is left 
 in the bladder, which may in time form a tense, rounded, dull 
 swelling in the hypogastrium. The quantity of urine trickling 
 away also increases, so that the patient's garments are always 
 wet, giving him an unpleasant urinous odour. A certain amount 
 of gleety discharge is present, whilst if the individual takes an 
 excess of alcohol, or is exposed to wet and cold, complete reten- 
 tion may ensue. Sometimes the onset of symptoms is so insidious 
 that such an attack of retention is the first marked feature in the 
 case. 
 
 The Pathological Conditions arising from a stricture are best 
 considered under the following live headings: (i) The urethra 
 anterior to the stricture is usually in a perfectly normal state, 
 although possibly the orifices of false passages may be seen. A 
 few granulations are sometimes present, projecting at the com- 
 mencement of the stricture. (2) The stricture itself is characterized 
 by the development of fibro-cicatricial tissue immediately under 
 the mucous membrane, and intimately adherent to it. It extends 
 for a variable distance, and is often associated with a good deal 
 of peri-urethral infiltration, (j) The urethra behind the stricture is 
 dilated, and the mucous membrane velvety and friable ; the 
 orifices of the lacunae and other glands are somewhat enlarged 
 and more than usually evident, and perhaps ulceration may be 
 present around them. In the later stages the inflammation may 
 extend to the peri-urethral tissue owing to lymphatic absorption, or 
 perhaps to the escape of a few drops of urine ; a perineal abscess 
 then results, leading subsequently to perineal fistulae. When the 
 obstruction becomes almost absolute, this portion of the urethra 
 may give way, leading to extravasation of urine into the perineum 
 and scrotum. (4) The bladder invariably manifests considerable 
 changes in structure. At first the vesical wall undergoes a com- 
 pensatory hypertrophy of its muscular elements and is thickened, 
 in order to overcome the obstruction to the onward passage of 
 urine (Fig. 395). The lattice-work arrangement of the muscular 
 bands becomes coarse, thickened, and evident, causing the vesical 
 wall to assume a fasciculated appearance. As the pressure in- 
 creases, the mucous membrane protrudes between the muscular 
 fasciculi, giving rise to sacculation ; it is also thickened and con- 
 gested as a result of chronic cystitis ; the superficial veins become 
 varicose, and haematuria may be caused by their rupture, whilst 
 ulceration may also occur. The urine becomes alkaline and 
 decomposes, containing muco-pus and phosphates. It is likely to 
 stagnate in any sacculi which exist, and may then determine the 
 formation of phosphatic concretions ; or the walls of the sacculi 
 ulcerate, and after a time perforation and extravasation of urine 
 into the cellular tissue lead to a fatal issue. Occasionally the 
 bladder, instead of being thickened, is dilated and atonic with very 
 
AFFECTIONS OF THE URETHRA AND PENIS 
 
 1 1 23 
 
 thin walls. (5) Consequent on the changes in the bladder, the 
 conditions already described as hydronephrosis, pyonephrosis, or 
 pyelonephritis may develop partly as the result of the backward 
 pressure, and partly from the extension of septic matter along the 
 ureter to the pelvis of the kidney and calyces. 
 
 Physical Examination. — The actual diagnosis of a stricture can 
 
 (College of Surgeons' 
 
 Fig 395-~ Stricture of the Urethra. 
 Museum.) 
 
 At A u? n f j B s . tricture3 are seen . under which glass rods have been passed The 
 bladder is somewhat dilated, and its walls are thick and hypertrophic 
 and with commencing sacculation. 
 
 only be confirmed by a careful physical examination of the urethra, 
 which is usually made by the introduction of a full-sized catheter 
 or a solid bougie, e.g., No. 9 or 10 (English), so as to ascertain 
 where the obstruction is situated. If this cannot be passed, 
 smaller instruments, and even filiform bougies, are inserted 
 until one is found which will enter the bladder. 
 
1124 A MANUAL OF SURGERY 
 
 A great variety of catheters is in use ; in old days only metal 
 instruments were obtainable, and even now the silver catheter 
 is the favourite with many surgeons of eminence. In selecting 
 such an instrument, care must be taken that it is suitably 
 curved, and that the ' eye ' is sufficiently large and bevelled 
 inwards, so that no projecting rim lacerates the urethral mucous 
 membrane. The great advantages of the metal instrument are 
 that it is easily kept aseptic, and that the point can be located 
 and thus guided more readily along the urethra. Of late years 
 many different forms of flexible catheters have been introduced, 
 and are now extensively employed, inasmuch as they give rise to 
 less irritation than those made of metal. The objections to them 
 are that the materials of which they consist are readily attacked 
 and injured by antiseptics, whilst they are less easily directed 
 through a stricture on account of their flexibility, it being impos- 
 sible to know with certainty the situation of the point. Probably 
 the best means of sterilizing a soft instrument is to expose it to 
 the action of steam, which should be made to act not only on the 
 exterior, but also inside the tube ; many appliances to obtain this 
 object have been devised. Amongst the best flexible instru- 
 ments are the English or gum-elastic catheter, the French olive- 
 headed or catheter-a-boule, and others made of silk-web coated 
 with shellac, etc. Some varieties are now polished and prepared 
 inside as well as out, and they should, if possible, always be 
 selected. 
 
 Bougies or solid instruments are preferred by some surgeons 
 for the examination and treatment of strictures. Those known 
 as Lister's bougies are the best, consisting of solid metal rods, 
 curved like catheters, the bulbous ends of which are three 
 sizes smaller than the shanks, thus enabling each instrument 
 passed to prepare the way for the next. Flexible bougies are 
 also made, whilst for finding a way through a tight and tortuous 
 stricture a filiform or a long graduated whip-lash bougie, made 
 of whalebone or catgut, may be employed ; in the latter variety, 
 the fine end is passed through the stricture, and coils up in the 
 bladder, whilst the thicker portion is thus brought to bear on the 
 stricture. 
 
 In order to introduce a silver catheter or bougie, the patient is laid 
 on his back, the surgeon standing on his left side. The umbilicus 
 should always be exposed, as also the upper parts of the thighs. 
 The catheter, which has been previously sterilized, warmed, and 
 covered with some antiseptic oil or grease, is taken in the right 
 hand, and inserted into the urethra, with the handle directed 
 over the left thigh and slightly downwards. The point of the 
 instrument is guided as far as the perineum, and then the handle 
 is carried round to the middle line of the body towards the 
 umbilicus ; it is then raised to the vertical, the penis being held 
 in the left hand, and gently depressed between the patient's 
 
AFFECTIONS OF THE URETHRA AND PENIS 1125 
 
 thighs, the so-called tour-de-mailre. The catheter finds: its way 
 along the urethra into the bladder rather by its own weight than 
 by any forcible action of the surgeon. The chief points at which 
 difficulty may be experienced are : (a) The orifice", which may be 
 small and contracted ; (b) the lacuna magna, which is avoided by 
 keeping the point of the instrument against the floor ; and (c) the 
 opening in the triangular ligament, which is best entered by 
 keeping the point against the upper wall of the canal. 
 
 Some authorities recommend that the patient should stand up, 
 with the back resting against a wall or firm support, the surgeon 
 sitting in front, and manipulating, it is said, with greater accuracy. 
 The objections to this position are : (a) The liability of the patient 
 to faint, and (b) the existence of greater muscular tension than 
 obtains in the horizontal posture. 
 
 When a flexible instrument without a stilette is used, it is 
 passed by pressing the point on with a little rotatory movement 
 until the bladder is reached, withdrawing a little, and pushing 
 on again, if any obstruction is met. In some instances, however, 
 the use of a stilette is absolutely necessary. 
 
 The chief Dangers of catheterism are as follow : 1. A consider- 
 able degree of shock is sometimes experienced, especially in sensi- 
 tive individuals, and if an instrument has not been passed before. 
 It may be obviated to a large extent by first introducing about 
 half a drachm of the 5 per cent, solution of cocaine into the 
 urethra. 
 
 2. Hemorrhage may be induced by laceration or abrasion of the 
 mucous membrane, even though no false passage has been made ; 
 it is best avoided by gentleness and the use of well-finished 
 instruments. In spite of these precautions, when the mucous 
 membrane is soft and congested, and in many cases of stricture, 
 some bleeding cannot be avoided. It is rarely sufficient to call 
 for special treatment, but if very abundant may be arrested by 
 injections of hazeline. 
 
 3. False passages are frequently produced in the treatment of 
 strictures. The point of the instrument is most likely to leave 
 the canal at some spot in the floor, travelling for a variable 
 distance, according to the force employed, under the mucous 
 membrane, occasionally re-entering the dilated urethra behind 
 the stricture, which it avoids altogether, or perforating the 
 posterior wall of the bladder by tunnelling under the prostate, an 
 accident which can only occur in unskilful hands. The occur- 
 rence of a false passage is indicated by the sudden onward move- 
 ment of the instrument, combined with pain and haemorrhage ; 
 the point is usually deflected from the middle line, as is plainly 
 seen by the obliquity of the rings at the end of the shaft ; no urine 
 comes unless the urinary passages are opened behind the stricture. 
 On rectal examination, the instrument can be felt out of the 
 middle line, and nearer the rectum than is normal, and in some 
 
1 126 .A MANUAL OF SURGERY 
 
 exceptional cases has even been found in it. False passages are 
 not necessarily matters of great importance, but when extensive 
 may lead to peri-urethral suppuration and extravasation of urine, 
 possibly followed by fatal results. 
 
 4. Inflammatory phenomena may be lighted up in the prostate 
 and acute epididymitis induced by extension along the vas 
 deferens ; these are almost always due to sepsis. 
 
 5. Urinary Fever, or, as it is sometimes termed, urethral or 
 catheter fever, is always liable to develop as a result of the intro- 
 duction of instruments. It may occur as a solitary rigor even in 
 individuals with healthy urinary organs, but is much more fre- 
 quently observed in those with damaged kidneys. As to its 
 causation, there has been much discussion, but there can now be 
 little doubt that it is essentially septic in origin. Possibly the 
 instrument employed may be dirty, or the urethra itself contains 
 septic material, especially in its deeper parts. It is quite sufficient 
 for a slight abrasion to occur near the neck of the bladder, to allow 
 of the absorption either of toxins or of bacteria, and then general 
 phenomena show themselves at once. If merely toxic products 
 are absorbed, probably a passing febrile condition, such as one or 
 more rigors, will develop, with no more serious phenomena ; but 
 if bacteria find their way into the submucous tissues, they are 
 likely to develop rapidly in the lymphatics, extending to the 
 bladder and thence up the ureters owing to the continuity of 
 lymphatic supply, giving rise finally to pyelonephritis (p. 1056). 
 Formerly reflex congestion of the kidneys was thought to be an 
 important factor in these cases ; probably the congestion which 
 occurs is due to the direct irritation of bacteria, and is not of 
 nervous origin. 
 
 The clinical manifestations vary considerably, according to the 
 character of the case and the type of infection, (a) The simplest 
 form consists in the development of a single rigor, the temperature 
 perhaps running up to 105 F. ; the patient shivers and feels very 
 ill, and the head aches, but when the temperature falls he soon 
 recovers, and within a few hours is all right again, (b) Sometimes 
 the temperature does not fall to the normal after the initial rigor, 
 but remains elevated a few degrees for a day or two, and there 
 may even be a repetition of the rigor. The patient, however, 
 recovers perfectly, and no permanent harm is done, (c) In the 
 more serious cases the symptoms of pyelonephritis supervene, 
 and are very likely to prove fatal, the patient perhaps dying in 
 seven or eight days, (d) General pyaemia may appear as a com- 
 plication of the last condition, (e) In patients who are com- 
 mencing the regular passage of catheters for enlarged prostate a 
 series of phenomena develop, which have been already alluded 
 to (p. 1 1 14), and though often mild, are of a similar nature. 
 (/) Finally, suppression of urine may accompany any of the 
 conditions alluded to above. 
 
AFFECTIONS OF THE URETHRA AND PENIS 1127 
 
 Treatment. — Whenever it seems probable that the kidneys are 
 damaged, the greatest care must be taken in order to avoid 
 septic infection. The instruments employed, whether bougies or 
 catheters, must be thoroughly sterilized, and it would also be well 
 to irrigate the urethra with a mild antiseptic lotion. It is perhaps 
 better to use soft, elastic instruments rather than silver ones, as 
 the latter give rise to more irritation than the former, and are 
 more likely to abrade the mucous membrane. 
 
 For the single rigor following catheterism, the patient must be 
 kept warm, plenty of hot diluent drinks given, and quinine 
 (2 grains) and opium (-J to 1 grain) administered in a pill, although 
 the latter drug must be sparingly used if any evidences of uraemia 
 are existent. If the febrile symptoms continue, the skin and 
 bowels are freely acted on, and a milk diet prescribed, although a 
 certain amount of stimulant may be given if necessary ; all 
 operative measures must be avoided, unless it is essential to 
 relieve obstruction, as they are almost invariably fatal. Should 
 suppression of urine ensue, the loins should be cupped in the 
 hope of relieving renal congestion, a free action of the bowels 
 obtained by the use of watery purgatives, and the patient made 
 to sweat freely, either by the use of hot-air baths or by the in- 
 jection of pilocarpine. Uraemic symptoms may sometimes be 
 relieved by copious and repeated intravenous injections of 
 normal saline solution, which encourage diuresis and a watery 
 diarrhoea ; several successful cases have been recorded. 
 
 The Treatment of Passable Strictures is conducted either by 
 dilatation or by a cutting operation (internal or external ure- 
 throtomy). 
 
 Treatment by Dilatation is effected in various ways, according 
 to the nature of the stricture and the urgency of the symptoms. 
 Where the obstruction is not serious, and an instrument can be 
 easily passed, gradual dilatation should always be employed ; this 
 consists in the use of instruments once or twice a week, steadily 
 increasing the size until a No. 12 is reached. If the intervals are 
 too short, the urethra may become irritated, spasm be induced, and 
 the lumen of the canal temporarily diminished in size ; by keeping 
 the patient quiet for a few days on a bland diet, and the bowels 
 well open, the spasm disappears. In cases where time is an 
 object, rapid dilatation may be undertaken by the passage of several 
 sizes of bougie at one sitting ; for this purpose, Lister's instru- 
 ments are particularly useful. Where only a very small catheter 
 can be introduced, and that with difficulty, continuous dilatation 
 may be adopted by keeping the patient in bed, tying in the small 
 instrument for forty-eight hours or more, at the expiration of 
 which period a catheter several sizes larger can be substituted. 
 This in turn may be tied in if the patient can bear it ; but the 
 presence of a catheter within the urethra for any length of time 
 
1128 
 
 A MANUAL OF SURGERY 
 
 is not always tolerated, and may give rise at the end of two or 
 three days to considerahle constitutional disturbance and fever. 
 Forcible dilatation is a plan which has now but few advocates. 
 I* consists in the passage of an instrument, the shaft of which 
 is; made in two portions, which can be separated from one 
 another in such a way as to destroy the stricture either by dis- 
 tension or rupture of its substance. It is but little used, on 
 account of the great tendency, when cicatrization is complete, to 
 the formation of an even more intractable stricture than before. 
 
 By whichever of these methods dilatation is accomplished, it is 
 essential that either the surgeon or the patient should subsequently 
 pass an instrument through the stricture at first every week or 
 two, and then at longer intervals, to overcome the tendency to 
 recontraction which is ever present. 
 
 The Treatment of Passable Stricture by a Cutting Operation is 
 conducted either by internal or external urethrotomy. 
 
 Internal Urethrotomy is a valuable means of treatment when 
 rightly employed, but in careless or inexperienced hands may be 
 attended with considerable danger. It has been performed either 
 
 Civiale's Urethrotome. (Down Brothers.) 
 
 by passing an instrument through the stricture, and dividing it 
 from behind forwards, or by passing an instrument down to the 
 stricture, and dividing it from before backwards. The latter plan 
 of treatment, though recommended by some skilled authorities, 
 is not an operation which commends itself to our judgment, inas- 
 much as it is almost impossible to gauge the amount of tissue 
 divided. The former plan of incising a stricture from behind for- 
 wards is of course only called for under special circumstances, 
 since if the urethrotome can be passed through a stricture, ordi- 
 nary dilatation is in the majority of cases practicable. It is use- 
 ful, however, (a) in the treatment of very old and dense carti- 
 laginous strictures, as also (b) for resilient strictures, and (c) when 
 the urethra is excessively irritable. It should only be employed 
 when the obstruction is situated in the anterior two-thirds of the 
 urethra. Many forms of urethrotome have been devised, but 
 perhaps the most useful is that known as Civiale's (Fig. 396), 
 which can only be used for a stricture which will admit the passage 
 of a No. 5 catheter. The end is bulbous, and contains a hidden 
 knife, worked by means of a button in the handle. The instrument 
 is passed through the stricture, the cutting blade projected, and by 
 withdrawing it the cicatricial tissue is notched to such an extent 
 
AFFECTIONS OF THE URETHRA AND PENIS 
 
 1 1 29 
 
 as to allow a full-sized catheter to be inserted at once, and, if 
 possible, tied in, Where the deeper part of the urethra is being 
 dealt with, the incision should be made along the roof so as to 
 avoid the bulb. Care must be taken not to cut 
 beyond the limits of the cicatricial tissue, other- 
 „ wise haemorrhage, peri-urethral suppuration, or 
 I even extravasation of urine, may ensue. It is 
 ] also advisable to sterilize the urethra as far as 
 J possible by washing it out with weak antiseptic 
 \ solutions before operating. 
 
 External Urethrotomy, or Syme's Operation, is 
 ; required under circumstances similar to those 
 I needing internal urethrotomy, if the stricture is 
 situated in the posterior third of the urethra, but 
 ! is chiefly employed where perineal fistulas are 
 ! present. It is performed by passing a special 
 : shouldered staff (Syme's, Fig. 397), the distal end 
 '< of which is small enough to pass through the 
 : stricture, and grooved in the middle line, whilst 
 the shaft of the instrument is of larger size, and 
 : ends abruptly, so that the shoulder rests against 
 the face of the stricture ; the groove extends on 
 ; to the larger portion for about \ inch. The 
 patient is then placed in the lithotomy position, 
 and the surgeon, seated opposite the perineum, 
 which is shaved and well purified, incises it in 
 the middle line, carrying his dissection carefully 
 downwards so as to reach the groove in the staff 
 behind the stricture. The knife is then carried 
 forwards to the anterior extremity of the groove, 
 and inasmuch as it extends on to the shaft of 
 the instrument, the stricture is completely divided. 
 Any fistulae which exist are laid open into the 
 median wound, and thoroughly scraped and puri- 
 fied. A full-sized soft catheter is then passed 
 into the bladder, through either the penis or the 
 perineum, according to circumstances, and re- 
 • tained in position for some days, the urine being 
 1 syphoned off in the usual way, whilst the perineal 
 wound, after all haemorrhage has been stopped, 
 is packed with strips of antiseptic gauze, and 
 allowed to heal by granulation. The catheter is 
 removed early or late according to the amount 
 of general disturbance caused thereby, and subsequently a full- 
 sized instrument can be passed into the bladder daily. Some 
 surgeons have recommended the use of the so-called self-retaining 
 catheters, in the hope of preventing urine from finding its way 
 through the external wound; several varieties have been suggested, 
 
A MANUAL OF SURGERY 
 
 but they are of little practical value, since the escape of urine along 
 the side of the instrument can never be totally prevented. 
 
 Excision of a Stricture has been undertaken with success in 
 several cases where dilatation and urethrotomy had failed to give 
 permanent relief. As much as one inch of the urethra has been 
 removed, and the ends sutured together with successful primary 
 union. 
 
 The Treatment of Impassable Stricture varies according to 
 whether or not the condition is complicated with retention of 
 urine. 
 
 If no retention is present, it is possible that the inability to pass an 
 instrument is due to some temporary spasm or congestion induced 
 by errors of diet or drink, 
 or perhaps by exposure to 
 cold. Hence the patient 
 should rest in bed for a 
 few days, his bowels be 
 well opened, the diet 
 regulated, and a mixture 
 containing some alkaline 
 purgative and tincture of 
 henbane administered. 
 Further attempts at in- 
 strumentation should then 
 be made, if necessary, 
 under an anaesthetic, and 
 if the stricture still remains 
 impassable, Wheelhouse's 
 operation (Fig. 398) is in- 
 dicated. This consists in 
 the urethra in 
 the constriction, 
 
 Fig. 393. — Wheelhouse's Operation for 
 Impassable Stricture. (Bryant's ' Sur- 
 gery.') 
 
 incising 
 
 front of 
 
 tracing the passage backwards, and dividing it. A Wheelhouse's 
 straight staff with a median groove and a blunt hook at the end 
 is inserted down to the stricture, and the urethra opened just in 
 front of it by cutting down on the groove. The staff is then 
 twisted round, the upper end of the incision drawn up by the 
 projection of the hook, and the sides of the urethra held apart 
 with artery forceps. The orifice of the stricture is thus exposed, 
 and granulations may often be seen projecting from it. A fine 
 probe-pointed director can generally be insinuated along the 
 urethra through the stricture, which is then divided. A full-sized 
 instrument is passed into the bladder and retained for a few days, 
 whilst the wound is allowed to heal by granulation. 
 
 If retention of urine is present in a case of impassable stricture, 
 no time must be lost. If seen at an early stage, and the 
 symptoms are not urgent, the patient is given a hot bath, 
 and the bowels are opened by a warm enema, whilst a moderate 
 
AFFECTIONS OF THE URETHRA AND PENIS 
 
 dose of opium or preferably a morphia suppository is adminis- 
 tered. If the urine is not passed naturally in the bath, and 
 the bladder is becoming distended, being felt in the lower part of 
 the abdomen, suprapubic aspiration, or puncture with a trocar 
 and cannula, should be undertaken, and temporary relief thus 
 obtained. Probably, when tension has been removed from the 
 posterior part of the urethra, a catheter will be introduced without 
 much difficulty. Failing this, aspiration may be several times 
 resorted to, but it is generally wiser to open the urethra in front 
 of or behind the stricture, and drain the bladder, since the risks of 
 septic troubles, extravasation of urine, dangerous pressure upon 
 the kidneys, and urinary infiltration along the lines of puncture, 
 are thereby lessened. 
 
 Cock's Operation, or Perineal Section, is sometimes adopted 
 when no guide can be passed into the bladder (Fig. 399). The 
 
 Fig. 399 
 
 Cock's Operation of Perineal Section. 
 (Eryant's ' Surgery.') 
 
 patient is placed in the lithotomy position, and the situation of the 
 membranous urethra ascertained by inserting the index-finger 
 into the rectum. A median perineal incision is then made, and 
 after dividing the cutaneous structures, the surgeon plunges the 
 scalpel boldly in towards the apex of the prostate, guided by his 
 finger in the rectum. He must keep strictly in the middle line, so 
 as to avoid the important vascular and other structures which are 
 so abundantly present in the perineum. As soon as the urethra 
 is opened, a gush of urine often escapes ; the upper urethral wall 
 should not be damaged with the knife, for fear of opening up the 
 deep pelvic cellular tissue. 
 
 This operation may be tolerably simple if the urethra behind 
 the stricture is dilated, as is not uncommonly the case ; but 
 sometimes it is extremely difficult, especially if the urethra has 
 been displaced laterally. If the stricture is not situated too far 
 from the incision, it is always wise to complete the operation by 
 
"32 
 
 A MANUAL OF SURGERY 
 
 dividing it, and a full-sized catheter can then be passed into the 
 bladder, and the perineal wound allowed to granulate. If the 
 stricture cannot be dealt with during the operation, and is of a 
 dense cartilaginous nature, a tube is inserted into the bladder 
 through the perineum ; probably at the end of a few days the 
 tissues will yield sufficiently to allow of the passage of a catheter, 
 or Wheelhouse's operation can be subsequently adopted. 
 
 The chief complications of stricture other than those already 
 mentioned are perineal abscess, perineal fistula, and extravasation 
 of urine. 
 
 A Perineal Abscess consists in a focus of peri-urethral suppura- 
 tion, which is due either to a limited extravasation of urine, or to 
 the absorption of septic material through an ulcerated surface. 
 It is indicated by the formation of a hard, brawny swelling in the 
 perineum, which is tender to the touch. As it approaches the 
 
 •-, 
 
 Fig. 400. — Perineal Fistula (Bryant's 'Surgery.') 
 
 surface, fluctuation can be detected, and the skin over it becomes 
 congested and cedematous. Constitutional disturbance and fever 
 of an asthenic type are also present. Left to itself, it bursts and 
 usually gives rise to a perineal sinus or fistula, discharging either 
 pus, or urine mixed with pus. One or many of these fistulas may 
 occur (Fig. 400), and the openings are not limited to the perineum, 
 but may also be found in the thighs, buttocks, or even the groins. 
 In chronic cases, the scrotal or perineal tissues become infiltrated 
 and of an almost cartilaginous consistency. 
 
 Diagnosis.— Every abscess in the scrotum or perineum is not 
 necessarily associated with stricture, for simple irritation of the 
 skin may lead to a superficial abscess ; suppuration in the lacunae, 
 or Cowper's glands, may follow gonorrhoea ; a prostatic or ischio- 
 rectal abscess may point in the perineum ; whilst the injury 
 inflicted by the passage of instruments, or the existence of false 
 passages, may lead to a similar result. 
 
 The Treatment of a Perineal Abscess consists in the application 
 
AFFECTIONS OF THE URETHRA AND PENIS 1133 
 
 of fomentations during the early stages ; as soon as pus is present, 
 it should be let out through a free incision, and it is often advisable 
 to take the opportunity of dealing radically with the stricture by 
 section at the same time. Perineal fistulae can rarely be cured 
 without operation, since, although the stricture may be completely 
 dilated, the discharge of urine and pus continues. Under these 
 circumstances Syme's or Wheelhouse's operation is the proper 
 treatment. 
 
 Extravasation of Urine is a condition due to a solution of con- 
 tinuity of the urethral walls, allowing the urine to find its way 
 into the perineal and scrotal tissues. It usually results from over- 
 distension of the urethra behind a neglected stricture ; during 
 some violent effort at micturition, the patient experiences severe 
 pain and a sensation as if something had given way in the 
 perineum, followed by a feeling of relief. This, however, is of 
 short duration, as it is soon succeeded by the local and constitu- 
 tional effects of extravasation. The same phenomena are pro- 
 duced in cases of traumatic laceration of the urethra if the patient 
 attempts to empty his bladder. Occasionally the onset of 
 symptoms is more gradual, being preceded by a peri-urethral 
 abscess, which bursts into the urethra ; at each act of micturition 
 the cavity becomes more and more distended with urine ; finally 
 the wall yields, resulting in diffuse extravasation. 
 
 The membranous urethra is almost always the site of the rupture, 
 the urine finding its way subsequently through the anterior layer 
 of the triangular ligament, and being guided towards the an- 
 terior abdominal wall by the arrangement of the fasciae. The 
 root of the penis, covered by its appropriate muscles, lies in an 
 interfascial cul-de-sac, formed by the anterior layer of the 
 triangular ligament above, and the deep layer of the perineal 
 fascia (or fascia of Colles) below ; these two layers are con- 
 tinuous, passing round the transversus perinei muscles, and are 
 both attached laterally to the ischio-pubic rami. Into this space 
 the urine finds its way, after the anterior layer of the triangular 
 ligament has yielded, and owing to the fact that its passage back- 
 wards and laterally is checked by the attachment of the fasciae, it 
 is necessarily forced forwards, infiltrating in order the perineum, 
 scrotum, and body of the penis. If more extensive, it travels 
 along the spermatic cords to the anterior abdominal parietes, its 
 passage downwards into the thighs being prevented by the attach- 
 ment of the deep layer of the superficial fascia 01 the abdomen to 
 the fascia lata just below Poupart's ligament. In the most severe 
 cases the urine may even find its way as far as the axillae. 
 
 The Effects of extravasation of urine are always serious. 
 Possibly, if the urine were pure and aseptic, part of it might be 
 absorbed ; but even then prolonged infiltration of the tissues is 
 likely to result in suppuration and sloughing. In cases of stricture, 
 however, the urine is almost certain to be foul and alkaline, and 
 
ii 3 4 A MANUAL OF SURGERY 
 
 hence wherever it travels it gives rise to a gangrenous cellulitis. 
 The parts at first become infiltrated and brawny, but soon emphy- 
 sematous crackling and putrefaction are observed, owing to necrosis 
 of the cellular tissue. The congested and cedematous skin turns to 
 a dusky purple or black colour, and finally gives way or separates, 
 allowing exit to a mixture of pus, urine, and decomposing slough 
 of a most offensive and penetrating odour. The superficial loss of 
 substance may be so extensive as to lay bare both testicles, and 
 even the body of the penis, or part of the anterior abdominal wall. 
 The inflammatory process is necessarily associated with severe 
 constitutional disturbance, at first characterized by high fever and 
 a quick, bounding pulse ; but later on the temperature may become 
 subnormal, and the patient profoundly collapsed from toxaemia. 
 
 The Treatment consists in early and free incisions, so as to give 
 exit to the urine and pus, and to prevent, if possible, the sloughing 
 of the skin and subcutaneous tissues. Every part that the urine 
 has infiltrated must be dealt with in this way ; thus, the perineum 
 should be incised in the middle line ; the scrotum is similarly 
 divided, if need be, down to the urethra, the testicles being laid 
 on either side ; the penis should be incised, if necessary, on either 
 side of the urethra, and along the dorsal surface. It is often 
 possible to expel a large portion of the urine, especially in the 
 scrotum, by firmly squeezing the infiltrated tissues. A full-sized 
 catheter must be passed into the bladder, and to effect this the 
 urethra has often to be laid open and the stricture divided ; 
 perineal drainage is always preferable for these cases. The parts 
 should be subsequently dusted over with iodoform, and dressed 
 with warm antiseptic applications, e.g., a charcoal or carbolic 
 linseed poultice, or boracic fomentations. Frequent hip-baths 
 should be employed, and, if practicable, a continuous sitz-bath 
 would be the very best means of treating the case. As soon as 
 the wounds become clean, they should be dressed in the ordinary 
 way to allow them to granulate. The general health of the 
 patient must of course be attended to, plenty of easily assimilated 
 nourishment, stimulants, and quinine being administered. 
 
 Urinary Fistnlse are mcst commonly found in the perineum, 
 scrotum, or body of the penis. They usually result from peri- 
 urethral suppuration in connection with a stricture, but are occa- 
 sionally due to other causes, e.g., a lacunar a.bscess after gonor- 
 rhoea, or a prostatic abscess. They vary much in size and 
 number; when the result of a stricture, many may be present 
 (Fig. 400), and great infiltration of the surrounding tissues is 
 usually produced. The Treatment of perineal fistulas has been 
 already in measure described, .external urethrotomy being neces- 
 sary if a stricture exists. Occasionally the perineal wound does 
 not close after such an operation, even when the stricture has been 
 divided ; the edges of the fistula should then be pared, and the 
 wound brought together by deep quilled sutures. A catheter 
 
AFFECTIONS OF THE URETHRA AND PENIS 1135 
 
 should be kept in the bladder for a few days, and the urine regu- 
 larly drawn off after its removal. 
 
 When of small size, and situated either in the perineum or the 
 penis, cure may be determined by cauterizing the passage either 
 with a probe coated with nitrate of silver or by a gal vano- cautery, 
 but in other cases some form of urethroplasty is necessary. 
 
 Affections of the Penis. 
 
 Phimosis, when complete, is a condition in which the prepuce 
 is so long, and the orifice so narrow, that it cannot be retracted 
 behind the corona. It is usually Congenital in origin, and may 
 exist to such a degree as to render micturition impossible. More 
 frequently the opening is a very small one (pinhole prepuce), 
 permitting micturition, but leading to irritability of the bladder 
 from the obstruction. In such cases the prepuce is usually 
 adherent to the glans, and considerable irritation is caused by 
 the retention of the smegma secreted by Tyson's glands ; this 
 may collect and become so inspissated as to give rise to definite 
 concretions. The child pulls at the foreskin, owing to the itching 
 produced, and thus the symptoms of vesical calculus may be 
 simulated. Attacks of balanitis are also frequent, and should the 
 prepuce be withdrawn, paraphimosis is almost certain to follow. 
 If allowed to remain untreated long enough, distension of the 
 bladder, and even hydronephrosis, may supervene. Not only is 
 this condition in itself a cause of irritation and even danger to the 
 individuals affected, but it is often provocative of masturbation, 
 whilst it tends to aggravate the symptoms of venereal disease, 
 and there is but little doubt that it acts as a predisposing cause to 
 epithelioma of the penis. Phimosis also occurs as an Acquired 
 condition, resulting from the cicatrization of venereal sores. 
 
 The Treatment of phimosis consists in circumcision. Other 
 methods have been suggested — e.g., dilatation of the prepuce, and 
 merely slitting it up — but they are not satisfactory. 
 
 Circumcision should always be performed on children with a 
 long prepuce within the first year of life, since at that time the 
 parts are but slightly developed, the operation is a trifling one, 
 and but little inconvenience is subsequently experienced ; the 
 longer it is postponed, the more troublesome does it become. 
 The best method of operating is as follows : The dorsal aspect 
 of the prepuce is put on the stretch by grasping it on either side 
 of the median line with a pair of catch forceps ; a director is then 
 introduced between it and the glans, and held exactly in the 
 middle line, and the prepuce slit up with a curved pointed 
 bistoury or scissors. The lateral halves are now separated from 
 the glans, adhesions, if necessary, being broken down ; this must 
 be very thoroughly attended to, so as to enable all retained 
 smegma to be removed, and the corona glandis defined. The 
 
1 136 
 
 A MA N UA L OF SURGE R Y 
 
 redundant preputial tissue, both skin and mucous membrane, 
 is cut away on each side by scissors, special attention being 
 directed to the removal of sufficient tissue on the under side to 
 prevent the unsightly projection so frequently seen just below the 
 frsenum. In adults several vessels will bleed and require to be 
 ligatured, especially that in the fraenum, but in a child the haemor- 
 rhage is trifling. Having carefully trimmed up the edges, and 
 snipped off all ragged corners so as to render the margins of the 
 wound regular, catgut sutures are inserted to prevent any raw 
 surface being left exposed ; in children only a few are required, 
 but possibly a considerable number in adults ; a continuous suture 
 should never be employed. The wound is dressed with strips of 
 gauze or lint dipped in carbolic oil, and around this, again, a wisp 
 of antiseptic wool ; no bandage or tape is required. In adults 
 considerable after-trouble may be experienced from nocturnal 
 
 erections, which may be so marked 
 and prolonged as to tear through the 
 stitches ; to control this the patient's 
 bowels should be freely opened, and 
 he should be kept on a low and un- 
 stimulating diet, and bromide of 
 potassium or other sedatives ad- 
 ministered. The stitches are usually 
 removed at the end of five days, and 
 the parts are then dusted over with 
 a mixture of powdered boric acid, 
 zinc oxide, and starch, so as to re- 
 duce their sensitiveness. 
 
 When a phimosed prepuce is com- 
 pletely retracted, the patient often 
 finds it impossible to -replace it, thus 
 giving rise to a condition known as 
 Paraphimosis. It is due to the narrow orifice of the prepuce 
 getting behind the corona, and is characterized by great cedema 
 and congestion, not only of the exposed mucous membrane, but 
 also of the glans itself. If left untreated, ulceration takes place 
 along the line of constriction, and the parts become fixed in their 
 deformed position, the vessels sooner or later accommodating 
 themselves to the new conditions, and the cedema slowly dis- 
 appearing. In some cases sloughing of the glands may occur. 
 
 Treatment consists in forcible replacement of the prepuce. 
 This is accomplished by grasping the penis between the first and 
 second finger of each hand, and compressing the glans penis with 
 the thumbs so as to empty the vessels and diminish the amount of 
 cedema present, and thus reduce its size (Fig. 401). At the same 
 time the fingers draw the prepuce forwards, and thus finally 
 reposition is effected. When the cedema of the prepuce is very 
 marked, it should be punctured in several places to permit the 
 
 Fig. 401. — Reduction of 
 Paraphimosis. 
 
AFFECTIONS OF THE URETHRA AND PENIS 1 137 
 
 escape of serum and diminish the tension previous to reduction 
 as just described. In more advanced cases reposition becomes 
 impossible, and then the narrow constricting band caused by the 
 orifice of the prepuce must be divided on the dorsal aspect. This 
 will free the parts, which can be subsequently drawn forwards, 
 and after the cedema has been reduced by applying lotio plumbi 
 for a few days, circumcision may be advantageously undertaken. 
 
 Balanitis, or inflammation of the glans, may be simple in nature, 
 arising from want of cleanliness in persons with a long foreskin, 
 but more frequently is associated with gonorrhoea or soft chancres. 
 The under surface of the prepuce is often involved, and then the 
 term Balano - posthitis is sometimes applied to it. A muco- 
 purulent or purulent discharge escapes from under the prepuce, 
 which is often swollen and cedematous. Occasionally, when a 
 considerable degree of phimosis exists, the under surface of the 
 prepuce may become ulcerated, and even perforated ; whilst in 
 very neglected cases, and especially if phagedena is present, the 
 prepuce will slough, and allow the glans to protrude, usually 
 through its upper surface. 
 
 Treatment. — In simple cases, all that is required is to thoroughly 
 cleanse the parts by washing beneath the foreskin, and then apply 
 lead lotion on lint between the glans and the prepuce ; but when 
 there is much discharge, and the foreskin is long and swollen, or if 
 perforation is threatening, the prepuce must be slit up, and, after 
 the parts have been restored to a healthy state, the redundant 
 tissues should be cut away by a modified circumcision. 
 
 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. The nature of the virus is still a 
 little uncertain, though it is certainly microbic and probably due to 
 Ducrez's strepto-bacillus. If artificially inoculated, it runs a typical 
 course. The spot becomes a distinctly red papule in twenty-four 
 hours, whilst in two or three days a vesicle, surrounded by a zone 
 of angry hyperemia, is seen. The serum within 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, if inoculated on the same patient, may produce a localized 
 pustule, but no typical sore. Frequently several sores are present 
 at the same time, whilst the discharge from one chancre is very 
 
 72 
 
1 138 A MANUAL OF SURGERY 
 
 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 
 resulting 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 an extensive ulcerative balanitis occur, which may 
 even result in the glans sloughing through the upper part of the 
 prepuce, which drops beneath it. If the fraenum is involved, 
 smart haemorrhage takes place from ulceration into a branch of 
 the artery found in that structure. When there is much inflam- 
 mation, 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 is then likely to run 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 en- 
 larged and tender, and the process is very liable to terminate in 
 suppuration, constituting a bubo. Two forms of this affection 
 are described : (a) The simple or sympathetic bubo 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 one due to the absorption into the lymph stream, not 
 only of pyogenic organisms, but also of the specific virus, so that 
 when suppuration ensues, the pus, if inoculated, always produces 
 a typical soft sore. In these cases the suppuration occurs not 
 only within, but even more abundantly around the lymphatic 
 glands [periadenitis), so that the skin becomes considerably under- 
 mined, and the wound produced by opening the abscess may take 
 on the form of a huge soft chancre in the groin, in the centre of 
 which may be seen the lymphatic gland only slightly enlarged. 
 
 The Treatment of soft chancre consists in keeping it 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 surface of the 
 chancre may be treated with caustics, such as pure carbolic or 
 nitric acid, and may perhaps heal quicker for such applications; 
 but they need not be employed as a routine treatment, since soft 
 chancres, if kept clean, are usually devoid of serious consequences. 
 If the smell of iodoform is objected to, iodol or aristol may be 
 substituted. 
 
AFFECTIONS OF THE URETHRA AND PENIS 1139 
 
 Buboes are treated in the early stages by keeping the patient at 
 rest and applying fomentations, 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 stuffing it with gauze 
 impregnated with iodoform. Some surgeons recommend that 
 enlarged glands of this nature should be freely removed by 
 dissection, but such is not required as a general rule. 
 
 Herpes not uncommonly affects the prepuce and glans. It may 
 result from simple local irritation, more especially in gouty 
 individuals ; but is most frequently se^n in patients who have 
 suffered from syphilis, and is then likely to be somewhat intract- 
 able. It manifests itself as a crop of small vesicles on a hyperaemic 
 base, which become abraded, leaving a number of small ulcers, 
 li is preceded by pain of a neuralgic type, and accompanied by 
 much itching and irritation. The only treatment required is to 
 keep the parts clean, and dust them over with powdered oxide of 
 zinc and starch. In the majority of cases the disease lasts from a 
 week to ten days. During the healing of the herpetic ulcers, a 
 patient is very liable to be inoculated with the virus of either the 
 soft chancre or syphilis if he exposes himself to the risk of infection. 
 
 Warts often arise on the penis in the shape of red, vascular 
 excrescences, usually pedunculated, and sometimes of considerable 
 size. They are met with most frequently as a sequela of gonor- 
 rhoea, and must be carefully distinguished from mucous tubercles. 
 They should be treated by snipping them away with scissors, and 
 cauterizing the base with a galvano-cautery. 
 
 Horns are also occasionally seen arising from the body of the 
 penis. They are of the usual sebaceous type, as described at 
 p. 36 t, and should be excised. 
 
 Epithelioma of the penis rarely arises except in patients who are 
 the subject of congenital phimosis or possess long foreskins, and 
 hence it is stated that the disease is unknown amongst the Jews. 
 It usually commences in the sulcus behind the corona glandis, 
 and rapidly spreads to the surrounding parts, manifesting itself 
 either as an irregular, papillated, wart-like outgrowth, or as a 
 diffuse infiltration, ulcerating early, and leading to considerable 
 destruction of tissue. At first the tumour is mainly beneath the 
 prepuce, which becomes distended, producing a sanious discharge, 
 which contains epithelial cells as well as pus corpuscles ; but as 
 the case progresses, the prepuce itself is attacked, and even 
 perforated. Later on the body of the penis is invaded and, owing 
 to its great vascularity, the disease makes rapid progress. The 
 inguinal glands are early affected, but when the body of the penis 
 is involved, the lumbar glands are also implicated. 
 
 The Diagnosis of epithelioma from warts is easily made by 
 contrasting the infiltration of the base produced by the former with 
 the soft and normal condition of the glans in the latter condition. 
 
ii40 A MANUAL OF SURGERY 
 
 The Treatment of epithelioma consists in amputation of the 
 penis whenever the disease is sufficiently limited to lead to the 
 hope that it can be eradicated. When confined to the distal end 
 of the organ, the operation may be performed through the body ; 
 but when this is impracticable, owing to the extent of the growth, 
 the whole penis must be removed. 
 
 Amputation through the body of the penis is an operation of but 
 little difficulty. A short flap is reflected from the dorsum, and 
 the corpora cavernosa cut through, the urethra and remaining 
 portions of the organ being removed at a lower level. Bleeding 
 is then arrested by securing the divided vessels ; five ligatures 
 are usually required, viz., one for the artery to the corpus caver- 
 nosum on either side, one for each dorsal artery, and one for the 
 artery to the septum. The urethra is then isolated, and passed 
 through an opening made in the upper integumental flap. It is 
 split along its upper wall, and secured by sutures to the margins 
 of the opening, so as to prevent subsequent retraction ; the flaps 
 are then united by stitches. 
 
 A mputation of the whole penis is a much more serious proceeding. 
 The patient is placed in the lithotomy position, and the perineum, 
 after being shaved and purified, incised freely in the middle line. 
 The corpus spongiosum is traced backwards, and divided at such 
 a level as to allow the mucous membrane lining the proximal 
 portion of the urethra to be stitched to the skin at the posterior 
 angle of the incision. The corpora cavernosa are freed from their 
 connections, and separated at their origins from the ischio-pubic 
 rami by suitable raspatories. An elliptical incision is then made 
 round the root of the penis, the dorsal vessels are divided and 
 secured, and the suspensory ligament cut through. The penis 
 can then be drawn forwards, and by a few final touches of the 
 knife completely removed. All bleeding points are ligatured, and 
 the anterior wound closed by a continuous suture in the middle 
 line, a drainage-tube being placed in the perineal portion for a 
 few days. The results of this operation have, on the whole, been 
 very satisfactory, although the patient has to assume the sitting 
 posture in order to micturate. 
 
 APPENDIX. 
 
 With regard to the surgical affections of the female genital 
 organs, it is not our intention to do more than briefly refer to a 
 few of those affecting the region of the vulva and labia. 
 
 Vulvitis, or inflammation of the lining membrane of the vesti- 
 bule, is due to gonorrhoea or to irritating discharges coming from 
 above. It is characterized by injection of the mucous mem- 
 brane, by itching or smarting pain, especially on walking, and a 
 secretion of mucus or muco-pus, causing the labia to stick together. 
 The mucous follicles may become affected, and a localized abscess 
 
AFFECTIONS OF THE URETHRA AND PENIS 1141 
 
 result, situated either immediately beneath the mucous membrane 
 or in the substance of the labium. The treatment consists in the 
 use of warm and mild antiseptic lotions to purify the part, sitting 
 in hot water being most beneficial. At the same time the patient 
 is kept quiet, and the bowels opened by a saline purge. When a 
 follicular abscess forms, k should be incised through the mucous 
 membrane and its cavity stuffed with a small portion of dressing. 
 A labial abscess should be freely opened at any spot where it is 
 tending to point, and the cavity packed with gauze to ensure 
 healing from the bottom. 
 
 Cysts of the Labia are occasionally seen, being due to the blocking 
 of the duct of a mucous follicle, or of the more specialized vulvo- 
 vaginal glands (glands of Bartholin) ; they may attain considerable 
 dimensions and must be freely dissected out. 
 
 Hematoma of the vulva is due to traumatism, e.g., a kick or 
 fall, or to rupture of a varicose vein, especially during parturition. 
 The labium is much swollen and firm to the touch, owing to 
 the coagulation of the blood ; suppuration often follows, especi- 
 ally if the injury is associated with a superficial abrasion. 
 Treatment. — If the swelling persists, or if suppuration ensues, an 
 incision should be made and the blood removed ; the cavity is 
 then stuffed, but of course the most thorough antiseptic precautions 
 must be adopted. 
 
 Another occasional result of traumatism is laceration of the 
 recto-vaginal septum, which may be caused by kicks, or by 
 falling on a stick or paling. The wound is usually contused, 
 and the margins irregular, so that immediate suture is unlikely 
 to succeed. The parts are, therefore, kept clean by frequent 
 douches and allowed to granulate, and the loss of substance is in 
 that way often repaired. Should a fistula persist, a plastic opera- 
 tion will be subsequently necessary. 
 
CHAPTER XXXIX. 
 
 AFFECTIONS OF THE TESTIS, CORD, SCROTUM, AND 
 SEMINAL VESICLES. 
 
 Congenital Affections of the Testis. 
 
 It is scarcely necessary to state that the testicles are not developed in the 
 scrotum, but from the posterior wall of the abdominal cavity, so that they lie 
 at first behind the peritoneum close to the kidneys. The body of the gland 
 arises from the so-called genital ridge, which is covered by columnar epithelial 
 cells, and lies to the mesial side of the Wolffian body. The vasa efferentia 
 are developed from the tubules of the latter structure, coming into relation at 
 a later date with the seminal tubules, whilst the vas deferens is formed by the 
 Wolffian duct. 
 
 Occasionally the body of the testis is entirely absent, whilst a few cases are 
 on record of absence or deficiency of the vas. Very rarely two testicles have 
 been developed on one side, and have both found their way into the scrotum 
 {polyorchism). 
 
 The passage of the testis from the abdominal cavity to the scrotum takes 
 place at about the end of the eighth month of intra-uterine life. ' The guber- 
 naculum testis is the active agent in bringing about the descent of the testis. 
 This is a band of involuntary muscular fibres which traverses the inguinal 
 canal, and establishes important connections both within and without the 
 abdominal cavity. Below three main attachments of the gubernaculum may 
 be recognised, viz.: (a) to the abdominal wall; (b) to the pubis; (c) to the 
 bottom of the scrotum. Above, the gubernacular fibres are chiefly connected 
 with the testicle ; but many of them are also attached to the peritoneum on 
 the posterior wall of the abdomen. By the traction which the gubernaculum 
 exerts on the testicle the descent of that organ is brought about. By the portion 
 attached to the abdominal wall the testicle is pulled down to the internal 
 abdominal ring, the pubic portion drags it through the inguinal canal, whilst 
 the scrotal part finally leads it into the scrotum. 
 
 ' The formation of the processus vaginalis is accounted for in the same way. 
 Some of those gubernacular fibres which are inserted into the peritoneum drag 
 down the peritoneal diverticulum which lines the inguinal canal and scrotum 
 and prepares the way for the testicle.' (Cunningham's ' Manual of Anatomy,' 
 vol. i., pp. 426, 427.) 
 
 Two chief forms of malposition of the testis are described, arising either 
 from its incomplete or abnormal descent. 
 
 1. Incomplete Descent or Retention of the Testis. — The testis may 
 remain in the abdominal cavity attached to the abdominal wall by a mesor- 
 chium {retentio abdominalis) ; more frequently, it is found just within the 
 internal abdominal ring {retentio iliaca) ; but most commonly it occupies the 
 inguinal canal, or lies just outside of it {retentio inguinalis) . The organ in the 
 latter position is freely mobile, being readily pressed up towards the abdo- 
 
AFFECTIONS OF THE TESTIS, CORD, ETC. 1143 
 
 minal cavity. The Causes of this condition must be looked for mainly in 
 some abnormal attachment of the gubernaculum, or possibly in the existence 
 of intra-uterine peritonitis. Less commonly a contracted condition of the 
 external abdominal ring, or an unduly large epididymis, may determine its 
 occurrence. 
 
 The condition is easily recognised by the absence of the testicle in the 
 scrotum, whilst in the inguinal variety the organ can usually be detected as 
 a small moveable swelling about the size of a horse-bean, giving the charac- 
 teristic testicular sensation on pressure. The scrotum on the affected side is 
 imperfectly developed. 
 
 In any of these varieties a late descent of the testis may occur, usually 
 accompanied by a congenital hernia, possibly of an interstitial type. 
 
 2. Malposition of the Testis.— Two distinct forms are described : (a) Ectopia 
 Perinealis. — In this variety the testis finds its way into the perineum, slipping 
 along the groove between the thigh and the scrotum. It may exist as a con- 
 genital condition, being then due to the contraction of an accessory band of 
 gubernacular fibres : or it may happen in consequence of a late descent of the 
 testicle, owing to atrophy of the scrotum. It always causes considerable in- 
 convenience to the patient, especially on sitting or riding, (b) Ectopia Cruvalis, 
 — The testicle here lies on the inner side of Scarpa's triangle, in the region of 
 the saphenous opening. It is said to escape along the crural canal, but 
 more probably it passes down the inguinal canal as usual, and then finds its 
 way over Poupart's ligament to this situation, guided by a second accessory 
 band of gubernacular tissue. When, as not uncommonly happens, a con- 
 genital hernia also exists, it may travel outwards to the anterior superior 
 spine, being directed there by the arrangement of the fasciae, as in a femoral 
 hernia (extraparietal interstitial hernia, p. 979). 
 
 In all cases of retained or misplaced testis the organ is atrophic, and 
 probably functionally useless. At first it is normal in texture, but as a resulc 
 of frequently repeated injury and inflammation it is likely to undergo de- 
 generative changes. If only one organ is affected, but little harm follows ; 
 but if both are involved, the individual is probably sterile. 
 
 Complications of a Retained or Misplaced Testicle. — Any of the conditions 
 to be described hereafter in this chapter may involve a retained or misplaced 
 testicle, just as if it were in the scrotum, and give rise to considerable trouble, 
 especially when the organ is lying in close proximity to the peritoneum. A 
 testis misplaced or retained in the inguinal canal is much exposed to injury, 
 and a subacute traumatic orchitis often occurs ; it is stated that such organs 
 are very prone to become the seat of malignant disease at a later period of life, 
 but the accuracy of this statement is a little doubtful. 
 
 Treatment. — Taking into consideration the discomfort occasioned by this 
 condition, as well as the risk arising from the tendency to malignant disease, 
 there can be little doubt that the best method of treatment is the removal of 
 the testicle. Many operations have been devised with the idea of placing the 
 organ in its normal position in the scrotum, but the majority of such methods 
 have proved useless, owing to the traction required and the defective length of 
 the spermatic vessels and cord. 
 
 Another condition met with congenitally is Inversion of the testis, the 
 epididymis lying in front, and the body of the organ behind. It is of no 
 clinical significance, except that in careless hands it may be injured whilst 
 tapping a hydrocele. 
 
 Torsion of the Spermatic Cord, resulting in acute strangulation of the test's, 
 has attracted some attention of late years. The cause still remains unknown, 
 but several of the cases recorded have been associated with late descent of the 
 testicle, and others have been attributed to twists and strains. The symptoms 
 are tolerably characteristic : the patient complains of an acute sickening pain 
 in the testis which persists until gangrene has supervened, and may then dis- 
 appear ; it is accompanied by a certain amount of pyrexia, and the appearance 
 of a tumour, either in the inguinal region or in the scrotum. The testicle, 
 
1144 A MANUAL OF SURGERY 
 
 slightly enlarged, is felt below, and above it a larger mass, consisting of the 
 twisted cord and the congested and swollen epididymis. In some cases the 
 latter swelling has been crepitant, owing to the development of gases due to its 
 putrefaction. The condition is very likely to be mistaken for a strangulated 
 hernia, which it closely resembles ; but the presence of fever, and the absence 
 of abdominal distension and of faecal vomiting, are important distinctive signs ; 
 moreover, constipation, though often present, is never absolute. If the testis 
 is situated in the scrotum, the cord and inguinal canal are found to be clear ; 
 whilst if in the canal, the affected side of the scrotum is empty. The only 
 Treatment possible is exploration and removal of the inflamed or gangrenous 
 testis and cord, unless the case is seen very early, when it may be feasible to 
 untwist it. 
 
 Injuries of the Testis and Cord. 
 
 Contusion of the Testis is a very common form of injury. It 
 arises from blows, kicks, squeezes, and the like, and is always 
 associated with immediate pain of a most sickening and intense 
 character, which is not only experienced in the testicle, but also 
 radiates along the cord towards the loins and back, and down 
 the front of the thigh. Severe shock accompanies the pain, and 
 may be so profound as to lead to a fatal issue. A well-marked 
 traumatic orchitis often follows, and this may in turn induce 
 atrophy of the organ, although the same condition sometimes 
 occurs without much evidence of inflammation, as a result of 
 thrombosis and occlusion of the spermatic vessels. A hematocele 
 is also induced by a subcutaneous lesion of this nature. Treatment 
 consists in keeping the patient in the recumbent posture with 
 the scrotum well raised, and in applying fomentations or an 
 icebag. 
 
 Penetrating Wounds or Punctures are uncommon except as a 
 result of surgical treatment (e.g., tapping a hydrocele). A certain 
 amount of haemorrhage usually follows, whilst the immediate 
 lesion is associated with severe testicular pain. If the wound 
 becomes septic, the tubules are likely to protrude, and a hernia 
 testis may result. All that is ordinarily required is to purify the 
 parts and allow them to heal ; sutures should not be inserted 
 into the tunica albuginea. If the gland is totally disorganized, 
 as by a gunshot wound, castration must be undertaken. 
 
 Hsematocele, or a localized collection of blood in the tunica 
 vaginalis or cord, is a common result of injuries. 
 
 i. Hematocele of the Tunica Vaginalis arises from traumatism, 
 such as a sudden blow or severe strain, and occasionally follows 
 the tapping of a hydrocele if a superficial vessel has been ruptured 
 or punctured, or if the body of the testis has been wounded ; it 
 may, however, be due to general oozing from dilated capillaries 
 in the serous membrane owing to the sudden relief of tension. 
 It also occurs more or less spontaneously in connection with 
 malignant disease. The History generally given is that the 
 patient was seized with a sudden sickening pain in the testicle, 
 which became quickly enlarged without any evidence of inflam- 
 mation. If blood is extravasated at the same time into the 
 
AFFECTIONS OF THE TESTIS, CORD, ETC. 11-15 
 
 scrotum, the integument becomes discoloured in the course of a 
 few days owing to a diffusion of the blood pigment. At first the 
 swelling is smooth and fluctuating, exactly resembling a hydro- 
 cele, except in the absence of translucency ; but owing to a 
 deposit of fibrin on the walls from the coagulation of the blood, it 
 becomes hard and firm in a short time, closely simulating a solid 
 tumour. In slight cases the blood is entirely absorbed, but when 
 the effusion is considerable the coagulum is likely to persist. On 
 laying open such a swelling, the testicle is usually found in a 
 healthy state, whilst the enlarged tunica is occupied by some 
 blood-stained brownish-yellow fluid, and surrounded by a mass 
 of fibrinous coagulum, part of which is deposited in laminae 
 upon the walls, and part remains as shreddy masses projecting 
 into its lumen. In very chronic cases the walls of the tunica 
 become thick and indurated, and may even undergo calcareous 
 changes. Suppuration is sometimes met with as a result of 
 auto-infection. The Diagnosis of a haematocele in the earlier 
 stages is easily made ; but when it has solidified it can only 
 be suspected by the history,, and by the exclusion of other 
 sources of enlargement, whilst an exploratory incision or puncture 
 is often necessary to settle the diagnosis. Treatment. — -When 
 the patient is seen soon after the injury, he must be kept at rest, 
 the parts elevated, and evaporating lotions applied ; whilst if the 
 effusion is large, removal of a portion by aseptic tapping will 
 expedite the process of absorption. In more chronic cases it may 
 be necessary to lay the cavity open and remove its contents, whilst 
 in the later stages, if the tunica has become thick and indurated 
 and the testis atrophied, castration may be advisable. 
 
 2. Hematocele of the Cord is but rarely seen. It is due to the 
 rupture of one of its vessels, as a result of injury or strain. A 
 swelling of considerable size rapidly forms, extending along the 
 cord from the inguinal region to the scrotum, but the testis 
 remains free and unimplicated. Such a condition may be mis- 
 taken for an omental hernia, but on careful examination the 
 tumour is felt to be more uniform in consistency, more rounded 
 in outline, and even semi-fluctuating. It is irreducible and with- 
 out impulse, whilst the history of the case will assist the surgeon 
 in making a correct diagnosis. Treatment in the early stages 
 consists in the application of evaporating lotions, and later on, if 
 the blood-clot is not absorbed, the cavity may be laid open and 
 the coagulum removed. 
 
 Rupture of the Vas Deferens has resulted from excessive strain ; 
 it is, however, very rare, not more than half a dozen cases 
 being on record. It may affect the intra-abdominal portion of 
 the vas, and then gives rise to haemorrhage from the urethra, 
 together with some amount of fever and hypogastric pain, leading 
 possibly to atrophy of the organ. Rupture of the scrotal portion 
 is followed by enlargement of the testis, and perhaps scrotal 
 haemorrhage. This was associated in a case under our observa- 
 
1 146 
 
 A MANUAL OF SURGERY 
 
 tion with haemorrhage from the urethra on attempting coitus 
 shortly after the accident, and subsequently with severe pain 
 and swelling of the testis produced by the same act, but atrophy 
 did not follow. If it occasions any inconvenience, it is best treated 
 by castration. 
 
 Inflammatory Affections of the Testis. 
 
 Inflammation of the Testicle may be chiefly confined at its 
 onset either to the body of the organ or to the epididymis ; in 
 the former case the term Orchitis is applied to it, in the latter 
 Epididymitis ; either condition may be acute or chronic. 
 
 ABC 
 
 Fig. 402. — Diagrammatic Sections of (A) Orchitis, (B) Epididymitis 
 
 and (C) Hydrocele of Tunica Vaginalis. (Tillmanns.) 
 
 Ho, Testis ; N, epididymis ; Hy, hydrocele. 
 
 Acute Orchitis most frequently results from injury, but it is 
 also met with as a primary affection in gouty and rheumatic 
 individuals, sometimes arising spontaneously ; or it may follow 
 mumps, typhoid, or other eruptive fevers, as a result of 
 metastasis, whilst it is always to some extent associated with 
 epididymitis. In mumps it may precede the parotid lesion, or 
 may even occur without it. 
 
 The testicle becomes considerably enlarged, exceedingly pain- 
 ful, and tender to the touch. The shape of the organ is more or 
 less globular (Fig. 402, A), whilst the pain is of a peculiarly 
 sickening character, extending upwards along the course of the 
 cord towards the back and loins. The scrotal integuments 
 become red and infiltrated, and owing to the acuteness of the 
 process, more or less adherent to the coverings of the gland. 
 A plastic or serous effusion into the tunica vaginalis is some- 
 times present, giving rise to what is known as an ' acute hydro- 
 cele.' Some constitutional disturbance accompanies the process, 
 the temperature being elevated two or three degrees, whilst 
 vomiting and constipation are marked symptoms. It is unusual 
 for suppuration to ensue, but an abscess occasionally forms, and 
 then, after the pus has been let out, a hernia testis may follow. 
 Atrophy is a more common sequela, especially in adults, being 
 
AFFECTIONS OF THE TESTIS, CORD, ETC. 1 147 
 
 caused by constriction of the vessels and tubules, owing to 
 organization of the inflammatory exudation. 
 
 Acute Epididymitis is almost always due to the extension of an 
 inflammatory process from the urethra, the usual cause being 
 gonorrhoea ; it occasionally follows the passage of instruments or 
 the lodgment of a calculus ; or it may be secondary to a suppura- 
 tive prostatitis, unconnected with gonorrhoea. It is ushered in 
 by pain in the inguinal region and perhaps in the hypogastrium 
 along the course of the vas deferens, which soon extends to the 
 scrotum. The testicle becomes enlarged, but its shape is that of 
 an elongated oval, somewhat flattened laterally. The epididymis 
 is readily felt as a crescentic swelling, partially overlapping 
 the gland in all directions, and in its concavity the rounded out- 
 line of the anterior wall of the testis can usually be distinguished 
 (Fig. 402, B), or the tunica vaginalis distended with fluid. The 
 scrotum is red, cedematous, and adherent to the testis, whilst the 
 cord is infiltrated, enlarged, and tender. The same constitutional 
 symptoms are met with as in orchitis. Suppuration is perhaps 
 more common than after the latter affection, since the condition is 
 usually due to a suppurating inflammation of the deeper parts of the 
 urethra ; but it is a rare complication. Atrophy of the testis is a 
 not unfrequent result in cases which are not efficiently treated, 
 the plastic material exuded into the epididymis being organized 
 into fibro-cicatricial tissue, and constricting the spermatic vessels; 
 an acute attack of double epididymitis may in this way render the 
 individual sterile. 
 
 The Treatment of both these conditions in the acute stage 
 consists in keeping the patient in bed, with the scrotum supported 
 on a small pillow. The part is assiduously fomented, except 
 when the case is seen very early, an icebag or Leiter's coil 
 being then employed. Leeching should not be utilized, as the 
 triangular leech-bites are very liable to become irritated and 
 septic, and never heal well in the scrotum ; if local abstraction 
 of blood appears desirable, one or more of the scrotal veins 
 may be punctured ; the haemorrhage is easily arrested by elevating 
 the part. Pain, if severe, may be mitigated by a hot sitz-bath, 
 or by morphia suppositories. As regards general treatment, 
 the patient, after a preliminary dose of calomel, is kept on 
 a fluid, unstimulating diet, whilst alkaline purgatives are ad- 
 ministered, with the addition of tincture of henbane or opium as 
 a sedative ; if the pulse is hard and the temperature high, vinum 
 antimonialis in 10 minim doses is also beneficial. When the 
 acute stage is passed, the organ usually remains enlarged, and 
 for a time somewhat tender ; it is then best treated by strapping 
 with lead plaster, or with the emplastrum ammoniaci cum 
 hydrargyro. This must be continued until all signs of thickening 
 and induration have disappeared. 
 
 Subacute or chronic forms of inflammation are also met with 
 affecting the testis or epididymis, either as a consequence of the 
 
1 148 
 
 A MANUAL OF SURGERY 
 
 above, or resulting primarily from blows or strains. The charac- 
 teristic enlargement is readily detected, associated with a certain 
 amount of tenderness. A useful diagnostic point between the 
 chronic epididymitis following gonorrhoea and that due to syphilis 
 is that the former usually involves the globus minor, and the 
 latter is almost limited to the globus major. The condition is 
 best treated by strapping, and perhaps the administration of 
 small doses of mercury and iodide of potassium may assist in the 
 absorption of the inflammatory products. Chronic orchitis is very 
 similar to the enlargement produced by syphilis, from which, indeed, 
 it can only be distinguished by the absence of a syphilitic history. 
 
 Tuberculous Disease of the Testis (Syn. : Tuberculous Sarcocele, 
 Chronic Tuberculous Orchitis). — This affection is most commonly 
 seen in young adults with a distinct 
 tuberculous history, but it also occurs in 
 otherwise healthy individuals. It may 
 commence as a primary affection of the 
 epididymis, or it may be secondary to 
 tuberculous disease elsewhere. 
 
 Pathological Anatomy. — The process 
 originates in the connective tissue of the 
 epididymis, and runs its usual course, 
 at first consisting merely of miliary 
 elements deposited around the vessels, 
 which by their coalescence and casea- 
 tion lead to the formation of cheesy 
 masses, and these at a later stage may 
 emulsify and give rise to abscesses. It 
 may be limited to any one part of the 
 epididymis (most often the globus 
 major), or may widely infiltrate its 
 substance, causing a general enlarge- 
 ment (Fig. 403). In the latter case it early tends to spread, either 
 into the body of the testis or along the vas deferens. The corpus 
 Highmorianum becomes first involved by a similar deposit, and 
 finally the intertubular connective tissue of the gland ; this is 
 always associated with overgrowth of the epithelium in the tubuli 
 seminiferi, the cells after a time undergoing fatty degeneration, 
 and perhaps to such an extent that, on microscopic section, the 
 normal appearance of the organ has entirely disappeared. An 
 abscess may form within it, and find its way to the surface by 
 burrowing through the tunica albuginea, the visceral and parietal 
 layers of the tunica vaginalis having previously become adherent. 
 After the pus has escaped, a hernia testis is likely to develop. 
 If the process extends upwards along the cord, the vas is mainly 
 implicated, becoming perceptibly thickened, the other structures 
 of the cord being but little affected. The disease spreads along 
 the vas on the outside of the bladder to the vesicular seminales and 
 
 Fig. 403. — Tuberculous 
 Disease of Testis, 
 mainly affecting the 
 Epididymis. (Treves' 
 ' Surgery.') 
 
AFFECTIONS OF THE TESTIS, CORD, ETC 1149 
 
 prostate, and may even involve the base of the bladder, the ureters, 
 and kidneys. Lastly, general dissemination of tuberculous disease 
 may occur, and it is a curious fact that meningeal mischief is 
 frequently associated with genital tuberculosis. 
 
 Clinical Signs. — The disease is generally unilateral, although the 
 other testicle often becomes involved at a somewhat later date. 
 Its onset may be abrupt or gradual ; in the former case the attack 
 simulates an acute orchitis, but at the end of a week, although 
 the pain subsides, the swelling persists, being followed by the 
 development of abscesses containing cheesy pus. In the more 
 chronic cases, one or more firm and indurated nodules, which are 
 free from tenderness, are felt in the epididymis, but more often 
 the whole of this structure is found to be enlarged and thickened, 
 forming a painless crescentic swelling, surrounding the posterior 
 half of the body of the testis, from which it is usually separated 
 by a deep groove or sulcus. The epididymis is nodular and 
 craggy to the feel, and may be of unequal consistency, areas of 
 softening being interposed between portions which are distinctly 
 hard. The vas is early thickened, and the body of the testis may 
 be involved and enlarged, the line of demarcation between it and 
 the epididymis becoming indistinct. Testicular sensation remains 
 as long as any normal glandular tissue exists, but effusion into 
 the tunica vaginalis is not usual. When suppuration occurs, 
 the pain increases, especially if the abscess is in the substance of 
 the organ. As it finds its way to the surface, the skin becomes 
 adherent to the testis, and is red and congested. Gradually 
 fluctuation manifests itself, and escape of the pus may be followed 
 by a hernia testis. An abscess forming in connection with the 
 epididymis is less painful, and may attain considerable dimensions 
 before it bursts ; it never gives rise to a hernia testis. Extension 
 of the disease to the seminal vesicles causes no characteristic 
 symptoms, and is only detected on rectal examination ; when, 
 however, the base of the bladder, and prostate are affected, con- 
 siderable dysuria and irritability of the bladder are induced. 
 
 The differential diagnosis is discussed at p. 1162. 
 
 Treatment.— Amongst the rich, if seen in the very earliest stage, 
 when only a small nodule exists in the epididymis, it is possible 
 that prolonged residence at the seaside, or a sea-trip, combined 
 with suitable constitutional treatment and local strapping, may 
 lead to its disappearance. If apparently limited to one portion of 
 the epididymis, the disease may be dealt with by the conservative 
 measure of incision, curetting, and applying pure carbolic acid ; 
 but such is seldom feasible, since the disease is rarely sufficiently 
 localized. 
 
 If the whole epididymis is enlarged and solid, and the body of 
 the testis more or less normal, epididymectomy may be undertaken. 
 In this procedure the tuberculous mass is freed from the body of 
 the organ, the spermatic vessels lying on the inner side are care- 
 fully guarded, and the vas is dissected out and cleared as high as 
 
1 150 
 
 A MANUAL OF SURGERY 
 
 possible. The presence of an abscess or sinus is no contra-indica- 
 tion, since it merely involves a somewhat freer removal of scrotal 
 integument. Should foci exist in the body of the testis, they are 
 likely to atrophy subsequently, or they can be scraped out at a later 
 date. In this way the function of the gland as the producer of a 
 valuable internal secretion can be retained, although its use as a 
 generative organ is lost — a retention the more important owing to 
 the likelihood of the other testis being subsequently invaded. If 
 the vas is thickened at the external abdominal ring, it need not 
 deter the surgeon from operating, even if the vesiculae are enlarged, 
 since tuberculous disease is not like cancer ; if the great bulk of 
 the mischief is removed, Nature can frequently eliminate any small 
 portion that remains. In such cases the inguinal canal should be 
 freely opened, and the vas traced backwards and divided. In one 
 case thus dealt with, the bladder was distended with boracic lotion, 
 the patient placed in the Trendelenburg position (p. 1105), and the 
 vas followed back along the. side of the bladder nearly as far as the 
 seminal vesicles. For tuberculous disease of the seminal vesicles, 
 see p. 1 164. 
 
 Castration (p. 1163) is reserved for cases where the testis is dis- 
 organized, and its value as a secreting gland totally destroyed. Of 
 course the cord is then removed also after its division as high up 
 as possible. 
 
 Syphilitic Disease of the Testicle. — The testicle may become 
 affected by syphilis, either in the late secondary or in the ter- 
 tiary stage ; most commonly it results 
 from the acquired variety, but occa- 
 sionally is met with in the inherited. 
 
 Secondary Syphilitic Epididymitis is 
 not very frequently seen. It occurs in 
 the form of a chronic enlargement of the 
 epididymis, associated perhaps with a 
 hydrocele, about six to twelve months 
 after infection. The case is very similar 
 to a simple chronic epididymitis, but 
 the nodular thickening mainly involves 
 the globus major, and is usually sym- 
 metrical. It readily disappears on the 
 administration of mercury. 
 
 Tertiary Syphilitic Orchitis is ob- 
 served at a much later period of the 
 disease, even twenty or thirty years after 
 infection. It is not unfrequently bi- 
 lateral. Pathologically, it resembles the 
 majority of tertiary manifestations in 
 consisting of a diffuse infiltration accompanied by overgrowth of 
 the connective tissue. If the process affects equally the whole 
 organ, the ordinary syphilitic sarcocele or sclerosis of the testis 
 
 Fig 404. — Tertiary Syphi- 
 litic Disease of Testis 
 with Gumma of the Body. 
 (Treves' 'Surgery.') 
 
AFFECTIONS OF THE TESTIS, CORD, ETC. 1151 
 
 results ; if it is more localized in its distribution, the gummatous 
 variety is said to be present (Fig. 404). The former affection is 
 much more common than the latter. 
 
 In the tertiary syphilitic sarcocele, the body of the testis is 
 primarily involved, and becomes evenly enlarged and stony hard. 
 It is globular in outline, frequently accompanied by a hydrocele, 
 and the normal testicular sensation early disappears. The same 
 process occasionally extends to the epididymis and cord. Sup- 
 puration is exceedingly rare. On section the characteristic 
 appearance of a testicle has entirely vanished ; the tunica 
 albuginea is much thickened, and extending from it through the 
 substance of the organ are bands of connective tissue, represent- 
 ing the normal septa ; in bad cases the gland substance is almost 
 completely destroyed. 
 
 In the gummatous variety a similar condition involves the greater 
 part of the organ, but in addition one or more gummatous foci 
 are present. On section they appear as yellowish-white masses, 
 fairly well defined, and since the central portions are non- vascular, 
 they undergo the usual degenerative changes, becoming soft and 
 diffluent. If the gumma comes to the surface the skin may 
 give way, and a deep syphilitic ulcer with a sloughy base like 
 wet wash-leather results. Hernia testis very rarely follows such 
 an occurrence. The clinical features of the gummatous variety 
 are at first similar to those of the former, but after a time one 
 portion of the organ becomes prominent and painful, and as this 
 increases in size the central parts become soft and fluctuating, 
 and finally yield, giving exit to the characteristic gummy contents. 
 Under suitable treatment the swelling in each of these varieties 
 may disappear entirely, leaving the testicle either of normal size 
 or atrophied ; but, as in tuberculous disease, its functional utility, 
 if not entirely destroyed, is probably considerably impaired. 
 
 For the differential diagnosis see p. 1162. 
 
 Treatment consists in the administration of iodide of potassium 
 and mercury, whilst the hydrocele may be tapped, and the organ 
 strapped or supported by a suspender. If a gummatous ulcer is 
 produced, it may be possible to excise the greater portion of the 
 characteristic slough at its base ; but in all cases it should be 
 dressed with lint or gauze steeped in lotio nigra, or some other 
 mercurial preparation. 
 
 Hernia Testis is the term applied to a protrusion of the sub- 
 stance of the gland, more or less infiltrated with granulation 
 tissue, through an opening in the tunica albuginea and skin of 
 the scrotum. It arises from various causes, such as a septic 
 penetrating wound of the testis, acute suppurative orchitis, or 
 from a chronic abscess, whether simple or tuberculous in nature. 
 It is rarely produced by the breaking down of a gumma, owing 
 to the extensive infiltration of the organ with fibro-cicatricial 
 tissue, and necessarily it never follows suppuration in the epi- 
 
1 152 
 
 A MANUAL OF SURGERY 
 
 didymis. It is always preceded by a condition of increased pressure 
 within the tunica albuginea, and consequently as soon as an aper- 
 ture is formed in this membrane, its natural elasticity, allowing of 
 its contraction, forces a portion of its contents out of the opening ; 
 this may even proceed to such an extent as to cause the whole of 
 the substance of the gland to protrude, the tunica albuginea being 
 practically turned inside out. A mass resembling granulation 
 tissue is then seen to project through an opening in the scrotum ; 
 it is often somewhat pedunculated or mushroom-like in shape, 
 possibly overhanging the margins of the skin, but in less advanced 
 cases the integument may be distinctly undermined. A consider- 
 able discharge of pus usually accompanies it. The condition must 
 be distinguished from the fungating growth which occasionally 
 results from malignant disease of the organ, when the protrusion 
 consists of tumour substance, with no trace of testicular tissue. 
 
 The Treatment of hernia testis usually consists in extirpation 
 of the organ, especially when it is affected by tuberculous disease. 
 In simple cases it may be possible to obtain healing of the wound 
 by keeping the part aseptic, and applying pressure by means of a 
 pad of gauze. In other cases it may be possible to separate the 
 mass, and after paring the edges of the w T ound, to bring them 
 together by sutures, and thus cover in the gland substance, 
 which, however, remains projecting from the opening in the 
 tunica albuginea. Such proceedings are seldom very satisfactory. 
 
 Tumours of the Testis are generally malignant in character, only 
 one non-malignant form being at all common, viz., fibro-cystic 
 disease, or adenoma testis. 
 
 Fibro-Cystic Disease (Syn. : Adenoma Testis, Cystic Sarcocele). — 
 This condition is characterized by the formation of a tumour of 
 variable size, scattered through the substance of which are 
 numerous cystic cavities, lined with cuboidal or stratified epithe- 
 lium (Fig. 405). These cysts are usually rounded, but occasionally 
 tubular in shape, and may communicate with one another ; they 
 contain serous fluid and sometimes intracystic growths. They 
 are surrounded by connective tissue, the amount and character 
 of which vary greatly in different cases. It consists mainly of 
 simple fibrous tissue, but it is very common to see cartilaginous 
 nodules and myxomatous foci scattered through its substance. 
 It is thus very similar in its structure to the simple parotid 
 tumour (p. 787), and like it is very prone after a time to undergo 
 a malignant transformation. According to Bland Sutton and 
 Eve, these tumours arise from the remains of the Wolffian body 
 or mesonephros, which is almost always normally represented in 
 the neighbourhood of the globus major of the epididymis by the 
 structure known as the organ of Giraldes (paradidymis). The 
 testicle can be found in most cases spread out in a thin layer over 
 the tumour substance. 
 
 Clinical Signs. — This condition is met with in young adults. 
 
AFFECTIONS OF THE TESTIS, CORD, ETC. 
 
 ii52 
 
 and may possibly be attributed to an injury. The organ steadily 
 becomes enlarged, but this gives rise to no inconvenience except 
 by its size and weight. It is round in outline a/id elastic in con- 
 sistency, the cord remaining unaffected unless malignant disease 
 supervenes. When of great size, the skin of the scrotum may 
 ulcerate. The case runs a chronic course, and even should the 
 growth become malignant, the change of type only appears late 
 in the disease. 
 
 Treatment consists in removal after an exploratory incision has 
 demonstrated the nature of the growth. 
 
 Other non-malignant tumours have been described, such as 
 
 Fig. 405. 
 
 -Fibrocystic Disease of the Testis. 
 Surgeons' Museum ) 
 
 (College op 
 
 chondroma, osteoma, fibroma, myxoma, etc., but they are ex- 
 ceedingly uncommon, if they occur at all apart from sarcoma or 
 fibro-cystic disease. 
 
 Sarcoma of the Testis commences in the body of the organ, 
 either within the first decade of life or between the ages of thirty 
 and forty, and is sometimes a sequela of late or imperfect descent. 
 It is usually a soft, round-celled growth, taking on the form of 
 a lympho-sarcoma ; in other cases it is harder, and of the nature 
 of a nbro-sarcoma. Frequently cartilaginous nodules are incor- 
 porated in its substance, and patches of myxomatous tissue or 
 cystic degeneration from haemorrhage are also seen. As already 
 stated, it is sometimes secondary to fibro-cystic disease. It 
 originates in the connective-tissue elements of the organ, the 
 glandular substance being early destroyed. It appears as a 
 rounded swelling, and at first its outline is irregularly smooth ; 
 
 73 
 
1 154 A MANUAL OF SURGERY 
 
 as the disease progresses, however, it may become nodulated 
 from the development of cysts. The tumour may attain very 
 large dimensions, but the cord and scrotal tissues only become 
 affected in the later stages, and then ulceration and the forma- 
 tion of a fungus testis occasionally follow. Secondary growths 
 are always found in the lumbar glands and internal organs, 
 whilst, when it has spread beyond the tunica albuginea, involv- 
 ing the scrotal structures, the inguinal glands may be similarly 
 affected. There are but few subjective symptoms at first, a 
 feeling of weight and dragging being alone experienced, whilst 
 testicular sensation is soon lost ; but at a later date, when the 
 cord is involved, pain and cachexia become very marked. The 
 Course of these cases is slow up to a certain point, but the tumour 
 may then rapidly increase in size, spreading along the cord to the 
 interior of the abdomen even in the course of a few weeks, thereby 
 rendering removal utterly impossible, although it would have 
 been easily practicable at an earlier period. Treatment consists 
 in the extirpation of the growth with the testis as early as possible, 
 the cord being divided high up. 
 
 Carcinoma of the Testis is usually of the encephaloid type, and 
 arises in the body of the organ as a soft rapidly-growing tumour, 
 which soon extends to the tissues of the cord, and contracts 
 adhesions to the scrotum ; ulceration and the formation of a 
 fungating mass follow, whilst secondary deposits are found in the 
 lumbar and inguinal glands, and sometimes in the viscera. It is 
 impossible to distinguish a carcinoma from a sarcoma of the testis 
 by clinical signs, since it occurs at the same period of adult life, 
 although never in children. Very rapid growth, and early enlarge- 
 ment of the cord and lymphatic glands, point, however, to cancer 
 rather than sarcoma. The only treatment is castration. 
 
 Hydrocele. 
 
 Any collection of fluid, other than pus or blood, in the neigh- 
 bourhood of the testis or cord, is termed a Hydrocele. The fluid 
 usually consists of serum, but in some forms spermatozoa are 
 also present, and in rare cases it may consist of chyle or a similar 
 milky fluid (chylous hydrocele). Two chief varieties are described, 
 according to whether the testis or the cord is involved. ■ 
 
 I. In Hydrocele of the Testis the fluid is contained in the tunica 
 vaginalis (vaginal hydrocele) or exists as a circumscribed swelling 
 in its neighbourhood (encysted hydrocele). 
 
 i. A Vaginal Hydrocele is one in which there is an accumula- 
 tion of fluid in the tunica vaginalis, and the following varieties 
 may be differentiated : 
 
 (a) Acute Hydrocele occurs in conjunction with acute inflamma- 
 tion of the testis or epididymis. The effusion of fluid is never 
 abundant, and is often only made out on careful examination ; 
 at first it consists of plasma, as in all acute inflammations of a 
 
AFFECTIONS OF THE TESTIS, CORD, ETC. 1155 
 
 serous membrane, and is therefore spontaneously coagulable. It 
 may merge into the chronic type, or may disappear entirely, 
 perhaps leaving a few adhesions. 
 
 (b) A Congenital Hydrocele occurs in cases in which the funicular 
 process is still patent. The general signs of a vaginal hydrocele, 
 as described below, are present, but the fluid can be returned by 
 pressure into the abdominal cavity. It is rarely seen in others 
 than infants, and may be treated by the application of evaporating 
 lotion to the scrotum, whilst a light truss or woollen support is 
 placed over the inguinal canal, as for congenital hernia. It is 
 often associated with phimosis, which should of course be dealt 
 with by circumcision. If it persists, it may be treated by operation 
 as for congenital hernia, to which, indeed, it frequently leads. 
 
 (c) An Infantile Hydrocele is one due to non- obliteration of the 
 funicular process of peritoneum, except at its upper extremity. 
 It presents the signs of an ordinary acquired hydrocele, the fluid, 
 however, extending along the cord, even into the inguinal canal. 
 Its treatment is the same as for an acquired hydrocele. 
 
 (d) A Bilocular Hydrocele is one in which there is an additional 
 loculus without the abdominal cavity, communicating by a neck of 
 variable size with the distended tunica vaginalis. It is due to a 
 persistence of the intra-abdominal portion of the funicular process 
 between the peritoneum and internal abdominal ring; this becomes 
 distended with fluid, and the collection burrows downwards in front 
 and by the side of the bladder towards the pelvis. We have 
 operated on a similar condition in a woman, originating in the 
 upper portion of the canal of Nuck. 
 
 (e) Acquired Vaginal Hydrocele is the most common variety. 
 Causes. — It may arise idiopathically in middle-aged persons, and 
 has then been looked on as resulting from some functional 
 disorder rather than from any organic change in the membrane, the 
 normal balance between secretion and absorption being disturbed. 
 In the majority of cases, however, the testicle is swollen and 
 perhaps in a state of chronic inflammation, and the tunica vaginalis 
 thickened. A hydrocele almost always accompanies a tertiary 
 syphilitic enlargement of the organ, but is uncommon in tubercu- 
 lous or malignant disease. Hydrocele is very frequently seen in 
 those who dwell in hot climates, probably as a result of the lax 
 and pendulous conditions of the scrotum and testicles. In India 
 natives always support the scrotum. 
 
 Signs. — Vaginal hydrocele appears as a rounded pyriform 
 swelling in the scrotum, which extends for a variable distance 
 along the cord. Its tension differs with the amount of fluid 
 present, and with the thickness of its walls ; it is generally 
 elastic, and with obvious fluctuation. The cord is felt distinctly 
 above the rounded upper part of the tumour, and the testis is 
 generally situated posteriorly (Fig. 402, C), although it projects 
 forwards into the cavity, and is thus not readily detected. Its 
 
1 1 56 
 
 A MANUAL OF SURGERY 
 
 ME 
 
 position may be ascertained by pressure over it, when the charac- 
 teristic testicular sensation is evolved. On holding a light close 
 to the scrotum, the tumour is seen to be translucent, and the 
 position of the testicle can be demonstrated. In old-standing 
 cases the walls become exceedingly thick, and even cartilaginous 
 or osseous plates have been observed in them ; the translucency 
 in such cases will be lost. Occasionally, when inflammation has 
 existed, adhesions may form between the testis and the anterior 
 wall, and irregularity in the shape of the tumour is thereby 
 induced, or the cavity may be divided into compartments by 
 fibrous bands or septa. 
 
 It is scarcely necessary to mention that there is no impulse on 
 coughing, and that the tumour is dull on percussion. When the 
 distension is very great, its 
 weight causes a dragging pain ; 
 the penis becomes buried in 
 the swelling, and eczema of the 
 scrotum may result from the 
 urine trickling over it. The fluid 
 in the sac is yellowish or straw- 
 coloured ; its specific gravity 
 varies from 1015 to 1025 ; it 
 contains a large amount of 
 albumen, especially fibrinogen. 
 In old-standing cases cholesterin 
 may also be present. 
 
 The Treatment of vaginal 
 hydrocele is palliative or radical. 
 Palliative treatment consists in 
 tapping the cavity and remov- 
 ing the fluid, the patient being 
 subsequently directed to wear a 
 suspender, and, where inflam- 
 mation of the testis exists, to 
 apply cooling lotions. In infants 
 it can often be cured without 
 tapping by simply applying an 
 evaporating lotion. In order to 
 tap a hydrocele, the tumour must be firmly grasped in the palm 
 of the left hand, and the skin over its anterior wall purified and 
 made tense. A spot at the antero-inferior margin is then selected, 
 as free from vessels as possible, and a fine sterilized trocar and 
 cannula inserted in a direction almost directly upwards, so as 
 to pass in front of the body of the testis. The site selected for 
 tapping must of course vary with the position of the testicle, 
 which should be previously demonstrated. The fluid having 
 been withdrawn, the cannula is removed, and the puncture 
 covered with some wool and collodion. The condition recurs 
 after a longer or shorter period, and the operation must be re- 
 
 Fig. 406. — Method of tapping a 
 Hydrocele. (Tillmanns.) 
 
 Ho, Testis; NH, epididymis; 
 Hy, hydrocele. 
 
AFFECTIONS OF THE TESTIS, CORD, ETC. 1157 
 
 peated. If a dirty instrument is employed, inflammation, and 
 even suppuration, may follow, whilst if a vessel or the body ol 
 the testis is punctured, a hematocele may result. 
 
 Many different plans have been suggested for the Radical treat- 
 ment of hydrocele. It is unnecessary, however, to do more than 
 describe the two most frequently adopted, (i.) Injection of the 
 cavity after tapping has long been a favourite method. Many 
 different reagents have been employed, such as port wine, tincture 
 of iodine, solution of corrosive sublimate (1 in 500), or glycerine 
 of carbolic acid. Perhaps the best is the tincture of iodine, but 
 that contained in the British Pharmacopoeia is not strong enough, 
 and the old Edinburgh tincture, which is nearly the same strength 
 as the lin. iodi, B.P., should be employed. The amount used 
 varies with the size of the hydrocele, but for one of moderate 
 dimensions it will suffice to inject, after tapping, 2 drachms of the 
 tincture, and after manipulating it well within the cavity, a part, 
 say 1 drachm, is allowed to escape. Smart inflammatory reaction 
 follows, and a cure will probably result, either from obliteration 
 of the vaginal space by the formation of adhesions, or by impress- 
 ing some change of function upon the serous membrane. In a 
 certain percentage of cases failure may be expected, and this is 
 more likely to happen if too weak an irritant has been employed, 
 or if the hydrocele is a chronic one with thick and indurated walls, 
 and has been tapped on several previous occasions, (ii.) The 
 open method of operation is now generally adopted, and is par- 
 ticularly recommended in large and chronic cases. The hydro- 
 cele is cut down on through an incision in the upper part of the 
 scrotum, and the tunica vaginalis isolated from the superjacent 
 structures. The cavity is opened, and the parietal portion of the 
 tunica snipped away with scissors close to the testicle. A number 
 of vessels will need to be ligatured ; a drainage-tube is inserted, 
 and the wound closed in the ordinary way. The results of this 
 practice are most satisfactory. 
 
 2. Encysted Hydrocele of the testis occurs in two main forms, 
 according to whether it arises in connection with the epididymis 
 or the body of the testis. 
 
 (a) Encysted Hydrocele of the Epididymis exists usually as a 
 rounded globular swelling, tense and elastic in consistency, and 
 translucent. It is situated above the body of the testis, and 
 close to the head of the epididymis (Fig. 407). As a rule, it does 
 not attain a size greater than that of the body of the testis itself, 
 so that it may appear as if a double testicle was present ; the 
 hydrocele is, of course, devoid of testicular sensation. Less 
 frequently it may attain considerable dimensions, even projecting 
 below and around the testicle, which, though enveloped by it, 
 is quite distinct from it. The fluid contained within these cysts 
 is usually milky and opalescent in appearance, owing to an ad- 
 mixture of semen ; under the microscope spermatozoa, either 
 living or dead, can be demonstrated ; on account of this it is 
 
ii58 
 
 A MANUAL OF SURGERY 
 
 sometimes termed a spermatocele. The specific gravity is lower than 
 that of ordinary hydrocele fluid, and there is but little albumen. 
 The origin of these cysts has given rise to much discussion. 
 They are of a very different nature to the ordinal y vaginal 
 hydrocele, or even to the encysted hydrocele of the cord, since 
 the walls are not lined with en- 
 dothelium, but with cuboidal or 
 columnar epithelium. They are 
 probably due either to a dilatation 
 of one or more of the vasa effer- 
 entia testis, or more frequently to 
 distension of some of the fcetal 
 relics always found near the head 
 of the epididymis, especially of 
 those known as Kobelt's tubes ; 
 these, as also the vasa efferentia 
 testis, are derived from the tubules 
 of the Wolffian body, differing, 
 however, from them in not be- 
 coming attached to the body of 
 the testis (Fig. 44). They are thus 
 homologous with the parovarian 
 cysts found in the female. Smaller 
 pedunculated cysts containing clear \ 
 serum are sometimes met with in vj 
 this region, arising from a disten- 
 sion of the hydatid of Morgagni, 
 which is developed from the re- 
 mains of the Mullerian duct. 
 
 Treatment is conducted along 
 the same lines as for vaginal 
 hydrocele, viz., by tapping as a 
 
 palliative measure, and injection or excision, in order to establish 
 a radical cure. 
 
 (b) Encysted Hydrocele of the Tunica A Ibuginea is a condition rarely 
 seen, consisting of a small collection of serous fluid beneath the 
 visceral portion of the tunica vaginalis. It is probably due to 
 dilatation of lymphatic spaces, and has absolutely no clinical 
 significance. 
 
 II. Hydrocele of the Cord occurs, as already described, in con- 
 nection with the congenital and infantile varieties of vaginal 
 hydrocele. If limited to the cord, it exists in one of two forms, 
 the encysted or the diffuse. 
 
 i. Encysted Hydrocele of the Cord arises from imperfect oblitera- 
 tion of the funicular process of peritoneum, the patent portion 
 becoming distended with fluid and giving rise to a cavity lined 
 with endothelium. It is usually detected as a rounded elastic 
 swelling, occupying the inguinal canal, moving freely up and 
 down within it. The upper border is sharply limited, and in 
 
 Fig. 407. — Encysted Hydrocele 
 of Epididymis. (College of 
 Surgeons' Museum.) 
 
AFFECTIONS OF THE TESTIS, CORD, ETC 
 
 1159 
 
 favourable cases translucency can be demonstrated. On fixing 
 the testicle the cyst is no longer moveable. The fluid contained 
 within it is identical in nature with that in a vaginal hydrocele. 
 In the female a similar condition arises from imperfect obliteration 
 of the canal of Nuck, giving rise to what is known as a hydrocele 
 of the round ligament. Treatment consists in removal of the fluid 
 by tapping, or, if a more radical proceeding is necessary, injection 
 or excision. 
 
 2. Diffuse Hydrocele of the Cord is but rarely seen. It results 
 from a diffuse oedema of its cellular tissue, and presents on exami- 
 nation a fusiform or sausage-shaped tumour, which extends along 
 the cord for a variable distance. 
 
 The term Chylous Hydrocele is applied to a distension of the 
 tunica vaginalis with a chylous fluid, recognised by being milky 
 in appearance, and under the microscope seen to consist of a 
 fatty emulsion. Several modes of origin have been suggested, 
 but none are very satisfactory. In a case recently under treat- 
 ment, a series of dilated lymphatics filled with a similar fluid 
 extended upwards from the testicle to the inguinal canal. 
 
 Varicocele. 
 
 A varicose condition of the pampiniform plexus is very com- 
 monly met with in young men, but seldom in those of advanced 
 age, except when it has become chronic, 
 or is due to malignant disease of the 
 kidney (p. 1067). It usually occurs in 
 individuals with a lax and pendulous 
 scrotum, and is often associated with 
 masturbation, which induces abnormal 
 vascularity of the testis. It may also 
 be caused by the pressure of a truss 
 applied for the relief of a hernia. It is 
 almost invariably on the left side, and 
 the reasons given for this are as follows : 
 (a) The left testis usually hangs lower 
 than the right, and hence the spermatic 
 veins are longer and exposed to greater 
 blood pressure, (b) The left spermatic 
 vein opens into the left renal vein at 
 right angles, and no valve is present 
 at the orifice, whilst that on the right 
 side opens obliquely into the vena cava 
 and is valved. (c) The presence of the 
 sigmoid flexure on the left side of the 
 body, and its distension by accumulated 
 faeces as a result of constipation, may lead to pressure on the 
 abdominal portion of the left spermatic vein. 
 
 Fig. 408. — Varicocele 
 (Treves' ' Surgery.') 
 
n6o A MANUAL OF SURGERY 
 
 A varicocele is characterized by the presence of a soft irregular 
 swelling in the scrotum, which is somewhat pyramidal in shape, 
 the main mass being below and slightly overlapping the testis, 
 and the apex above. It consists of dilated and tortuous veins 
 the outlines of which can often be seen through the skin ; they 
 impart a sensation to the finger which has been likened to a col- 
 lection of worms in a bag ; there is a distinct impulse down the 
 veins on coughing. On assuming the recumbent posture the 
 swelling almost disappears, owing to the vessels being emptied 
 of their contained blood ; if pressure is subsequently applied over 
 the external abdominal ring, and the patient allowed to stand, 
 the tumour reappears, filling from below upwards. A sensation 
 of weight and pain usually accompanies a varicocele, whilst severe 
 neuralgia of the testis may be induced. It is a frequent source of 
 seminal emissions, and may result in testicular atrophy. Phlebitis 
 is liable to follow an injury, and may lead to a spontaneous cure ; 
 if one of the dilated veins is ruptured, severe haemorrhage ensues, 
 causing a diffuse haematocele of the cord. In favourable cases 
 the condition disappears spontaneously. 
 
 The Diagnosis of varicocele is easily made, the only condition 
 for which it is likely to be mistaken being an omental hernia ; 
 the difference between the two conditions has been discussed at 
 p. 981. 
 
 The Treatment of slight cases of varicocele consists of support- 
 ing the testicle and scrotum by means of a well-fitting suspender, 
 whilst the patient is also instructed to bathe the parts with cold 
 water night and morning, and to take such measures as shall 
 ensure a daily action of the bowels. 
 
 Radical Treatment by excision of the veins is advisable in 
 neuralgic cases, where atrophy of the testis is threatening, or in 
 order to fit the patient for admission into any of the public services. 
 The operation is conducted as follows : The pubic region having 
 been shaved and purified, an incision 1^ inches long is made in the 
 direction of the cord, with its centre a little below the external 
 abdominal ring. The structures of the cord are raised on the 
 fingers, and the coverings divided, so as to expose the spermatic 
 veins at their upper end. Two main branches are usually found in 
 this situation, but occasionally there is only one. These are cleaned 
 and carefully isolated from the other structures of the cord, and a 
 ligature is applied to them at the external abdominal ring. The 
 vessels are now clamped with a pair of Spencer Wells' forceps 
 below the ligature, and divided between it and the forceps. The 
 lower end, grasped by the forceps, is stripped downwards, 
 so as to free the pampiniform plexus from the other elements 
 of the cord, and the dissection can be carried nearly as far as 
 the epididymis by drawing the testicle up into the wound. 
 The lower end of the veins is ligatured in one or two portions, 
 and divided. By this means the whole varicocele is removed. 
 
AFFECTIONS OF THE TESTIS, CORD, ETC. 1161 
 
 If the scrotum is pendulous, and the testicle hangs low, it may 
 be advisable to raise it by tying the upper and lower ligatures 
 together, care being taken net to pull them off in so doing ; 
 perhaps it is wiser to introduce a suture through the divided 
 ends of the veins above and below, which are purposely left long. 
 The wound is then closed without a drainage-tube, and dressed 
 as usual. The patient is kept in the recumbent posture for ten 
 days or a fortnight, until a firm cicatrix has formed. This method 
 of treatment is infinitely superior to that often practised of ex- 
 posing the veins in the scrotum, since a wound in the groin 
 always heals much more readily than one in the scrotum ; whilst 
 it is easier to dissect the veins out from above, where only one 
 or two trunks exist. The venous return after the operation is 
 maintained by the vein or veins running with the artery to the vas 
 in the posterior portion of the cord. 
 
 Neuralgia of the Testis is characterized by the organ becoming 
 exquisitely tender and painful, although apparently healthy. It 
 usually occurs in young adults of nervous temperament, or in 
 middle-aged gouty men. It is not uncommonly associated with 
 a varicocele. The pain is usually paroxysmal in character, and 
 very intractable. 
 
 Treatment must be directed mainly to the general health, con- 
 sisting in the administration of nerve tonics, such as iron and 
 quinine, whilst locally sedatives, such as belladonna and aconite, 
 may be applied. It is also advisable for a suspender to be worn, 
 
 Atrophy of the Testis results from several causes : (i.) It may 
 be due to a congenital arrest of development, as met with in 
 displacement or late descent, (ii.) It is most frequently the con- 
 sequence of inflammatory affections, either of the body or epi- 
 didymis, owing to the cicatricial contraction caused thereby lead- 
 ing to compression of the vessels. It occasionally follows the 
 metastatic orchitis of mumps, especially in adults, whilst it is 
 also due to syphilitic disease. (iii.) It arises from impaired 
 nutrition, as after the division of the spermatic arteries in opera- 
 tions for varicocele or hernia, or from compression of the cord by 
 closing the inguinal canal too firmly in the operation for the 
 radical cure of hernia, (iv.) Chronic congestion of the organ, as 
 by a varicocele, may induce atrophy ; whilst (v.) sexual excesses 
 are also stated to lead to it. If unilateral, it is of comparatively 
 little importance; but where both organs are affected, sterility is 
 sure to result, and the patient, if previously young and healthy, 
 is likely to become depressed in spirits and melancholic. This 
 may be due in part to mental causes, but also in measure to the 
 absence of seminal secretion, the reabsorption of which into the 
 system is, according to Brown-Sequard, an important factor in 
 the maintenance of a vigorous state of mind and body. 
 
n62 A MANUAL OF SURGERY 
 
 General Diagnosis of Scrotal Tumours. 
 
 When a patient presents himself for examination with a swelling 
 in the scrotum, the surgeon has to decide whether it is a hernia, 
 a hydrocele, a haematocele, a varicocele, or a solid enlargement of 
 the testis, and, if the latter, of what nature. The first point to 
 which attention is directed is the condition of the cord immediately 
 below the external ring. If this is of normal size and consistency, 
 hernia and diffuse hydrocele of the cord are thereby excluded, 
 whilst the existence of a rounded tense swelling, moveable within 
 the canal, but becoming fixed on holding the testis, indicates that 
 an encysted hydrocele of the cord is probably present. When, 
 however, the cord is more or less masked, further examination 
 speedily determines whether a hernia, or a diffuse hydrocele or 
 haematocele of the cord exists, since the former is often reducible, 
 has an impulse on coughing, and is rounded or nodular in outline, 
 and the latter are sausage-shaped, always irreducible', and semi- 
 fluctuating. 
 
 When the swelling is purely scrotal, inspection and manipula- 
 tion will at once decide if it is a varicocele, by its characteristic 
 feel, by its disappearance on assuming the recumbent posture, 
 and filling again from below on standing up. If the swelling is 
 rounded in outline, the next point to be determined is whether it 
 is solid or fluid. If fluid, it is probably a hydrocele, or the early 
 stage of a haematocele ; the translucency of the former, and the 
 sudden appearance and non-translucency of the latter, should 
 suffice to demonstrate its nature. It is possible that the hydrocele 
 is merely a secondary complication, and hence no final opinion 
 should be given until it has been tapped, and the condition of the 
 body of the testis investigated. If, however, a solid mass exists 
 in the scrotum, it is either a haematocele in its later stages, or 
 some form of sarcocele, whether simple, syphilitic, tuberculous, or 
 neoplastic. A hematocele is possibly recognised by its history, 
 and by there being a fluid centre to the swelling, surrounded by 
 solidified tissue. Chronic orchitis and syphilitic enlargement of 
 the testis are so much alike as to render diagnosis always uncer- 
 tain in the absence of a distinct syphilitic history ; but if the 
 swelling is extremely hard, with a smooth and regular outline, 
 without testicular sensation, limited to the body of the testis, and 
 accompanied by a hydrocele, it is probably syphilitic. Tuberculous 
 disease, on the other hand, occurs more frequently in younger 
 individuals than does the syphilitic variety, whilst the epididymis 
 is usually first attacked, becoming nodulated, the cord is early 
 implicated, hydrocele is rare, suppuration is frequent, and tes- 
 ticular sensation remains till the body of the testis is disorganized. 
 Tumours always impart a distinct sense of weight to the hand, 
 quite different to that noticed in tuberculous or syphilitic disease ; 
 
AFFECTIONS OF THE TESTIS, CORD, ETC. 1163 
 
 if a simple tumour is present, it is rounded, slow in growth, and 
 the cord is unaffected. Malignant disease is characterized by 
 rapid growth, more severe pain, and early implication of the 
 structures of the cord and of the lumbar lymphatic glands. The 
 enlargement of both testes is in favour of tubercle or syphilis 
 rather than of malignant disease. A certain small number of 
 cases will remain where, in spite of every care, the nature of the 
 mass is still a matter of doubt ; in such the diagnosis cannot be 
 established without puncture or an exploratory incision. 
 
 Whilst weighing carefully the local conditions, we must not 
 omit to thoroughly investigate and appreciate the general history 
 and condition of the patient, his age, appearance, previous habits 
 and illnesses, etc. At the same time, an examination of the 
 internal organs should be made to ascertain, as far as possible, 
 the existence or not of concurrent disease, e.g., tuberculous disease 
 of the lungs or kidneys, or secondary malignant deposits. 
 
 Castration is required for many different conditions, which have 
 been already described, e.g., for malposition, tuberculous disease, 
 old-standing hematoceles, and simple or malignant tumours ; it 
 has also been undertaken for chronic enlargement of the prostate. 
 The operation is conducted as follows : The pubes and perineum 
 having been previously shaved and purified, the surgeon, standing 
 on the same side of the patient as the organ to be removed, 
 makes an incision down to the testis. If large and adherent to 
 the scrotal tissues, the incision must necessarily involve the 
 scrotum, but wherever practicable it is wise to avoid the scrotal 
 integuments, making the incision over the cord. It should always 
 extend upwards as far as the external abdominal ring, so as to 
 enable the structures of the cord to be divided high up, a most 
 important matter in tuberculous and malignant disease ; the 
 inguinal canal can then also be closed, if necessary. The testis 
 or tumour is enucleated from its surroundings, and the cord 
 isolated and divided as high as possible, after transfixing and 
 securely ligaturing it with silk. Some surgeons prefer to separate 
 the tissues of the cord, and to take them up individually, but this 
 is a matter of little importance. The stump should not be 
 allowed to slip back into the canal until all bleeding has completely 
 stopped, and it has been suggested that the cut end of the vas 
 should be touched with pure carbolic acid as a precautionary 
 measure. Considerable attention was formerly directed to the 
 condition of the pulse at the moment when the cord was divided, 
 and it was a regular instruction to the anaesthetist, that if ether 
 was being administered it should be pushed, whilst the amount of 
 chloroform should be diminished. Such a distinction, however, 
 is unnecessary, since it is now fully recognised that one of the 
 best means of preventing shock is the maintenance of complete 
 anaesthesia, the medul'ary centres being thereby guarded from the 
 
1164 A MANUAL OF SURGERY 
 
 action of afferent stimuli ; consequently, it is only necessary that 
 the patient should be fully under the influence of the anaesthetic. 
 All bleeding points in the scrotum are now secured by ligature, 
 and these may be numerous ; the wound is closed by sutures, a 
 drainage-tube being inserted in the scrotum, and by choice coming 
 to the surface at the upper end of the wound, that is, as far from 
 the perineum as possible. 
 
 In the performance of double castration, it is recommended to 
 make two crescentic flaps from side to side, so as to include 
 between them a portion of the scrotal integument, in order to 
 reduce the subsequent redundancy of unnecessary tissue. 
 
 Affections of the Vesiculae Seminales. 
 
 Acute Vesiculitis is not often met with, but sometimes arises, in association 
 with prostatitis, as a complication of gonorrhoea. It is characterized by 
 deep-seated pain in the perineum, together with irritability of the neck of 
 the bladder and increasing frequency of micturition. Defalcation becomes 
 painful, and on examination of the rectum the vesiculae can be felt enlarged 
 and tender. If suppuration ensues, an abscess forms, which usually bursts 
 into the rectum, but sometimes into the bladder or peritoneal cavity. As a 
 rule, the condition disappears pari passu with the gonorrhoea; but when sup- 
 puration has supervened, it is advisable to open the abscess by a deep incision 
 through the perineum, guided by a finger in the rectum. 
 
 Subacute or Chronic Vesiculitis is not uncommon, the latter condition being 
 often associated with prostatitis, and one of the most frequent causes of gleet. 
 Seminal emissions and priapism may be caused by it, and the enlarged organ 
 can be felt through the rectum. A good deal of pain, often referred to the 
 back, is experienced. The treatment is the same as for chronic prostatitis. 
 
 Tuberculous Disease attacks the vesiculae seminales as a result of extension 
 from the testis along the vas, being almost always associated with similar 
 disease of the prostate and base of the bladder. The organs can be felt 
 enlarged, and if suppuration occurs, the abscess may burst into the rectum or 
 bladder, or possibly into both, a recto-vesical fistula being thereby developed. 
 It is possible to reach the vesiculae through a semilunar incision in the 
 perineum, displacing the rectum backwards, and the bladder and prostate 
 forwards, or from behind by removing the coccyx and part of the sacrum, 
 as in Kraske's operation. When exposed, complete excision is sometimes 
 possible, or an opening is made into them, and the cheesy contents scooped 
 out. 
 
 Affections of the Scrotum. 
 
 Injuries of the Scrotum. — Contusions and blows give rise to ecchymosis, 
 which may be so extensive as to warrant the term hematoma scroti which has 
 been applied to it. 
 
 Incised wounds may affect the skin and subcutaneous tissues, or may lay 
 open the tunica vaginalis, with or without protrusion of the testicle. All that 
 is needed in such cases is to render the wound aseptic, and to deal with it on 
 general principles. Considerable destruction of scrotal tissue may be repaired 
 by transplantation of flaps from the inguinal region, or by grafting according 
 to Thiersch's method. 
 
 Cellulitis of the Scrotum most commonly results from extravasation of urine, 
 for which see p. 1133. It may occasionally arise from other causes, but needs 
 no special description. 
 
 (Edema of the Scrotum is usually due to dropsy, being often associated with 
 
AFFECTIONS OF THE TESTIS, CORD, ETC. 
 
 1165 
 
 general anasarca and ascites. It may attain considerable dimensions. Acute 
 inflammatory oedema of the scrotum is a term sometimes applied to erysipelas 
 affecting this region, on account of the absence of the vivid red colour usually 
 associated with that affection. Considerable cedema is always present, and 
 gangrene of the skin may result. As soon as the gangrene becomes limited, it 
 should be excised, and the margins of the wound brought together by sutures, 
 or allowed to heal by granulation. 
 
 Scrotal Fistulse are usually due to the bursting of abscesses in connection 
 with the urethra (see Perineal Abscess). 
 
 Sinuses of the Scrotum are often found in connection with tuberculous or 
 syphilitic disease of the testicle. 
 
 Eczema of the Scrotum is a troublesome affection, giving rise to great 
 
 Fig. 
 
 409. 
 
 -Epithelioma Scroti following Paraffin Eczema. 
 (Tillmanns.) 
 
 pruritus and irritation. It results from the presence of pediculi, but the 
 more chronic forms occur amongst workers in tar and paraffin, and also in 
 chimney-sweeps, being due to the constant irritation of the corrugated scrotal 
 integument by dirty clothes. It is characterized by the presence of warty 
 outgrowths, and not unfrequently runs on to epithelioma, originating the con- 
 dition known as chimney-sweep' s or paraffin cancer (Fig. 409). The usual charac- 
 teristics of such a new growth are present, and in some of the deeper cells 
 particles of soot have been demonstrated. The inguinal glands are usually 
 involved, but not till late, and the progress of the case is slow. The only 
 treatment which can be adopted is complete removal, the wound caused 
 thereby being closed or allowed to granulate. 
 For Elephantiasis Scroti, see p. 31b. 
 
CHAPTER XL. 
 
 AMPUTATIONS 
 
 By the term Amputation is meant the removal of some portion of the body 
 which is injured or diseased to such a degree as to endanger the patient's life, 
 or to preclude any hopes of its restoration to a normal, or even useful, con- 
 dition. In this chapter we shall merely deal with the operation as applied to 
 the extremities, amputations of organs such as the breast and penis having 
 been described elsewhere. Necessary limitations of space force us to treat the 
 subject somewhat briefly. 
 
 Methods of Amputation. — Since the introduction of anaesthesia, the methods 
 employed for the purpose of removing limbs have been almost revolutionized ; 
 there is now no necessity to hurry through the operation, and hence many 
 new proceedings, and these sometimes of a most complicated nature, have 
 
 
 Fig. 410. — Circular Amputation for the Arm, 
 showing Flap of Skin turned back, and 
 Knife applied for Division of the Muscles. 
 
 Fig. 411. — Section of 
 Parts after Circular 
 Amputation. 
 
 A, Skin and subcutaneous 
 fat; B, muscles; C.bone. 
 
 been devised. They are in the main merely modifications of three cardinal 
 operations, the circular, the racquet-shaped, and the flap. 
 
 The Circular Amputation (Fig. 410), although formerly much employed, is 
 now but little used ; in it the skin and subcutaneous tissues are divided around 
 the whole circumference of the limb by a circular sweep of the knife. These 
 are then retracted or dissected back like a cuff, and the superficial muscles 
 divided in a similar manner. The soft parts are again further retracted, and 
 the deeper muscles divided, allowing the bone to be cleared and sawn through 
 at a still higher level. The end of the bone is thus placed at the apex of a 
 conical hollow (Fig. 411), and can be completely covered over; the vessels, 
 
AMPUTATIONS 
 
 1167 
 
 moreover, are divided transversely. The stump is not very shapely, and 
 after a time, owing to the shrinking; of the soft parts, the cicatrix is likely 
 to become attached to the bone. The arm is almost the only situation in 
 which a pure circular operation is ever undertaken at the present day ; but 
 a modified form is still occasionally utilized else- 
 where. Thus, one or two vertical incisions may 
 be associated with the circular cut, in order to 
 facilitate the removal of the bone at a higher 
 level, as in disarticulation of the hip-joint by 
 Furneaux Jordan's method (p. 1182). 
 
 The Racquet-shaped Method (Fig. 416) is very 
 similar to the last-described modification of the 
 circular. In it an oval incision is made around 
 the limb with one end pointed, and if necessary 
 prolonged upwards to form, as it were, the 
 handle of the racquet. This method is useful 
 for removing fingers and toes, and is also 
 employed at the hip and shoulder joints. 
 
 A somewhat similar operation is known as 
 the Elliptical or Oval Method (Fig. 417, A). In 
 it an oval incision is made around the limb ; the 
 lower or distal portion is then dissected up so as 
 to enable the amputation or disarticulation to be 
 completed at a spot a little below the proximal 
 end. The free convex border of the flap is then 
 turned over, and fitted into the concavity of the 
 wound . 
 
 The Flap Method is that chiefly made use of 
 at the present day in amputating through the 
 shafts of the long bones. It was formerly per- 
 formed by transfixion in order to save time ; 
 but the bulk of muscles included in the flap, and 
 the fact that the vessels and nerves are often 
 sliced longitudinally, render this an undesirable 
 proceeding. Hence it has been discarded, and 
 the flaps are now usually marked out super- 
 ficially, and then raised by dissection . As a rule, 
 they consist merely of skin, subcutaneous tissue 
 and deep fascia, a little muscle being perhaps 
 included towards the base. 
 
 The best method of amputating in muscular 
 parts, such as the thigh, is that known as the 
 Modified Flap and Circular (Fig. 412), which was 
 originally suggested by Lord Lister. In this two 
 rectangular flaps with the corners rounded off 
 are raised on opposite sides of the limb, the 
 length of the anterior being two-thirds of the 
 diameter of the limb at the point at which it is 
 proposed to divide the bone, and the posterior 
 flap half the length of the anterior. These, consisting merely of skin and sub- 
 cutaneous tissues, are dissected up ; the muscles are then divided circularly, 
 being retracted for another half-diameter. The advantages of the flap and 
 circular methods are thus combined. In cutting the flaps it is most essential 
 that they should not taper, but should remain the same breadth throughout, 
 the corners being merely rounded off. 
 
 General Remarks on Amputations. 
 
 Certain important details must always be attended to by the operator when 
 selecting an amputation suitable for any particular case. 
 
 Fig. 412. — Lister's Modi- 
 fied Flap and Circular 
 Amputation. 
 
 The continuous dark line in- 
 dicates the outline of the 
 anterior flap ; the dotted 
 line, the lower end of the 
 posterior flap ; the line of 
 section and retraction of 
 the muscles is represented 
 as an interrupted line. 
 
n68 
 
 A MANUAL OF SURGERY 
 
 k 
 
 1. A Sufficient Covering is necessary, in order to protect the end of the 
 bone from injurious pressure. Ii the skin were not contractile, and if the 
 muscles did not retract, it would suffice to provide two flaps, each equal 
 to half the diameter of the limb at the point of section of the bone ; but 
 owing to the contractility and retraction of living tissues, it is essential to 
 allow at least a diameter and a half, and sometimes two diameters ; in 
 non-muscular parts the former may suffice, but in fleshy parts, especially 
 when amputating low down in the thigh, where the range of muscular 
 contraction is much greater, the latter. It is usually a matter of some 
 
 significance whence the flaps are derived ; thus, 
 a single flap, e.g., a long anterior or posterior, 
 is not to be recommended owing to the difficulty 
 of maintaining its nutrition. Equal flaps are 
 used in parts like the arm, where the end 
 of the stump will not be exposed to pressure. 
 Generally, however, the anterior flap is cut longer 
 than the posterior, as in the case of the modified 
 flap and circular, or sometimes vice versa; in the 
 former, owing to the additional retraction of the 
 muscles, a covering equal to two diameters of 
 the limb is provided, leale's amputation (Fig. 413) 
 consists in raising a long square anterior flap, 
 equal in breadth and length to half the circum- 
 ference of the limb at the point of section of the 
 bone, and including everything down to the 
 bone. The posterior flap is similar in nature to 
 the anterior, but only a quarter of its length. 
 The free end of the anterior flap is doubled 
 over, and accurately stitched to the posterior. 
 The advantages claimed for this operation are 
 that the vessels are cut long, and thus the 
 nutrition of the flaps 
 secured, whilst a 
 covering nearly equal 
 to two diameters of 
 the limb is provided. 
 The great objection 
 to the method con- 
 sists in the amount 
 of the limb which 
 has to be sacrificed 
 on account of the 
 length of the anterior 
 flap, and hence it 
 is rarely employed. 
 Occasionally the covering is derived from the sides of the limb (amputation 
 by lateral flaps). 
 
 2. The Cicatrix should be situated away from the end of the bone, especially 
 in the lower extremity, where the weight of the body has to rest upon the 
 stump. 
 
 3. A Dependent Opening is desirable for purposes of drainage, and to 
 ensure this the anterior flap is often made longer than the posterior. This, 
 however, is not such an important matter since the introduction of antiseptic 
 methods. 
 
 4. All these objects should be attained with as little sacrifice of the limb as 
 possible, since the higher the operation, the greater the shock to the patient. 
 
 As to the operation itself, the greatest care must be taken to maintain 
 Asepsis, since muscular and fascial planes have been freely opened, and 
 possibly the medullary cavity of the bone exposed; the dangers of septic, 
 
 Fig. 
 
 413. — Teale's Amputation. (Treves' 
 ' Operative Surgery.') 
 
AMPUTATIONS u $g 
 
 absorption under such circumstances are obvious. Haemorrhage is prevented 
 by previous exsanguination of the limb by elevating it for two or three minutes, 
 and then applying an elastic tourniquet. In the leg a piece of rubber tubing 
 may be employed, Samway's tourniquet being perhaps the best. In the arm, 
 however, the subcutaneous position qf the principal nerves leaves them much 
 exposed, and paralytic symptoms have followed the use of such appliances, 
 especially when made of solid rubber ; a fiat elastic bandage carried several 
 times around the limb, and secured by a knot or with a safety pin, is all that is 
 needed. Should the tourniquet have to be applied close to the area of opera- 
 tion, it must, of course, be soaked in carbolic or sublimate lotion ; it is then 
 advisable to protect the skin over which it is placed by a few layers of gauze, 
 so as to prevent blistering. After the limb has been removed, the main vessels 
 are at once ligatured, both artery and vein being separately tied. It is well to 
 isolate and draw them down for a little distance, so as to make sure that they 
 have not been buttonholed. Any other vessels which can be seen are tied 
 before the tourniquet is removed. An assistant should for a time be ready to 
 control the main trunk after releasing it from the tourniquet. In some cases 
 it may be impracticable or undesirable to apply a tourniquet, and then the 
 main vessels may be temporarily controlled by digital compression at some 
 suitable spot whilst the amputation is completed. Any bleeding-points are 
 rapidly secured by pressure forceps, and subsequently tied, and the main 
 trunks isolated, and clamped or ligatured before division. 
 
 For special methods of controlling the haemorrhage in amputation through 
 the hip-joint, see p. 1181. 
 
 We have already drawn attention to the necessity of not tapering the flaps, 
 but of cutting them square, the corners alone being rounded. In dissecting 
 them up, the deep fascia should be included with the flap, and the blade of 
 the knife always turned towards the part which is to be removed, so that the 
 under surface of the flap, and with it the nutrient vessels, shall not be scored. 
 Whilst dividing the muscles the flaps must be carefully guarded by the hands 
 of assistants. Before sawing the bone, it is recommended that the periosteum 
 should be retracted for some distance, so as to more efficiently provide for its 
 nutrition ; this plan should certainly be adopted for the humerus and femur. 
 Any irregular bony spicules left after sawing should be trimmed off with 
 cutting pliers. Attention must next be directed to the main nerves and to 
 any tendons which lie exposed in the wound, all such structures being cut short, 
 the nerves as high as possible. The wound is usually closed by a continuous 
 suture, but one or two deep stitches should also be inserted to draw the 
 muscles together, and provision made for drainage from one of the angles of 
 the incision. The dressing is applied in such a way as to draw the flaps down 
 over the end of the bone, and a splint is often necessary in order to control 
 the upper ends of the divided muscles and to keep them at rest. 
 
 The chief Complications likely to arise in the subsequent course of the case 
 are shock, reactionary haemorrhage, and those which result from sepsis; these 
 conditions and their treatment have been described elsewhere. 
 
 In a Healthy Stump the end of the bone is rounded, and the medullary 
 cavity closed by a layer of compact tissue. The divided muscles and tendons 
 are either incorporated in the cicatrix, or gain fresh adhesions to the bones. 
 The vessels are obliterated as far as the next patent branches, whilst the nerve- 
 ends usually become bulbous (Fig. 83, p. 327), but, if suitably shortened, do 
 not adhere either to the end of the bone or to the cicatrix, and hence give rise 
 to no trouble. A sufficient covering of non-adherent skin and subcutaneous 
 tissue should form a pad for the protection of the bones. 
 
 Affections of Stumps. — (a) Necrosis of the end of the bone is sometimes the 
 result of. carelessness on the part of assistants, who can readily. denude it of 
 its periosteum by rough sponging, etc. ; it rarely follows if the periosteum has 
 been first retracted before the bone is divided, and practically never apart from 
 sepsis. A small annular sequestrum is usually all that separates, but should 
 the inflammation spread up the medullary cavity (septic osteomyelitis), a more 
 
 74 
 
1 170 
 
 A MANUAL OF SURGERY 
 
 extensive destruction of bone tissue follows (for symptoms and treatment of 
 which see p. 509). (b) Sloughing of the ends of the flaps occurs in debilitated 
 individuals, especially if thin skin flaps have been employed, or if their nutri- 
 tion has been impaired by trauma, or if unhealthy tissue has been incorporated 
 in their substance by amputating too close to the seat of disease or injury. 
 The process is usually limited in extent, and rarely calls for treatment other 
 than keeping the part dry and aseptic, the slough being then slowly absorbed ; 
 if sepsis is present, the consequences may be very serious, even necessitating 
 re-amputation at a higher level, (c) A conical stump results either from the 
 flaps being cut too short, or from the parts shrinking as a result of septic in- 
 flammation , or in young people from continued growth of the upper epiphyseal 
 cartilage of the divided bone. In bad cases the bone may even project 
 through the integument, and necrose ; re-amputation is the only treatment. 
 (d) A painful stump is usually due to the adhesion of a bulbous nerve-end to 
 the cicatrix or bone, so that it is dragged upon at each movement of the limb. 
 The pain is of a severe neuralgic nature, and is treated by excising the bulb, 
 or re-amputation, (e) A spasmodic stump sometimes occurs, being due either to 
 irritation of the enlarged nerve-ends, or to some central cause. In the former 
 instance, excision of the bulbs or re-amputation will cure the case ; in the 
 latter, the trouble will persist in spite of treatment, affecting fresh groups of 
 muscles after re-amputation. 
 
 Special Amputations. 
 
 Amputation of the Fingers is frequently required after machine accidents 
 and similar injuries, or in necrosis following a whitlow ; in these cases it is 
 
 Fig. 414. — Incisions for Amputa- 
 tion of Terminal Phalanx of 
 Finger. (Tillmanns.) 
 
 Fig. 415. — Amputation of Finger at 
 metacarpophalangeal articu- 
 LATION, showing Divided Tendons 
 and Ligatured Vessels. (Till- 
 manns.) 
 often impossible to follow any regular routine, the flaps being obtained from 
 any portion of sound tissue present. The following, however, are the chief 
 plans adopted : 
 
 Amputation of the Terminal Phalanx is usually conducted by opening the 
 joint on the dorsal aspect, and cutting a palmar flap from the pulp of the finger 
 (Fig. 415). 
 
 No useful result follows amputation through the first inter-phalangeal 
 articulation, since the portion left is practically fixed and useless, no tendons 
 being inserted to govern it. An operation which is sometimes advantageous 
 consists in amputating through the middle of the second phalanx, so as to leave 
 the insertion of the flexor sublimis tendon, the flaps for such an operation being 
 derived from am- ^art of the finger, and the bone divided by cutting pliers. 
 
AMPUTATIONS 
 
 1171 
 
 Removal of a finger at the Metacarpophalangeal Joint (Fig. 415) is an 
 operation frequently necessary. It is best conducted by means of a racquet- 
 shaped incision (Fig. 416, A), which starts over the knuckle, extends between 
 it and the next finger, curves round to the palmar aspect so as to be placed a 
 little below the crease in the skin at the root of the finger (Fig. 417, C), and 
 returns in the same way to the back of the knuckle. This incision can be made 
 with one sweep of the knife, but there is no real advantage in such a pro- 
 cedure. The articulation is then opened from behind, and is found further 
 forwards than one would at first expect ; the structures on either side are then 
 successively divided, making them tense by rotation of the finger, and the 
 flexor tendons finally cut across. Bleeding-points (usually one on each side) 
 are secured, and the wound closed. 
 
 The question of removing the head of the matacarpal bone is one which 
 
 must be decided by the occupation of 
 the patient ; if he is a working man, or 
 needs strength of hand, it should be 
 left, as its removal always causes weak- 
 ness. In ladies and those where small- 
 ness and elegance of the hand are 
 required rather than strength, it can 
 be taken away by slightly prolonging 
 the incision upwards, clearing the bone 
 on either side, and applying cutting 
 pliers. The gap between the adjoining 
 fingers can in this way be almost ob- 
 literated. It is especially advisable to 
 do this in the case of the index-finger, 
 since the head of the second metacarpal 
 bone forms an unsightly projection, 
 and is very exposed to injury. For 
 this finger, Faraboeuf's method (Fig. 
 416, B) is often used (p. 1174). 
 
 Occasionally the four fingers and 
 their attached metacarpal bones have 
 to be removed en bloc. Short equal 
 flaps may then be cut from the front 
 and back of the hand, and the dis- 
 articulation effected. The stump that 
 remains, although consisting merely of 
 the carpus and thumb, is very service- 
 able. 
 
 Amputation of the Thumb should 
 never be undertaken unless absolutely 
 necessary, since its removal seriously impairs the functional utility of the 
 hand; as' large a portion must be saved as practicable, so so to assist the 
 patient in grasping. The phalanges may be removed by any method which 
 enables the bone to be covered with the least possible sacrifice. 
 
 When it is also necessary to take away the metacarpal bone, one of the two 
 following plans should be adopted : . 
 
 1 The racquet method (Fig. 416, C) . In this an incision commences in the inter- 
 tendinous hollow known as the tabatfere, and extends along the dorsum of the 
 thumb to the head of the metacarpal bone, the oval portion sweeping round it 
 at the level of the web when the thumb is abducted, and on the palmar aspect 
 corresponding to the oblique crease at its root. The remainder of the operation 
 resembles that for removal of a finger. Care must be taken not to wound the 
 trunk of the radial artery as it passes through the base of the interosseous 
 space • the blade of the knife is therefore kept closely applied to the bone. 
 
 2 By apahnarflap. In this the knife is first carried across the dorsal aspect 
 of the thumb f-om the centre of the web between it and the index-finger, to a 
 
 Fig. 416. — A, incision for amputation 
 of finger by racquet method ; B,- 
 Faraboeuf's method of amputation, 
 as applied for index-finger; C, 
 racquet-shaped incision for disarti- 
 culation of thumb at carpo-meta- 
 carpal joint. 
 
1 172 
 
 A MANUAL OF SURGERY 
 
 point on the palmar surface of the wrist just above the thenar eminence. The 
 knife is then rotated so that its cutting-edge looks outwards, and inserted 
 deeply through the ball of the thumb, transfixing it, so as to emerge at the 
 same spot in the centre of the web as th.at at which the incision commenced 
 A muscular flap with a well-rounded border is readily fashioned by cutting 
 outwards. The remaining soft parts are then divided, and disarticulation 
 completed by opening the joint. It is a prettier and more showy operation 
 than the former, but otherwise has no advantages. 
 
 Amputation through the Wrist-Joint is seldom performed except for injuries, 
 and then the flaps must be derived as best they can from healthy tissues. Three 
 chief methods are, however, described : (a) In the elliptical (Fig. 417, A), the 
 incision takes the form of an ellipse, 
 the highest point being on the dorsum 
 \ inch below the level of the wrist- 
 joint, and the lowest in the centre of the 
 palm 2 inches below the former. On 
 the ulnar side, the incision passes be- 
 tween the pisiform bone and the base 
 of the fifth metacarpal, whilst on the 
 radial side it crosses the carpo-meta- 
 carpal articulation. After dividing the 
 cellular tissue, and dissecting up the 
 palmar flap, the joint is opened from 
 the posterior aspect, and the disarticu- 
 lation completed. The convex end of 
 the palmar flap is fitted into the con- 
 cavity of the dorsum, and the cicatrix 
 thus forms a curved line on the back 
 of the stump, (b) A long palmar flap 
 (Fig. 417, B) is sometimes utilized, ex- 
 tending from just below either styloid 
 process down to about the middle of 
 the metacarpal bones, the sides of this 
 flap being parallel to each other. The 
 dorsal incision crosses the carpus hori- 
 zontally between the two extremities 
 of the former wound. Thepalmarflap FlG - 4*7-— A ( thi ck lines), Amputa- 
 is then dissected up so as to include tion ^^g? 1 . wrist . b y elliptical 
 
 method; B (thin lines), amputation 
 through wrist by single palmar flap 
 — the dotted lines in each represent 
 the dorsal incisions ; C, situation of 
 palmar incision (a little below the 
 web) in amputation of finger. 
 
 only skin and subcutaneous tissue, with 
 perhaps a little muscular tissue from 
 the thenar and hypothenar eminences. 
 The wrist-joint is opened from the 
 dorsum , and the amputation completed 
 by the division of the flexor tendons. 
 (c) In a few cases, amputation by an 
 external flap (Fig. 418) may be desirable (Dubreuil's method). The incision 
 commences at the junction of the middle and outer thirds of the back of the 
 wrist, reaches down to the head of the metacarpal bone of the thumb, termi- 
 nating at a point in the palm immediately opposite its commencement. This 
 flap is dissected up, and should contain a certain amount of muscular substance 
 from the thenar eminence. The skin and subcutaneous tissues on the ulnar 
 aspect are now divided by a circular sweep of the knife around the inner side 
 of the limb. Disarticulation follows, and the external flap is carried inwards, 
 and sutured so as to close the wound. 
 
 Amputation through the Forearm is usually conducted by means of a flap 
 operation, the flaps being either equal in length or one a little longer than the 
 other. The muscles are divided circularly, and the bones should be thoroughly 
 cleared before division. 
 
 Disarticulation at the Elbow-Joint is an operation very rarely seen, and is 
 either undertaken by the elliptical method or with a long anterior flap. 
 
AMPUTATIONS 
 
 "73 
 
 Amputation through the Arm may be carried out by any of the methods 
 described, e.g., the flap, circular, or modified flap and circular, the choice in 
 any particular instance being determined by the requirements of the case. 
 
 Disarticulation at the Shoulder-Joint. — Three chief methods are practised 
 for the performance of this operation, viz., Spence's and Larrey's, or that by 
 means of an external or deltoid flap. In all, the third part of the subclavian 
 artery may be controlled by digital compression, the surgeon endeavouring to 
 leave the division of the main vessels until the last stage of the proceedings ; 
 but it is perhaps better to clamp all the smaller vessels as soon as they are 
 cut, and to isolate and tie the main trunks before their division. 
 
 (a) Spence's operation (Fig. 419)- — A preliminary incision similar to that for 
 excision of the shoulder is first made, extending downwards and outwards 
 through the fibres of the deltoid, from a point midway between the coracoid 
 and acromion processes. This passes directly down to the bone, and, if neces- 
 sary, the joint is at once opened and examined prior to any further steps being 
 taken. The surgeon, standing on the outer side of the limb, then carries his 
 
 Fig. 418. — Amputation through 
 Wrist by Dubreuil's Method. „ 
 
 (tlllmanns > ■+ i 9" s^ence s amputation at the 
 
 '' Shoulder by Anterior Racquet. 
 
 (Treves' 'Operative Surgery.') 
 
 knife from the lower part of the incision downwards and inwards across the 
 axillary folds around the limb to the point from which it first started, thus 
 making the incision racquet-shaped. The skin is first dissected up all round 
 for an inch or so, and then the muscles on the inner side, the deltoid in part, 
 the pectoralis major, the coraco-brachialis and biceps, are divided on the 
 slant, thereby exposing the main vessels and nerves. The vessels may now 
 be secured and divided, and the nerves isolated, pulled down and cut short, 
 or they may be left intact for a time. The soft structures on the outer side of 
 the vertical incision are next separated from the bone, and then the outer half 
 of the capsule, together with the muscles inserted into the greater tuberosity 
 of the humerus, and the long tendon of the biceps, are divided. The inner 
 half of the capsule and the subscapularis are then divided from the bone so as 
 to free the head. By retracting the external flap and protruding the head 
 of the bone from its socket, the remainder of the capsule can be severed, and 
 then the knife, travelling downwards between the humerus and the axillary 
 vessels, is made to cut its way out, thus completing the disarticulation, the 
 vessels and nerves, if not already dealt with, being divided as the last step in 
 the proceeding. If the knife is kept close to the bone, the trunk of the posterior 
 circumflex artery is not interfered with. 
 
 (b) Larrey's operation (Fig. 420) is very similar to the above, except that the 
 vertical incision is made on the outer aspect of the joint, reaching downwards 
 from the prominence of the acromion for a distance of about 6 inches, the oval 
 portion starting from its centre, and being directed obliquely downwards and 
 
"74 
 
 A MANUAL OF SURGERY 
 
 inwards. The tissues are reflected on either side of the humerus ; the joint 
 is opened by a transverse cut over the great tuberosity, which also divides the 
 muscles inserted into it. The knife is finally carried down on the inner side oi 
 the humerus so as to sever the vessels last, if considered desirable. 
 
 (c) Amputation by the external or deltoid flap is but little practised at the 
 present time. The flap is either cut by transfixion, or dissected up. It is 
 U-shaped, its base extending from the coracoid process in front to the root of 
 the acromion behind. A skin incision is now made across the inner aspect of 
 the limb, joining the ends of the former incision, and extending about 2 inches 
 below the axilla. Disarticulation is then 
 carried out in the same way as in the 
 previous methods. 
 
 Occasionally it is necessary to remove the 
 whole of the upper limb together with the 
 scapula and outer third of the clavicle, for 
 new growths, usually of a sarcomatous nature, 
 or for injury. This so-called Interscapulo- 
 thoracic Amputation is best performed ac- 
 cording to Berger's method. An incision is 
 made along the middle third of the clavicle, 
 and this portion of bone is then removed so 
 as to enable the surgeon to divide between 
 ligatures the subclavian artery and vein on 
 a level with the lower border of the first 
 rib. The anterior flap is then formed by 
 an incision reaching from the centre of the 
 former and extending downwards and out- 
 wards over the shoulder, across the anterior 
 fold of the axilla, and as far as the lower 
 angle of the scapula. The pectorales major 
 and minor are divided along this line, thereby 
 exposing the brachial plexus, the constituent 
 nerves of which are severed on a level with 
 the section of the vessels. The axillary 
 space can now be opened up along the outer 
 
 surface of the serratus magnus. The limb is then rotated inwards and adducted 
 across the trunk, and the patient drawn well to the edge of the table so as to 
 enable the posterior incision, which unites the outer ends of the two former, 
 to be made. The flap thus marked out is dissected up, and the different 
 muscles retaining the scapula in connection with the body are divided one 
 after the other, including the trapezius, omo-hyoid, levator anguli scapulae, 
 rhomboids, and serratus magnus. These may be incised as near to the bone 
 as is thought compatible with the total removal of the growth. Any remaining 
 fibres are cut across, and the limb is thus detached. In cases of new growth 
 there may be a large number of vessels, both arteries and veins requiring 
 ligature ; but in a healthy limb removed for injury, none but the posterior 
 scapular and supra-scapular will give any trouble. Naturally, such an opera- 
 tion is accompanied by some amount of shock, but the results hitherto 
 obtained have been very gratifying. 
 
 Amputations of the Lower Extremity. 
 
 Amputation of the Toes at the metatarso-phalangeal articulations is precisely 
 similar to the analogous operation on the fingers. It must be remembered 
 that the joint Jies as far behind the web as the apex of the toe is in front of it, 
 and hence the incision must start farther back than might be expected. 
 
 For the removal of the great toe from the metatarsal bone, Farabceufs opera- 
 tion is the best. The incision (Fig. 421) commences over the head of the latter 
 bone, and well to the inner side of the extensor tendon ; it extends downwards 
 nearly as far as the interphalangeal articulation, and then crosses the plantar 
 
 Fig. 420. — Larrey's Ampu- 
 tation THROUGH THE 
 Shoulder Joint by Ex- 
 ternal Racquet. (Treves' 
 ' Operative Surgery.') 
 
AMPUTATIONS 
 
 "75 
 
 surface of the toe so as to reach the centre of the web between it and the 
 second toe ; thence the knife is carried straight back to the commencement of 
 the incision. These cuts are deepened, the tendons divided, the joint opened, 
 and the toe removed. It will then be found that an internal flap remains, 
 which can be brought across the head of the metatarsal bone, and covers it in 
 so that the L-shaped cicatrix is not exposed to pressure. 
 
 Amputation of the great toe at the tarso-metatarsal articulation is conducted 
 either by a racquet-shaped incision, or by dissecting up a flap from the inner 
 side. It is a bad operation, leaving a terribly mutilated foot, and should, if 
 possible, never be undertaken. 
 
 Amputation of the foot at the Tarsometatarsal Articulation is performed 
 either by Lisfranc's or Hey s operation. 
 
 Lisfranc's amputation (Fig. 422) consists really of a disarticulation, no bone 
 
 Fig. 421. — Farabceuf's Ampu- 
 tation of the Great Toe. 
 (Treves' ' Operative Sur- 
 gery.') 
 
 Fig. 422. — Incisions for Lisfranc's Ampu- 
 tation. (Treves' 'Operative Surgery.') 
 
 being sawn across. The patient lies on the back with the foot elevated, and 
 extending beyond the end of the table. On the right foot a slightly convex 
 dorsal incision extending down to the bones is made from the tip of the fifth 
 metatarsal bone on the outer side to the base of the first on the inner. The 
 plantar flap is then marked out, reaching from the terminations of the former 
 incision forwards as far as the roots of the toes, and being necessarily longer 
 on the inner than the outer side. On the left foot the incisions are made in 
 the opposite direction. This latter flap is dissected up, the toes being fully 
 extended by an assistant ; only the skin and subcutaneous tissues are raised 
 for the first inch, but further back all the structures in the sole of the foot are 
 included. The appearance of the peroneus longus tendon will indicate that 
 the dissection has been carried back far enough. Disarticulation is now per- 
 formed from the dorsal aspect, the line of the joints (Fig. 423) being kept in 
 mind. The knife is entered behind the spur of the fifth metatarsal bone, and is 
 at first directed forwards and inwards towards the head of the first metatarsal 
 bone. The line of the articulation is then followed as far as the base of the 
 
1 1 7^ 
 
 A MANUAL OF SURGERY 
 
 X-CHOPART. 
 
 LIS F RAK'G 
 
 second metatarsal, which projects backwards between the internal and ex- 
 ternal cuneiform bones. The joint between the first metatarsal and the in- 
 ternal cuneiform is now opened transversely on the inner side, and the dorsal 
 ligament between the second metatarsal and the middle cuneiform divided. 
 The strong interosseous ligament passing between the internal cuneiform and 
 the base of the second metatarsal is next severed by inserting the point of a 
 knife downwards between the first and the second metatarsal bones, and 
 
 cutting backwards towards the ankle, ele- 
 vating the handle of the knife in order to 
 do so. By grasping the toes in the left 
 hand, and forcibly depressing them, the 
 remaining ligaments on the dorsal aspect 
 are divided, and the disarticulation can 
 then be completed. 
 
 The plantar flap is sometimes formed 
 as the last stage of the operation, having 
 merely been mapped out in the first 
 instance. In such a case the dorsal in- 
 cision is first made, the metatarsus dis- 
 articulated, and the plantar flap cut from 
 within outwards. 
 
 Hey's operation is essentially similar to 
 the above, with the exception that the 
 projection of the internal cuneiform is 
 sawn across (Fig. 423), leaving a more 
 even surface of bone. It is certainly to 
 be preferred to a simple disarticulation. 
 Skey advised that the three outer joints 
 should be opened as above, and that then 
 the saw should be applied so as to leave 
 in its mortice the base of the second meta- 
 tarsal, whilst the projection of the internal 
 cuneiform is removed. 
 
 Amputation at the Mid -tarsal Joint 
 (Choparf s amputation, Fig. 423) is conducted 
 in a very similar manner to Lisfranc's. A 
 plantar flap with convex end is marked 
 out, reaching on the inner side of the 
 foot from a point immediately behind the 
 tubercle of the scaphoid forwards to within 1 inch of the root of the toes, and 
 terminating on the outer side on a level with the calcaneo-cuboid articulation, 
 i.e., midway between an external malleolus and the spur of the fifth metatarsal. 
 It should be 1 inch longer on the inner than on the outer side. This plantar 
 flap is first dissected up, including everything down to the bones, and then a 
 dorsal incision is made with a slightly convex border. The joints between the 
 astragalus and scaphoid on the inner side, and between the os calcis and 
 cuboid on the outer, are opened from above. Disarticulation is completed by 
 a few touches of the knife, and after all haemorrhage has been arrested, the 
 plantar flap is drawn up, and united by sutures to the dorsal. Some surgeons 
 prefer to fashion the plantar flap after opening the joints from the dorsum. 
 
 Chopart's amputation is not, on the whole, a very satisfactory proceeding, 
 since it consists in the removal of the anterior segment of the arch of the foot, 
 the posterior half being left without support. The natural result of this is that 
 the head of the astragalus travels downwards, and presses upon the anterior 
 portion of the stump, causing a good deal of pain and discomfort, whilst the 
 os calcis is drawn upwards by the traction of the tendo Achillis. Formerly 
 it was considered that the resulting deformity was purely due to unbalanced 
 muscular traction, and hence attempts to prevent it were made by dividing 
 the tendo Achillis, or by stitching the extensor tendons to the under surface 
 cf the os calcis. Seeing, however, that the trouble is mainly mechanical, and 
 
 Fig. 423. — Skeleton and Out- 
 line of Foot, showing Level 
 of Various Amputations. 
 
AMPUTATIONS 1177 
 
 hence unavoidable, it would perhaps be wiser to avoid the operation entirely, 
 substituting for it a subastragaloid amputation, or modifying it by removing 
 the astragalus after the foot has been taken away. Tripier's amputation has 
 also been utilized to prevent such displacement ; in it an oblique external 
 racquet is made, reaching backwards to the anterior border of the tendo 
 Achillis ; disarticulation follows at the mid-tarsal joint, and then the os calcis 
 is sawn across horizontally on a level with the sustentaculum tali, so as to 
 leave a broad base of support, which is not so likely to become tilted forwards. 
 It is but fair to say, however, that in not a few cases of Chopart's amputation 
 an excellent stump remains without any of these inconveniences. 
 
 Subastragaloid Amputation of the foot is occasionally possible in cases of 
 injury, where the astragalus remains uninjured. The best plan to adopt is 
 that known as Maurice Perrin's oval operation. A racquet-shaped incision is 
 made, commencing at the insertion of the tendo Achillis, and extending along 
 the outer border of the foot to a point immediately behind the spur of the 
 fifth metatarsal, from which it sweeps over the dorsum, along the instep, and 
 after crossing the sole returns to the same spot. The dorsal part of the flap 
 is then dissected up, the astragalo-scaphoid joint opened, the tendo Achillis 
 
 divided, and by twisting the foot in- 
 wards the joints between the astragalus 
 and os calcis can be entered, and the in- 
 terosseous ligament severed. By still 
 further inverting the foot until it as- 
 sumes a position of extreme varus, the 
 structures on the inner side of the os 
 calcis can be detached, and by con- 
 tinuing the same torsion, the inner 
 surface of the bone is finally cleared, 
 the dorsal aspect of the foot looking 
 downwards. When the foot has been 
 Fig. 424.— Incisions in Syme's rem o ve d, bleeding-points are secured, 
 Amputation of Foot. tendons and nerves cut short, and the 
 
 wound, which now lies horizontally, is 
 secured by sutures. A very firm basis 
 of support is provided by this operation, and the stump is covered by the skin 
 of the heel, which is accustomed to pressure. 
 
 Amputation of the Foot. — Syme's amputation consists of a disarticulation at 
 the ankle-joint, together with removal of the two malleoli and the articular 
 surface of the tibia. The patient lies on the back with the leg well elevated 
 and projecting over the end of the table, the surgeon standing either below 
 or a little to the right of the patient. Having exsanguinated the limb, the 
 operation is, on the right foot, commenced by making an incision from the 
 tip of the external malleolus down to the heel, and extending up to a 
 point $ inch below and behind the internal malleolus (Fig. 424). On the 
 left side the incision is made in the opposite direction. For this purpose a 
 short-handled strong-bladed knife should be employed (an ankle knife). The 
 incision is directed slightly backwards, otherwise a bucket-shaped heel flap 
 is formed, in which discharges may collect. The knife is carried down to 
 the bone at the first cut, and the. surgeon then proceeds to dissect up the heel 
 flap thus marked out by inserting his thumb into the wound, and partly 
 peeling, partly cutting, the soft tissues from the back of the os calcis (Fig. 425). 
 This is sometimes a tedious and tiring proceeding, since it is most important 
 to keep close to the bone for fear of dividing the nutrient vessels of the flap 
 (external and internal calcanean). The dorsal incision is then made, uniting 
 the ends of the former wound, and carried slightly forwards so that a short 
 convex flap is thereby made. This is dissected up, and the ankle-joint 
 opened, the line of the articulation being placed £ inch above the tip of the 
 internal malleolus. By division of the lateral and posterior ligaments, of the 
 tendo Achillis, and of the few remaining fibrous connections along the top of 
 
1 1 78 
 
 A MANUAL OF SURGERY 
 
 the os calcis, the foot is removed. The lower ends of the tibia and fibula are 
 then cleared and sawn off, the ends of the dorsal flap being meanwhile held 
 out of harm's way (Fig. 426). The main vessels are tied, as also any other 
 bleeding points ; the tendons and chief nerves are drawn down and cut short, 
 and the wound closed by sutures, provision being made for drainage through 
 one of the angles. 
 
 A much quicker and prettier method of performing this operation consists in 
 opening the joint, and disarticulating immediately after the incisions have been 
 made, whilst the os calcis is subsequently dissected out of the heel flap from 
 above, keeping the knife close to the bone. 
 
 Syme's amputation gives excellent results with only slight shortening, and 
 the patient is able to walk on skin which is already accustomed to pressure. 
 It is specially useful where amputation is required for tarsal disease, inas- 
 
 Fig. 425. — Method of raising 
 Heel Flap from Os Calcis. 
 
 Fig. 426.— Section of Tibia and 
 Fibula in Syme's Amputation. 
 
 much as it is then rarely safe to undertake any of the partial or more con- 
 servative methods of operating. 
 
 Pirogojfs operation is one in which the posterior portion of the os calcis is 
 sawn off, and applied to the under surface of the previously sawn ends of 
 the tibia and fibula. The operation here described is not strictly that of 
 Pirogoff, but rather the modification suggested by Sedillot. The patient and 
 surgeon being relatively placed as for Syme's operation, an incision is made 
 extending from the same points, viz., between the tip of the external malleolus 
 and a point f inch below and behind the inner malleolus, but instead of passing 
 directly downwards it is carried obliquely forwards. Everything is divided at 
 once down to the bone, and the dorsal incision is then made, being placed 
 at right angles to the plantar. The ankle-joint is opened from above, and 
 disarticulation completed ; the structures to the side of and behind the joint 
 are then divided, so that a saw can be applied to the exposed surface of the 
 os calcis, and the bone cut through along the line of the plantar flap. The 
 lower ends of the tibia and fibula are now cleared, and the malleolus and 
 articular surface sawn off obliquely, the saw-cut being as nearly as possible 
 parallel to that made through the os calcis. The object of this obliquity is 
 to enable the sawn end of the posterior part of the os calcis to be brought into 
 apposition with the similarly treated ends of the bones of the leg, and wired to 
 them without any traction on the tendo Achillis. By this operation a some- 
 
AMPUTATIONS 
 
 i '79 
 
 what longer stump is obtained than in Syme's, and the patient is able to walk- 
 on the posterior part of the os calcis instead of on the sawn ends of the tibia 
 and fibula. The operation is more useful in cases of injury than for disease. 
 
 Amputations of the Leg maybe undertaken either immediately above the 
 malleoli (supramalleolar) or in the middle third, or a hand's-breadth below 
 the knee (site of election). In the 
 two former positions almost any 
 operation may be practised accord- - — .... 
 
 ing to the needs of the case, but " '"- ■-- _,__ 
 
 perhaps the most satisfactory is "^, 
 
 that by means of equal lateral 
 flaps, each of which is equal in 
 length to one diameter of the limb, 
 and consists below of skin, fat and 
 deep fascia, but for the upper half 
 the muscles are also included. In 
 dividing the bones, care must be 
 taken not to leave a sharp project- 
 ing edge on the front of the tibia 
 This is best prevented by partially 
 sawing through the bone in an 
 oblique direction from above down- 
 wards, and when this has reached 
 a little beyond its centre, the saw 
 is withdrawn, and a horizontal in- 
 cision made, cutting across the 
 oblique incision in such a way as to 
 remove a wedge of bone from the 
 front of the tibia, which thus be- 
 comes suitably bevelled (Fig. 427). 
 The fibula should always be di- 
 vided before completing the sec- 
 tion of the tibia. 
 
 In the lower third of the leg, 
 Teale's amputation (Fig. 413) is 
 sometimes recommended, and gives 
 good results 
 
 Amputation of (Toe Leg at the 
 Site of Election may be performed either by the modified flap and circular 
 operation, or by a large external flap (Favabceufs operation). In the latter, 
 the external flap (Fig. 427, A C), which is U-shaped, is first marked out with 
 the knife, extending ii inches higher in front than behind, and its length 
 being equal to the diameter of the limb at the point at which the bones are to 
 be divided. The incision on the inner side is then made, extending directly 
 across the limb from a point ih inches below the upper end of the anterior 
 horn of the former incision to its posterior extremity (Fig. 427, B C). The 
 external flap is dissected up, commencing anteriorly ; the fingers and knife 
 being inserted between the tibialis anticus and the tibia, all the soft parts 
 down to the bone and interosseous membrane are divided obliquely. The 
 anterior tibial artery is cut long, and care must be taken not to free the flap 
 from the interosseous membrane too high, for fear of injuring the trunk of this 
 vessel as it passes between the bones, an accident which would seriously 
 imperil the vitality of this large and fleshy mass. The tissues on the inner 
 side of the limb are now divided, either by transfixion or circular division. 
 The interosseous membrane and bones are bared, and the saw applied 
 according to the method already described. 
 
 Disarticulation at the Knee-joint is a very useful and valuable proceeding. 
 The methods chiefly employed are as follows: (i ) Stephen Smith's operation, 
 or amputation by equal lateral flaps. The incisions extend from a point 
 
 Fig. 427. — Farabckuf's Amputation at' 
 the Site of Election, a Hand's- 
 Breadth below the Knee. 
 
 The continuous line, A, B, C, indicates 
 the shape of the large external flap ; 
 the dotted line, B, C, the incision on 
 the inner side of the limb. The direc- 
 tion in which the bones are sawn is 
 also shown. 
 
nSo 
 
 A MANUAL OF SURGERY 
 
 immediately below the tuberosity of the tibia backwards in a semilunar 
 
 fashion, to terminate in the middle line behind on a level with the joint 
 
 (Fig. 428). The incision on the inner side should reach a little lower than 
 
 that on the outer, in order to ensure sufficient covering for the inner condyle, 
 
 which is always larger than the outer. The flaps are dissected up all round, 
 
 including the subcutaneous and deep fascia, being turned back in front like 
 
 a collar, so as to enable the surgeon to reach and divide the insertion of the 
 
 ligamentum patellae. The knife is now carried along the upper margin of the 
 
 tibia, separating the attachments of the semilunar cartilages to the bones 
 
 by dividing the coronary ligaments. The surrounding muscles and tendons 
 
 are cut through at the same level, together with the crucial ligaments, and 
 
 the leg is finally separated by boldly sweeping the knife through the soft parts 
 
 at the back of the joint, the flaps being 
 
 well retracted. The popliteal vessels are 
 
 secured, and the flaps drawn together 
 
 in the median line. When union has 
 
 occurred, the cicatrix is drawn up behind 
 
 into the intercondyloid notch so that an 
 
 excellent hooded covering is provided for 
 
 the lower end of the femur. The chief 
 
 objection to the operation is that the 
 
 upper part of the synovial membrane of 
 
 the joint remains intact, and may become 
 
 distended by a serous effusion through 
 
 the irritation produced by wearing an 
 
 artificial limb, (ii.) Amputation can be 
 
 undertaken by a long anterior flap, the 
 
 patella being left in situ or removed, 
 
 according to circumstances. A short 
 
 posterior flap is also formed and dissected 
 
 up, so as to enable the muscles and 
 
 vessels to be divided transversely. 
 
 Supracondyloid Amputation of the 
 Thigh is an operation often requisite 
 in order to deal with disease or injury 
 involving the knee-joint. (a) Carden's 
 amputation is one excellently adapted to 
 this purpose. It consists in the forma- 
 tion of an anterior flap, extending from 
 the level at which the femur is to be 
 divided to a point midway between the lower border of the patella and the 
 tubercle of the tibia ; this is dissected up as far as the upper border of the 
 patella. A short posterior flap is then cut by transfixion, and usually there is 
 a good deal of retraction, since the hamstring muscles are included in it. The 
 soft parts are now divided down to the bone all round just above the patella 
 by cutting from without inwards, and retracted for a short distance. The 
 condyles thus cleared are removed by the saw in a direction parallel to the 
 articular surface. The chief objection to this operation is the length of the 
 anterior flap, which is badly nourished, and sometimes liable to slough. 
 (b) Lister's modification consists in making a transverse incision across the 
 front of the limb on a level with the upper border of the tibia. The horns 
 of this incision are joined posteriorly by carrying the knife downwards at an 
 angle of forty-five degrees to the axis of the leg. This flap is dissected up, 
 and the whole of the integuments and subcutaneous tissues are freed and 
 retracted like a cuff, so as to enable the muscles to be divided circularly just 
 above the patella. The saw is then applied, and the bone removed. By this 
 means the covering of the end of the bone is taken more from the back than 
 from the front of the limb, (c) Gritti's operation is thus performed : A large 
 anterior flap similar to that used in Carden's operation is dissected up, includ- 
 
 Fig. 428. — Stephen Smith's Am- 
 putation THROUGH THE KnEE- 
 
 Joint by Lateral Flaps. 
 
AMPUTATIONS 
 
 ing the patella, and a shorter posterior flap is then fashioned. The soft parts 
 are divided by a circular cut of the knife, and the femur sawn across about the 
 level of the adductor tubercle. The cartilaginous surface of the patella is then 
 removed with the saw, and the remaining portion of the bone secured by a 
 silver wire to the divided end of the femur. Considerable difficulty may be 
 experienced in keeping the patella in accurate apposition, and to obviate this 
 Stokes recommended division of the femur at a slightly higher level (above 
 rather than through the condyles), (d) Amputation by a long posterior -flap is 
 sometimes required in cases where the tissues in front of the limb have become 
 disorganized from disease of the joint, or when cicatrices produced by a 
 previous excision are present. The posterior flap is first marked out and dis- 
 sected up, including merely the skin and subcutaneous tissues. A transverse 
 incision is made across the limb above the cicatrices or sinuses, the bone sawn 
 just above the site of the preceding excision, and the posterior muscles and 
 vessels divided circularly. A very good stump usually results. 
 
 Amputation of the Thigh may be conducted by any of the general methods 
 already described, but the modified flap and circular (Lister's operation, 
 Fig. 412) is perhaps the best. 
 
 Amputation through the Hip-Joint.— Disarticulation at the hip-joint is 
 always an operation of the greatest gravity, and every precaution should be 
 taken to minimize the immediate risks by preventing haemorrhage and 
 lessening shock. No part of the body should be unnecessarily exposed, whilst 
 the head is kept low, and although the operation must not be hurried over, no 
 time is wasted. 
 
 Perhaps the best way of preventing haemorrhage is to secure the main 
 vessels before dividing them, and then to take up each bleeding-point as it 
 appears ; the limb can thus be removed with the loss of merely a few ounces 
 of blood. Other plans which have been suggested are : (a) Lister's aortic 
 tourniquet, which, however, is not to be recommended, partly because it is 
 difficult to apply to stout or muscular individuals, and in any case it is very 
 liable to slip, (b) Davy's rectal lever for compression of the common iliac 
 artery consists of a rod of ebony, vulcanite, or metal, which is inserted into 
 the rectum, and directed so as to compress the artery against the brim of the 
 pelvis. It is dangerous in application, and not always efficient, (c) An elastic 
 tourniquet may be applied either around the upper part of the thigh to control 
 the lower end of the external iliac, or around the body in such a way as to 
 compress the abdominal aorta. For the latter purpose a pin-cushion or pad 
 is placed on the abdomen over the aorta, and behind the back a board pro- 
 jecting a few inches on each side of the trunk, and with two notches cut at 
 either end. The elastic rod is passed over the cushion, and around the notches 
 at the end of the board in a figure-of-8 fashion, sufficient tension being em- 
 ployed to force the cushion down on the aorta, and thus control the circulation 
 through it. This method, which was also suggested by Lord Lister, is cer- 
 tainly efficient, though somewhat cumbersome, (d) More recently Wyeth, of 
 New York, has introduced a method of preventing haemorrhage by applying a 
 rubber tourniquet close to the pelvic brim, which is prevented from slipping 
 by inserting long needles immediately below it. The limb is first exsan- 
 guinated by elevation, or possibly by the use of an Esmarch's bandage. Two 
 long steel needles, 10 inches in length and fa inch in thickness, are then in- 
 serted, one on the outer side of the thigh and one on the inner. The former 
 'is introduced J inch below the anterior superior spine of the ilium, and 
 slightly to the inner side of this prominence, and is made to traverse super- 
 ficially for about 3 inches the muscles and fascia on the outer side of the hip, 
 emerging on a level with the point of entrance. The point of the second 
 needle is thrust through the skin and tendon of origin of the adductor longus 
 muscle h inch below the crutch, the point emerging 1 inch below the tuber 
 ischii. The points should be shielded at once with cork to prevent injury to 
 the hands of the operator. No vessels are endangered by these skewers. A 
 mat or compress of sterile gauze 2 inches thick and 4 inches square is laid over 
 
Il82 
 
 A MANUAL OF SURGERY 
 
 the femoral artery and vein as they cross the brim of the pelvis ; over this a 
 piece of strong white rubber tubing, ^ inch in diameter when unstretched, and 
 long enough when in position to go five or six times round the thigh, is now 
 wound very tightly around and above the fixation needles and tied.'* By this 
 means the limb can be removed with practically no loss of blood. 
 
 Formerly but one operation was utilized for the removal of the limb at the 
 hip-joint, viz., by transfixion, the flaps being cut antero-posteriorly. The 
 great advantage of this method was the rapidity with which it was executed ; 
 it has, however, been replaced by other plans, one of which should always be 
 adopted. 
 
 Amputation by an external racquet incision (Fig. 429) has been recommended 
 by many surgeons, especially Furneaux Jordan, Esmarch, and Lister, each of 
 whom has advocated some slight modification. The surgeon should always 
 
 Fig. 429. — Amputation through the Hip-Joint. 
 
 On the right leg Furneaux Jordan's method is indicated ; on the left leg the 
 flaps required for the anterior racquet operation are shown. 
 
 stand to the outer side of the limb, whilst the pelvis of the patient rests at the 
 extreme edge of the table. The essential features of this operation consist 
 in a circular division of the structures down to the bone below the lesser 
 trochanter, whilst the head of the bone is disarticulated and removed through 
 the external vertical portion of the incision extending downwards from above 
 the great trochanter ; it matters little whether the vertical incision is made 
 before or after the tissues in the thigh have been divided. Perhaps the 
 simplest plan of carrying out this operation is as follows : A circular incision 
 is made through the skin and subcutaneous tissues 5 or 6 inches below the 
 great trochanter. These are dissected up for a few inches, and the muscles 
 divided circularly down to the bone, which is at once sawn through. The 
 external incision, 6 or 8 inches long, is then made, the tissues being freed 
 from the anterior and posterior surfaces of the femur, and the rotator muscles 
 divided along the borders of the great trochanter. The lower end of the 
 fragment of the femur is then grasped by lion forceps, and after forcibly flexing 
 and rotating the bone inwards, the capsule of the joint is laid open on its 
 posterior aspect. By everting the bone, the anterior part of the capsule can 
 be reached and incised, and the attachment of the ilio-ps^oas muscle severed. 
 The ligamentum teres is then divided by inserting the point of the knife into 
 
 * Wyeth, Annals of Surgery, February, 1897. 
 
AMPUTATIONS 1183 
 
 the acetabulum, and the head of the bone is thus set free. One great advan- 
 tage of this operation is that the incisions are placed as far as possible from 
 the risk of septic contamination from the genital organs and perineum. 
 
 To our minds, the best method of amputating at the hip-joint is by means 
 of an anterior racquet incision (Fig. 429). This commences over the centre of 
 Poupart's ligament, and is carried down along the course of the main vessels 
 for about 3 inches. The common femoral s"heath is exposed, and both artery 
 and vein are secured by double ligature and divided. The incision is then 
 completed ; it sweeps over the inner side of the thigh 4 or 5 inches below the 
 perineum to the back, and is brought up again to the front 3 or 4 inches below 
 the great trochanter. The muscular structures in the outer flap are then cut 
 through, and the external circumflex artery and other bleeding vessels secured 
 by pressure forceps en route. By rotating the limb inwards, the insertion of 
 the gluteus maximus can be divided, as also the muscles attached to the great 
 trochanter. The muscles in the inner flap are then similarly dealt with after 
 rotating the limb outwards, the internal circumflex artery, etc., being secured. 
 The capsular ligament is next divided transversely, and the head of the bone 
 disarticulated. Finally, the limb is rotated forcibly outwards, and all the soft 
 parts at the back of the limb, including the sciatic vessels and nerves, are 
 divided from within outwards with one sweep of the knife. The wound when 
 sutured lies antero-posteriorly. 
 
CHAPTER XLI. 
 ANESTHESIA. 
 
 The practice of surgery has always been of such a nature as to render some 
 means of abolishing the pain caused thereby a desideratum ; but although in 
 the old days various plans were adopted to attain this object, yet it was not 
 until the end of the last century that any real advance was made in this 
 direction. In 1799 Sir Humphrey Davy suggested the possibility of using 
 nitrous oxide gas as a means of rendering patients anaesthetic during surgical 
 work; but as then employed, it was so uncertain in its action that no great 
 benefit was derived from the knowledge thus acquired, and many years elapsed 
 before it came into extensive use. The demonstration of the properties of 
 ether in 1846 by Morton in Philadelphia, and of chloroform in January, 1847, 
 by Sir James (then Professor) Simpson, iieralded in a new era of surgery. 
 Operations, which before were scanty in number, became greatly multiplied, 
 and at the present day, with our advanced knowledge and experience, and our 
 constant dependence on this agent, it is difficult to understand how surgical 
 practice could have been conducted without it. Anaesthetics have enabled the 
 surgeon confidently to attack almost every region of the body, and instead of 
 operations being hurried over, in order to minimize the patient's sufferings, 
 they are now undertaken with much more deliberation, accuracy being the 
 great requisite at the present day, and not, as formerly, rapidity. 
 
 Anaesthetics may be divided into two groups — the local and the general. 
 
 Local Anaesthesia is utilized for the purpose of rendering parts insensitive to 
 pain, where slight operations of short duration are to be undertaken, or, 
 occasionally, in more serious cases, where the patient cannot stand a general 
 anaesthetic. 
 
 1. Cocaine is an alkaloid obtained from the dried leaves of the Erythroxylon 
 coca (S. America). The salt most commonly used is the hydrochlorate, which 
 exists in the form of colourless needles, or a crystalline powder readily soluble 
 in water. Its properties as a local anaesthetic were discovered by Koller of 
 Vienna, and it was at the Ophthalmic Congress at Heidelberg in September, 
 1884, that its value in ophthalmic and surgical work was first publicly 
 demonstrated. 
 
 Mucous membranes are readily anaesthetized by applying a 5 or 10 per 
 cent, solution to them for about five or ten minutes, the insensibility lasting 
 for about the same time. In dealing with the skin or deeper tissues, 
 hypodermic injections of the drug are relied on, the anaesthesia following the 
 course of the peripheral nerves. The action of cocaine is supposed to depend 
 partly on an anaemic condition of the affected tissues induced by arterial con- 
 traction, partly on paralysis of the terminations of the sensory nerves. Much 
 less effect is produced on inflamed tissues. In making use of this reagent, it 
 must always be remembered that cocaine has a distinctly depressing influence 
 upon the heart, and hence more than h grain should never be employed. When 
 a syringe is used the needle should be inserted in the line of incision, and the 
 
ANESTHESIA 1185 
 
 injection equally diffused along it. Should any toxic effects be manifested (as 
 by pallor of the face, a cold clammy sweat, giddiness, weak and rapid pulse \ 
 the patient should be laid with the head low, and stimulants administered. 
 Some recommend that a little nitro-glycerine (1 drop of a 1 per cent, solution) 
 should always be injected at the same time as the cocaine, so as to prevent 
 contraction of the peripheral arterioles. In some parts of the body it may be 
 possible to control the circulation so as to hinder the general absorption of the 
 drug. Thus, for circumcision the base of the penis may be constricted by an 
 elastic band, whilst a similar arrangement may be applied to the fingers and 
 toes for small operations, such as avulsion of a toe-nail. 
 
 2. A substitute for cocaine has recently been proposed in the synthetic com- 
 pound known as Eucaine Hydrochloride. Its toxic properties are much less 
 marked than those of cocaine, and doses of even 5 or 10 grains may be 
 employed either hypodermically or by painting over a mucous membrane. Its 
 action is somewhat slower than that of cocaine, and it causes a little congestion 
 of the part, whilst cocaine leads to anaemia ; it also gives rise to a little 
 tingling pain on injection, and may leave a certain amount of oedematous 
 thickening for a time. The reports hitherto given have been very satisfactory, 
 although, on account of the irritation produced, it does not seem to be quite so 
 suitable for ophthalmic work. 
 
 3. Local anaesthesia is also produced by freezing the part, either by the 
 application of ice and salt, or by the ether spray, or with ethyl chloride. 
 The latter reagent is now put up conveniently in small glass or thin metal 
 flasks with a fine capillary outlet ; on holding the flask in the hand a spray is 
 produced, which is allowed to play upon the part to be operated on. The 
 rapid evaporation from the surface leads to the freezing of the skin, which 
 becomes of a dead white colour. The anaesthesia produced is of a very 
 fugitive nature, and a certain amount of pain may be associated with the 
 thawing process, but less than that caused by the ether spray. 
 
 General Anaesthesia. — 1. Nitrous Oxide Gas (N 2 0) is most commonly used in 
 dental work, or for short operations, such as bending a stiff joint and breaking 
 down adhesions, the avulsion of a toe-nail, or the opening of an abscess. It 
 is practically safe and not unpleasant, either in its use or in its subsequent 
 effects. It is also employed in conjunction with ether, the patient being first 
 anaesthetized with gas, and the condition maintained by ether. Gas has also 
 been recommended for the removal of adenoids ; but the general opinion 
 now obtaining is that, to perform this operation satisfactorily, a more lasting 
 anaesthetic is required. The gas is stored in a condensed and liquefied form 
 in special steel cylinders, closed by a screw which can be readily loosened, so 
 as to allow the gas to escape through a tube into an indiarubber bag. This is 
 attached to a closely-fitting face-piece, with a suitable arrangement of valves 
 and stop-cocks, by means of which the gas is allowed to reach the patient. 
 A valvular exit for the expired air is also present (Fig. 430, A, B, C and E, 
 p. 1187). In its usual method of administration the bag is first filled with gas,' 
 and then air is completely excluded by carefully adjusting the padded face- 
 piece to the irregularities of the face. Some anaesthetists, however, by means 
 of a special apparatus devised by Dr. Hewitt, allow the administration of a 
 minute proportion of pure oxygen at the same lime, in order to prevent the 
 lividity of the face and the twitching of the limbs often present when anaes- 
 thesia is induced in the ordinary way. These symptoms of incipient asphyxia 
 may also be avoided by allowing the last few inspirations of the gas to be 
 mixed with air. This may be done by raising the face-piece, by opening the 
 air-valve, or, as suggested by Dr. Flux, by using an open inhaler into which 
 the gas is poured. Of course, in removing teeth the mouth is firmly gagged 
 open prior to the commencement of the administration. 
 
 2. Chloroform is perhaps the anaesthetic most generally employed, on account 
 of the ease with which it can be administered, although there can be but little 
 doubt that its use is attended with somewhat more risk than that of ether. 
 Much controversy has arisen as to whether the heart is ever directly affected 
 
 75 
 
1 1 86 A MANUAL OF SURGERY 
 
 Dy the drug, or whether the dangerous symptoms met with are not due to 
 primary failure of the respiration. The experimental evidence on the subject 
 is of a very conflicting nature ; and it is impossible as yet to consider the 
 question solved. The Scotch school of surgeons, headed by Syme and Lister, 
 has always maintained that the breathing alone need be watched during the 
 administration of chloroform, failure of the respiration being the first danger 
 signal ; the second so-called Hyderabad Commission has sought to confirm 
 this view. Many practical surgeons and anaesthetists oppose this statement, 
 holding that, although the respirations may fail first in a large percentage, and 
 probably a majority, of fatal cases, yet there are a certain number in which 
 heart failure is also seen as a result of the direct toxic effect of the chloroform 
 upon its muscular substance. Certainly, in not a few instances of death during 
 the administration of chloroform the heart stops first, but a great distinction 
 must be drawn between the deaths which result from chloroform, and the deaths 
 that occur during the administration of chloroform. An overdose of chloroform, 
 without doubt, leads to failure of the respirations ; but in the majority of such 
 cases, if suitable precautions are adopted sufficiently early, a fatal result may 
 be averted. Cases in which the heart stops first are probably due to syncope, 
 and are not entirely dependent on the nature of the anaesthetic administered. 
 
 Chloroform may be given in several different ways, but in all the chief points 
 to be attended to are regularity of dose, and full admixture with air, so that 
 not more than 4 per cent, of the vapour is inspired. The plan so often 
 employed of pouring an unknown quantity of chloroform on a piece of lint, 
 folded in two or three layers and held close to the patient's nose and mouth, is 
 most unscientific and to be strongly condemned. The Open Method is that 
 recommended by Lord Lister. A mask reaching from the root of the nose to 
 the chin is made from the side of a towel, and fixed with a safety-pin. , This 
 is first held some inches above the patient's nose, and moistened from the 
 outside with chloroform from a drop-bottle. As the respiratory passages 
 become tolerant of the drug, the mask is gradually lowered to touch the face, 
 and is kept continually moistened. At the end of two or three minutes the 
 respirations increase in frequency, and a stage of excitement may be reached, 
 during which the patient may sing, shout, or struggle violently The anaesthetic 
 is still cautiously pushed, care being taken that during the deep respirations 
 which follow the struggling stage an overdose is not administered. Complete 
 anaesthesia is indicated by relaxation of the muscles, loss of the corneal reflex, 
 and contraction of the pupil, and it is usually attained in about five minutes. 
 As long as the operation lasts, the anaesthetist must endeavour to maintain this 
 condition, but the amount needed during the later stages is much less than at 
 its commencement. 
 
 Junker's inhaler is often used for giving chloroform, especially in operations 
 about the nose and face. It is economical, and on the whole satisfactory. In 
 this apparatus air is pumped through a layer of chloroform to an inhaler 
 placed over the patient's mouth, or to a tube passed into his nose. The air 
 laden with chloroform is inspired, and produces the usual constitutional effects ; 
 the amount administered is, to a certain extent, regulated by the rapidity with 
 which the indiarubber bulb of the apparatus is squeezed ; after a time, how- 
 ever, the lowered temperature induced by the evaporation leads to a diminu- 
 tion in the amount of chloroform vapour given off. Accidents have happened 
 with this apparatus from filling the bottle too full, or from having the india- 
 rubber tubes fixed to the wrong nozzles ; in either instance liquid chloroform 
 may be pumped out of the exit-tube. 
 
 3. Ether is generally considered to be a safer anaesthetic than chloroform, in 
 that it is a cardiac stimulant. It is usually administered by Clover's apparatus 
 or by an Ormsby's mask. 
 
 ^Clover's apparatus (Fig. 430, D and E) consists of a face-piece similar to that 
 utilized for giving nitrous oxide, a metal receptacle for the ether, and a bag. In 
 this apparatus the air used in respiration passes over the surface of the ether 
 contained in the receptacle, the proportion of ether inspired being regulated, 
 
A MYESTHESIA 
 
 1 187 
 
 so that at first a considerable admixture of air is permitted, whilst later on ether 
 vapour in the proportion of a third, a half, or even two-thirds, is inhaled. 
 The great value of this apparatus is the ease with which the amount of ether 
 administered is regulated; but a distinct disadvantage exists in the fact that 
 
 Tig. 4jo. — Apparatus for the Administration of Nitrous Oxide and 
 Ethet. in Combination. 
 
 A, steel cylinders containing compressed nitrous oxide ; B, indiarubber bag ; 
 C, three way stop cock with valves; D, Clover's ether chamber; E, face- 
 piece. If nitrous oxide alone is administered, D is omitted. When ether 
 alone is used, A and C are omitted, and a smaller bag substituted for B. 
 
 the patient breathes his own expired air again and again, and so, unless cam 
 is taken, he is likely to become cyanosed. This can, however, be prevented 
 by removing the mask occasionally, and giving the patient a few breaths of 
 unmixed air. Another objection lies in the amount of mucus which often 
 
1 1 88 A MANUAL OF SURGF.UY 
 
 collects about the pharynx, whilst the moisture in the expired air condenses in 
 the bag, which becomes very objectionable unless carefully washed out. 
 
 In Ormsby's mash the ether is poured over a sponge which is contained in a 
 wire frame prolonged from the face-piece, and covered over by a bag into 
 which the patient breathes. It is an unpleasant means of inducing anaesthesia, 
 but may be employed for maintaining it after the use of gas. The same 
 objections hold good as in Clover's apparatus, and the same precautions as to 
 letting in atmospheric air from time to time must be observed. 
 
 In the administration of ether it is now usual to adopt what is known as the 
 ' gas and ether method,' by which is meant that the patient is first anaesthetised 
 with nitrous oxide, and the anaesthesia is continued and maintained by means 
 of ether. If the Clover's inhaler is to be employed, the arrangement shown in 
 Fig. 430 is employed, a Clover's ether-chamber being interposed between the 
 face-piece and the three-way tube of a nitrous oxide apparatus. The patient 
 is first allowed some six or eight full inspirations of nitrous oxide, and then the 
 ether-chamber is turned to permit of gradually increasing doses of ether vapour. 
 As soon as symptoms of nitrous oxide narcosis present (twitching of muscles, 
 irregular stertor, etc.), the gas-bag is detached and the ordinary ether-bag 
 substituted. 
 
 The Ormsby's mask does not permit of this gradual addition of ether vapour ; 
 full nitrous oxide anaesthesia must be induced with the ordinary apparatus, 
 and then a rapid change is made to the iully-charged ether inhaler. The 
 results are sufficiently satisfactory, but much more experience and skill are 
 required than when the Clover is used. 
 
 The advantages claimed for this ' combined method ' are that anaesthesia is 
 induced much more rapidly (two minutes), and, what is far more important, 
 the process is much less unpleasant for the patient than when ether alone is 
 employed. The patient is apt, especially when the Ormsby's mask is used, to 
 become rather livid and rigid, but these conditions pass off in the course of a 
 minute or two. 
 
 4. To obviate the depressing effects of chloroform, a combination known as 
 the A.C.E. Mixture is often used, consisting of alcohol, chloroform, and ether, 
 blended in the proportion of one, two and three parts respectively. It may be 
 given either from a Rendel's mask, or by the open method as for chloroform, 
 but the latter plan is only applicable to children and weakly individuals, who 
 require but little anaesthetic. Renders mask consists of an oval box open at 
 one end and shaped to fit the nose and mouth, and the fundus perforated with 
 holes to permit of the free entrance of air ; it may be made of leather, or pre- 
 ferably of celluloid or metal. Two or three sponges are placed within it, and 
 soaked with the anassthetic, the patient breathing in and out of the cone. The 
 inspired air is thus laden with the vapour, and the amount admitted is regu- 
 lated in measure by covering a certain proportion of the inlet holes with the 
 hand. The objection to this reagent is that it evaporates somewhat unequally, 
 the ether coming off first, and leaving an excess of chloroform, which when 
 administered in a cone may be dangerous ; this can, however, be obviated by 
 remoistening the sponges alternately with the mixture and with pure ether. 
 
 General Remarks as to the Administration of Anaesthetics. 
 
 The medical practitioner must never lose sight of the fact that a certain 
 element of risk is necessarily attached to the artificial induction of a condition 
 in which the activity of the nervous system is entirely suspended, except 
 for the maintenance of those phenomena which are actually essential for life. 
 Hence, an anassthetic should never be given, unless absolutely necessary, 
 without careful preparation of the patient, or such examination as shall satisfy 
 the doctor as to his capability of safely taking it. 
 
 The Preparation of the Patient is a most important proceeding. When 
 practicable, the general habits of the individual should be carefully regulated 
 
ANESTHESIA 
 
 for a few days prior to the operation, and on the preceding night a suitable 
 purgative is administered, castor-oil being perhaps the most efficacious. Any 
 food given on the morning of the operation should be light and easily 
 assimilable, whilst nothing should be taken for at least three hours pre- 
 viously, so as to make sure that the stomach is empty. In casualty cases, it 
 may be advisable to relieve gastric distension with an emetic, or by washing 
 out the organ before commencing the administration. The anaesthetist must 
 ascertain that no loose artificial teeth are present in the mouth, and that no 
 tight clothes or bands encircle the neck or thorax. In very nervous cases, or 
 where much shock is anticipated, a preliminary hypodermic injection of 
 strychnine or a nutrient enema may be administered. 
 
 The anaesthetic should never be pushed in the early stages, but is given 
 slowly and gradually, especially in nervous individuals. When there is any 
 struggling, the movements of the limbs should be restrained with as little force 
 as possible, and care must be taken during the deep respirations which follow 
 such struggling not to administer an overdose. The condition which the 
 administrator should aim at maintaining is one characterized by total muscular 
 relaxation, insensitiveness of the cornea, and a contracted state of the pupil, 
 whilst the pulse and breathing continue regular. If the pupil commences to 
 dilate, and the corneal reflex is present, the patient is apt to move when the 
 knife is used, indicating that more anaesthetic is required. Dilatation of the 
 pupil with an insensitive cornea is always an indication for suspending the 
 administration for a time. If the anaesthesia is not sufficiently deep, vomiting 
 is likely to occur, being ushered in by weakness and rapidity of the pulse, and 
 pallor of the face ; this may often be averted by pushing the anaesthetic. The 
 anaesthetist's chief attention must be directed to observing the state of the 
 respiration and pupil ; but he should also note the colour of the lips, cheeks, 
 and ears, as thereby valuable information is gained as to the condition of the 
 circulation. The pulse should be felt occasionally, but it is less important to 
 attend to this than to the other points noted above. After the deep anaesthesia 
 required in division of the skin, most operative proceedings on the subcu- 
 taneous tissues are comparatively painless, and hence the anaesthetic need not 
 be pushed quite so far. Whilst the wound is being closed, the patient must 
 be again somewhat more completely under control. In operations upon the 
 mouth associated with haemorrhage, the head must be occasionally turned to 
 one side to allow the blood to gravitate out of the mouth, and the pharynx 
 well sponged, so as to prevent the admission of clot and other matters into the 
 air-passages. It is also a valuable routine plan to insist upon the head always 
 being turned 'on one side, especially when ether is being given, since mucus 
 tends to collect about the pharynx. 
 
 The After-Treatment of the patient is always a matter of considerable im- 
 portance. He is carried from the table and placed on his back, or preferably, 
 when possible, on his right side, in bed with the head low. Where there is 
 any tendency to shock, hot-water bottles, well wrapped up, should be applied 
 to the feet and sides, and hot blankets over all. Absolute quiet must be 
 enjoined for some hours, and the room darkened, so that, if possible, the 
 patient may fall asleep. No food is administered for at least three or four 
 hours, and then only very cautiously, a little weak tea, soda-water, or beef-tea 
 being given. The patient is likely to vomit on returning from unconsciousness, 
 perhaps bringing up a little bile-stained mucus, but if the anaesthetic has been 
 judiciously given, it soon ceases. Occasionally, however, the vomiting persists 
 for some time, becoming very troublesome. It may generally be checked by 
 a hypodermic injection of morphia, and by washing out the mouth with warm 
 water ; but in more severe cases, lasting for some days, the patient's nutrition 
 may have to be maintained by enemata, and the stomach kept absolutely at 
 rest. Benefit may sometimes be derived by giving a little bismuth and hydro- 
 cyanic acid in an effervescing mixture, or perhaps champagne ; but, as a ride, 
 all administration of food by the mouth should be stopped until the vomiting 
 has ceased. 
 
moo A MANUAL OF SURGERY 
 
 Three chief Dangers are encountered during the administration of anaes- 
 thetics : 
 
 i. Obstructed Respiration usually results from falling backwards of the root 
 of the tongue, which blocks the entrance of air into the larynx. The respira- 
 tions gradually become more and more stertorous, the face and ears become 
 dusky, and, if the condition is not relieved, the chest continues to heave 
 without any air entering or leaving it, and finally ceases when the patient is 
 completely asphyxiated. The early stages of this condition are of common 
 occurrence, whatever the anaesthetic, and the administrator must always be on 
 the look-out and endeavour to prevent it by turning the head or the patient 
 himself so that the tongue falls to one side. If it occurs in spite of this 
 position being adopted, the administration is at once suspended, whilst the 
 tongue must at all hazards be drawn forwards. This may be accomplished in 
 the early stages by pulling on the beard or chin, or by pressing the mandible 
 forwards by the fingers placed behind the angle of the jaw. In the later stages 
 the mouth should be forcibly opened by a gag, and the tongue grasped by 
 forceps and pulled well forwards, or a finger may be passed back into the 
 pharynx to draw the root and epiglottis forwards, and at the same time 
 ascertain that the entrance to the glottis is free from obstruction. Artificial 
 respiration should be undertaken if the breathing has actually stopped. 
 Death should never result from this cause, and if it occurs, it can only be 
 attributed to the carelessness of the anaesthetist. 
 
 Obstruction to the respiration may occasionally arise from the entrance of 
 vomited material into the air-passages or lungs, the patient becoming cyanosed 
 during an attack of vomiting, and passing rapidly into a state of asphyxia. 
 In such a case the finger must be swept around the pharynx, if the mouth 
 can be opened, to see that the glottis is clear, whilst tracheotomy or laryngo- 
 tomy may be necessary should the teeth be firmly clenched, or if the obstruc- 
 tion is below the entrance to the glottis. Fortunately, this accident is of rare 
 occurrence. 
 
 2. Complete Cessation of Respiration is the usual primary phenomenon from 
 an overdose of chloroform ; it is also stated to happen occasionally during ether 
 narcosis. The pulse continues to beat distinctly for a few seconds, although 
 respiratory movements have ceased. Treatment consists in at once stopping 
 the administration, whilst the tongue is drawn forwards, and the fauces 
 cleared by the finger. The head should be lowered over the end of the table, 
 and young children may even be completely inverted, so as to induce a 
 flow of blood to the head. Artificial respiration is commenced without delay, 
 whilst the thoracic parietes may be flicked with a cold wet towel, or alternately 
 douched with hot and cold water. Strychnine or ether should also be injected 
 hypodermically, and if the condition persists and the heart's action ceases, a 
 Faradic current may be passed from the second or third intercostal space in 
 front to an electrode placed over the spine. Attempts at resuscitation should 
 be continued for half to three-quarters of an hour. At the same time, these 
 measures must be undertaken with discretion, as otherwise it is quite possible 
 to extinguish the feeble spark of life by the very means which, used wisely, 
 would have restored it. 
 
 3. Death occasionally results from primary Cardiac Failure, which may 
 arise (a) from fright during the administration of the anaesthetic ; (b) from 
 shock with cardiac inhibition, by commencing the operation before com- 
 plete anaesthesia has been obtained ; and (c) from an overdose of chloroform 
 or ether acting directly on the nerve centres or on the muscular substance 
 of the heart. On post-mortem examination in such cases, the heart muscle is 
 found to be thin and flabby, and perhaps infiltrated with fat; the ventricular 
 walls are especially affected. Unfortunately, this condition cannot be recognised 
 with certainty by the stethoscope. Patients with simple valvular lesions, where 
 the defect has been more or less compensated, do not generally run any extra 
 risk. The treatment to be adopted in cases of cardiac failure during anaesthesia 
 is the same as for stoppage of the respiration. 
 
ANESTHESIA 1191 
 
 The Choice of an Anaesthetic in any particular case depends mainly on the 
 condition of the circulatory and respiratory apparatus of the patient. Ether is 
 perhaps, on the whole, the safest drug to employ, especially in adults, although 
 it is less pleasant to take ; it may cause a good deal of bronchial irritation and 
 congestion, and is more likely to give rise to troublesome after-vomiting, 
 although such does not usually last long. It is sometimes followed by un- 
 pleasant delirium. Chloroform is easier to administer, more pleasant to take, 
 and less likely to lead to objectionable after-effects. It is the best anaesthetic 
 for young children and old people, though its action upon the heart contra- 
 indicates its use in patients whose circulation is weak. The A.C.E. mixture 
 may also be safely employed, if the precautions already indicated on an earlier 
 page are attended to. 
 
 Ether is certainly contra-indicated in patients suffering from any bronchitic 
 or pulmonary trouble, and its administration for operations about the face or 
 mouth is, of course, impracticable. Chloroform should not be given in cases 
 of cardiac weakness or advanced renal disease ; for abdominal work it is 
 always to be preferred to any other agent, as also in operations on the brain. 
 
INDEX 
 
 N.B. — The more important references are always placed first, the less important 
 afte>~wanis. 
 
 Abdominal aorta, ligature of, 291, 279 
 
 aneurism, 277 
 
 operations, general remarks on, 966 
 
 surgery (Chapter XXXII.), 891-969 
 
 walls, injuries of, 891 
 
 wounds, mortality of, 203 
 Abscess, acute, 41-50 
 
 alveolar, 735 
 
 anal, 1029 
 
 antrum, 740 
 
 appendix, 948 
 
 axillary, 49, 318 
 
 cerebellar, 720, 821 
 
 cerebral, 694, 718, 821, 818, 713, 761 
 
 chronic tuberculous, 50, 143, 655, 662 
 diagnosis of, 261, 659, 980, 990 
 
 dorsal, 656, 662 
 
 iliac, 660 
 
 in bone, 504, 505, 519 
 
 in hip-joint disease, 615, 616 
 
 in kidney, 1058 
 
 in spinal disease, 655 
 
 intra-mammary, 868, 871, 49 
 
 ischio-rectal, 1027, 49, 657 
 
 lacunar, 119 
 
 lumbar, 657, 662 
 
 of labium, 1140 
 
 of liver, 955 
 
 of spleen, 965 
 
 of tongue, 775 
 
 palmar, 208, 49 
 
 perineal, 11 32 
 
 perinephritic, 1058, 660, 1052 
 
 prostatic, 1108 
 
 psoas, 657, 662 
 
 pyremic, 104, 106 
 
 residual, 52, 659 
 
 retro-pharyngeal, 805, 656 
 
 subcranial, 690, 677, 694, 720, 818 
 
 sublingual, 783, 93 
 
 submammary, 868, 872, 92 
 
 subpericranial, 705 
 
 subperiosteal, 503 
 
 subphrenic, 900, 921, 948 
 
 supramammary, 868 
 Abscess, chronic, treatment of, 662, 55 
 of breast, 871 
 
 A.C.E. mixture, 1188, 46S 
 Accessory thyroids, 837 
 Acetabulum, fractures of, 566 
 Achondroplasia, 528 
 Acinous cancer, 179 
 Acne, 753 
 Acro-arthritis, 605 
 Acromegaly, 531 
 Acromion, dislocation of, 550 
 
 fracture of, 449 
 Actinomycosis, 148, 784, 22, 046 
 Acupressure, 231 
 
 Acupuncture for aneurism, 268, 270, 276 
 278 
 
 for abscess of liver, 956, 957 
 
 for hydatid of liver, 959 
 Adams osteotomy, 610 
 Adder's bite, 205 
 Adductor longus, injury to, 366 
 Adenoids, 766, 793 
 Adenonn, 172 
 
 of adrenal bodies, 1066 
 
 of breast, 875 
 
 of kidney, 1066 
 
 of palatal glands, 798 
 
 of post-anal gut, 649 
 
 of prostate, 11 11 
 
 of rectum, 1035 
 
 of testis, 1 152, 183 
 
 of thyroid, 830, 834 
 Adeno-sarcoma of breast, 877 
 Adhesions in hernial sac, 972, 979, 994 
 
 in joints, 423, 573, 609 
 
 intraperitoneal, 897, 8 
 1010, 1015 
 Adrenal tumours, 1066 
 Adventitious bursre, 373 
 Aerial fistula, 828 
 Aerobic bacteria, 4 
 Air into veins, entrance of. 
 Air-passages, surgery 
 
 XXX.), 838-865 
 Albuminuria, 1091 
 Alexines, 13 
 Alibert's keloid, 214 
 Alopecia in syphilis, 128 
 Alveolar processes, affections of, 735 
 
 906, 947, 
 
 See Veins 
 of (Chapter 
 
1 194 
 
 INDEX 
 
 Alveolar sarcoma, 158 
 
 Ambulatory treatment of fractures, 431 
 
 Amoeba coli, 955, 22 
 
 Amputation of penis, 1140 
 
 Amputations (Chapter XL. ), 1166-1183 
 
 during shock, 219, 200 
 
 for acute arthritis, 581 
 
 for aneurism, 269, 277 
 
 for compound fractures, 199, 435 
 
 for gangrene, 74, 76, yj, 79, 80, 83, 
 199, 269, 283, 434 
 
 for infantile paralysis, 666 
 
 for lacerated wounds, 198 
 
 for rupture of main artery, 200, 248, 
 424 
 
 for sa'coma of bone, 536 
 
 for secondary haemorrhage, 241 
 
 for spreading traumatic gangrene, 83 
 
 for tuberculous diseases of joints, 592, 
 593. 594. 595. 618 
 Amussat's operation, 940 
 Amyloid degeneration, 53, 255, 580, 1092 
 Anaerobic bacteria, 4 
 Anaesthesia (Chapter XLL), 1184-1191 
 
 dolorosa, 658 
 Anaesthetic, choice of, 1191 
 
 leprosy, 147 
 Anatomical wart, 206 
 Anel's ligature for aneurism, 265 
 Aneurism (Chapter X.), 256-280 
 
 by anastomosis, 170, 537, 706 
 
 cirsoid, 170, 706 
 
 diffuse traumatic, 247 
 
 of bone (osteo-aneurism), 537 
 
 treatment of, 263-269 
 
 varicose 250, 705 
 Aneurismal varix, 249, 275, 305, 311, 683, 
 
 705 
 Aneurisms, special, 270-280 
 Angini of Ludwig, 93, 784 
 Angioma, 169 
 Angular curvature of spine. See Pott's 
 
 disease, 650 
 Ankle, acute arthritis of, 583 
 
 amputation at, 1177, 5 l8 
 
 ankylosis of, 610 
 
 effusion into, 574 
 
 excision of, 626 
 
 fracture-dislocations of, 490, 569 
 
 tuberculous disease of, 595 
 Ankyloglossia, 773 
 Ankylosis, 608, 78, 147, 332, 615. 665, 
 
 7Si 
 Anterior crural nerve, affections of, 350 
 Anthrax, 113 
 Antisepsis, 14 
 
 Antiseptic treatment of wounds, 14 
 Antiseptics, 15 
 
 Antistreptococcic serum, use of: 
 before abdominal section, 966 
 
 operations on tongue or pharynx, 
 
 783, 802, 804 
 operations on joints, 569 
 in cellulitis, 92 
 in erysipelas, 99 
 
 Antistreptococcic serum in pyaemia, 107 
 
 in septicaemia, 102 
 Antrum, affections of, 740 
 Antyllus' ligature for aneurism, 265 
 Anus, affections of, 1026, 1029, 1032, 1034, 
 1036, 1047 
 
 artificial, 938, 922,924, 926, 927, 928, 
 939, 999, 1004, 1007, 1014, 1016, 
 1022, 1038 
 Aorta, abdominal, aneurism of, 277 
 
 compression of, 237, 278, 1181 
 
 ligature of, 291, 279 
 
 thoracic, aneurism of, 270 
 Aphasia, 700, 720 
 Aplasia cranii congenita, 709 
 Apncea, 863 
 Appendicitis, 945, 1014 
 Arachnoid cyst, 683, 191, 186, 668 
 Arm, amputation through, 1173 
 
 deformities of, 388 
 Arterial haemorrhage, 222, 235 
 Arterial suture, 249 
 
 thrombosis, 246, 255, 76, 79 
 
 varix, 706 
 Arteries, affections of (Chapter X.), 246- 
 280 
 
 ligature of, 280-297 
 Arterio-venous wounds, 249, 706 
 Arteritis, varieties of, 250 
 Arthrectomy for tuberculous disease of 
 
 joints, 591, 593, 594 
 Arthritis, acute, 578, 540, 504, 750 
 
 deformans. See Osteo-arihritis, 596 
 
 following nerve lesions, 604 
 
 tuberculous, 586 
 Arthrodesis, 666 
 Artificial respiration, 865 
 Ascarides, 1027, 1084 
 Asepsis, 14, 1 168 
 Asphyxia, 863 
 Aspiration for hydronephrosis, 1055 
 
 of bladder, 1131 
 
 of chronic abscess, 55 
 
 of empyema, 859 
 
 of hepatic abscess and cyst, 957, 959 
 
 of pericardium, 863 
 Asthenic fever, 32, 220 
 Astragalus, dislocation of, 570 
 
 excision of, 627, 407 
 
 fracture of, 493 
 
 tuberculous disease of, 516 
 Atheroma, 252, 256 
 Atlas, dislocation of, 635, 658 
 Atony of bladder, 1086, 1100, 11 12 
 Atrophic scirrhus, 884, 180 
 Atrophy of bone, 529, 418, 470, 709 
 
 of muscles, 328, 642 
 
 of skull, 709 
 
 of testis, 1 161 
 Auditory nerve, injury of, 342 
 Autoplasty, 709 
 Axillary abscess, 49, 318 
 
 artery, aneurism of, 277 
 ligature of, 288 
 
 cellulitis, 92 
 
INDEX 
 
 i'95 
 
 Bacilli, 2 
 
 Bronchus. See Air-passages 
 
 
 Bacillus anthracis, 113 
 
 Bruise, 190, 191 
 
 
 coli communis, 6, 44, 506, 661, 891, 
 
 Bryant's test-line, 474 
 
 
 895. 8 99. 901. 922, 928, 946, 955, 
 
 Bubo, 1138, 119 
 
 
 961, 997, 1018, 1027, 1076, 1 120 
 
 Bubonocele, 975,. 980 
 
 
 leprae, 146 
 
 Bulb, haemorrhage from artery of 
 
 1 104 
 
 mallei, 145 
 
 Bullet wounds. See Gunshot wounds 
 
 of malignant oedema, 82, 100 
 
 Bullets, kinds of, 204 
 
 
 tetani, 107 
 
 Bunion, 414 
 
 
 tuberculosis, 141 
 
 Burns, 85 
 
 
 typhosus, 3, 44, 5T0, 585 
 
 Bursse, diseases of, 373 
 
 
 Bacteria, 1-5 
 
 Bursal cysts in neck, 825 
 
 
 Bacteriology of acute abscess, 42 
 
 Butcher's wart, 206 
 
 
 Baker's cysts, 578, 369, 185 
 
 
 
 Baker's operation for fractured patella, 
 
 Caecjal hernia, 973 
 
 
 484 
 
 Caecum, cancer of, 928 
 
 
 operation for hernia, 987 
 
 Calcium chloride in blood, 298 
 
 
 Balanitis, 1137, 119 
 
 for haemophilia, 245 
 
 
 Ballooning of rectum, 1034 
 
 Calculous anuria, T063 
 
 
 Banks' (Mitchell) ODeration for hernia, 
 
 Calculus, biliary, 960, 1012 
 
 
 987 
 
 impacied in urethra, 1120 
 
 
 Basal meningitis, 692 
 
 intestinal, 1013 
 
 
 Base of skull, fracture of, 669 
 
 prostatic, 1110 
 
 
 Basilar artery, aneurism of, 274 
 
 renal, ic6i 
 
 
 Bassini's operation for hernia, 984 
 
 salivary, 786 
 
 
 Beatson's operation (oophorectomy), 890 
 
 vesical, 1094 
 
 
 Bedsores, 80, 433, 633 
 
 Callosity, 354 
 
 
 Bell's palsy, 341 
 
 Callus, 425 
 
 
 Bellocq's sound, 770 
 
 Canalization of veins, 242 
 
 
 Benign tumours, 151 
 
 Cancellous osteoma, 164 
 
 
 Berger's amputation of upper extremity, 
 
 Cancer en cuirasse, 883 
 
 
 "74. 536 
 
 Cancer, general facts of, 172-181 
 
 
 Biceps cruris, tenotomy of, 372 
 
 of bladder, 1082 
 
 
 cubiti, injuries of, 364, 365 
 
 of bone, 536 
 
 
 Bilharzia ha;matobia, 1090, 1027, 1055 
 
 of branchial cleft, 823 
 
 
 Biliary fistula, 894, 960, 963 
 
 of breast, 880, 180 
 
 
 passages, affections of, 959 
 
 of intestine, 927 
 
 
 Bilocular hydrocele, 1155 
 
 of jaw, 738, 742, 743, 749 
 
 
 Biniodide of mercury, 15, 16, 18 
 
 of kidney, 1067 
 
 
 Bites, snake, 205 
 
 of larynx, 843 
 
 
 Bladder, affections of (Chapter XXXVII.), 
 
 °f 1>P. 733 
 
 
 1072- 1 107 
 
 of liver, 959 
 
 
 Bladder in hernia, 973 
 
 of nasal fossa;, 765, 766 
 
 
 Blastomycetes, 22 
 
 of oesophagus, 809 
 
 
 Blood-clot, organization of, 2r3, 228, 512 
 
 of pancreas, 965 
 
 
 Blood-cysts, 825, 186 
 
 of parotid, 788 
 
 
 Bobbins, decalcified bone, 937 
 
 of penis, 1139 
 
 
 Boil, 351, 814 
 
 of pharynx, 804 
 
 
 Bone, diseases of (Chapter XVIII.), 495- 
 
 of prostate, 11 16 
 
 
 538 
 
 of pylorus, 909 
 
 
 Bone, injuries of (Chapter XVII.), 417-494 
 
 of rectum, 1036 
 
 
 Boric acid, 15 
 
 of scrotum (chimney-sweep's) 
 
 1 165 
 
 Bottini's operation, 1115 
 
 of spleen, 965 
 
 
 Bougies, urethral, 1124 
 
 of stomach, 907 
 
 
 Brachial artery, compression of, 237 
 
 of testis, 1154 
 
 
 ligature of, 289, 244 
 
 of thyroid, 836 
 
 
 plexus, affections of, 343 
 
 of tongue, 778 
 
 
 stretching of, 344 
 
 of tonsil, 801 
 
 
 Brain. See under Cerebral, Concussion, 
 
 Cancrum oris, 83, 751, 773 
 
 
 and Compression 
 
 Capillary hcemorrhage, 222, 24^ 
 
 
 Branchial cleft, affections of, 822 
 
 naevus, 308 
 
 
 Brasdor's operation for aneurism, 266. 274 
 
 Carbolic acid, 15 
 
 
 Breast, diseases of (Chapter XXXI), 866- 
 
 Carboluria, 15, 1C92 
 
 
 890 
 
 Carbuncle, 352 
 
 
 Bronchocele. See Goitre 
 
 Carcinoma. See Cancer 
 
 
1 196 
 
 INDEX 
 
 Garden's amputation, 1180 
 Caries, 498, 496 
 necrotica, 510 
 of spine, 650 
 of temporal bone, 815 
 syphilitic, 521 
 tuberculous, 514, 650, 711 
 Carotid artery, aneurism of, 272 
 compression of, 236, 273 
 ligature of, 283, 271, 273, 274, 275 
 Carr's splint, 465 
 Carrying angle, 456 
 
 Cartilage, affections of, in joint disease, 
 584, 580, 587, 596, 598, 606 
 semilunar. See Semilunar 
 Cartilages, necrosis of laryngeal, 842, 843, 
 
 844 
 Cartilaginous tumours. See Chondroma 
 Caseation in tubercle, 143 
 Castration, 1163, 1150 
 
 for enlarged prostate, 1115 
 Catarrhal inflammation, 34 
 Catgut ligatures, 232, 18 
 Catheter fever, 11 13 
 
 Catheterism, asepsis in, 634, 664, 1078, 
 1113, 1124 
 dangers from, 1125 
 difficulties in, 1125 
 for enlarged prostate, 11 13 
 Catheters, 1124 
 Cavernous nrjevus, 308 
 Cautery, uses of, 231, 358, 590, 639, 660, 
 
 1046, 1049 
 Cellulitis, 90 
 of axilla, 92 
 
 of ischio-rectal fossa, 1028 
 of orbit, 93 
 of scalp, 93 
 of scrotum, n 64 
 pelvic, 93, 1074, 1104, 1083 
 submammary, 92 
 submaxillary, 93, 784 
 Cellulo-cutaneous erysipelas, 96 
 Central necrosis, 509 
 Cephalhematoma, 667, 191 
 Cephalhydrocele, 668 
 Cephalotetanus, no 
 Cerebellar abscess, 720 
 Cerebral abscess, 718, 692 
 treatment of, 721 
 hremorrhage, 684, 695 
 irritation, 686 
 tumours, 714, 720 
 
 operations on, 716 
 Cerumen in ear, 813 
 Cervical plexus, injury to, 343 
 
 rib, 381, 276 
 Chancre, hard, 123 
 of anus, 1034 
 of lip, 731 
 of nipple, 867 
 of tongue, 777 
 of tonsil, 801 
 of urethra, 124, 1121 
 Chancre, soft (chancroid), 1137 
 
 Chapped lips, 732 
 
 Charcot's disease, 602 
 
 Chemiotaxis, 12, 24 
 
 Chest. See Thorax 
 
 Cheyne's, Watson, operation for femoral 
 
 hernia, 991 
 Cheyne-Stokes respiration, 687, 719 
 Chinosol, 16 
 
 Chloroform, administration of, 1185 
 Cholangitis, suppurative, 955, 961 
 Cholecystectomy, 964 
 Cholecyst-enterostomy, 963, 960 
 Cholecystitis, 961,911 
 Cholecystotomy, 962, 955 
 Cholelithiasis, 960 
 Cholesteatoma, 816 
 Cholesterine, 911, 52 
 Chondro-arthritis, 596 
 Chondroma, 163, 742, 747 
 Chopart's amputation, 1176 
 Chordee, 119 
 
 Chronic abscesses, treatment of, 662 
 Chronic inflammation, 37-40 
 Chylous hydrocele, 1159, 315 
 Chyluria, 1091 
 Cicatrices. See Scar 
 Circular amputation, n66 
 Circumcision, 1135, 983 
 Circumflex nerve, affections of, 344 
 Cirsoid aneurism, 706, 170 
 Clavicle, dislocations of, 549 
 
 fractures of, 446 
 Claw foot, 412 
 
 hands in leprosy, 146 
 
 of ulnar paralysis, 348 
 Cleft palate, 790 
 Cline's splint, 488, 492 
 Cloacce, 501 
 Clover's inhaler, 1186 
 Club-foot, 400 
 
 hand, 389 
 Coagulation necrosis, 25, 44, 45 
 Cocaine, 1185 
 Cocci. See Micrococci 
 Coccydynia, 470 
 Coccyx, excision of, 469, 1026, 1039, 1164 
 
 fracture of, 469 
 Cock's operation of perineal section, 1131 
 Cold in treatment of inflammation, 36 
 Coley's fluid, 160, 181 
 Colic, appendicular, 949 
 
 biliary, 961 
 
 renal, 1063 
 Collapse, 215, 896, 999, 1021, 1023 
 Colles' fascia, 1133 
 
 fracture, 463 
 
 law, 136 
 Colliquative necrosis, 25 
 Colloid cancer, 180, 909, 83i, 927 
 Colopexy, 1049 
 
 Colotomy, 939, 1018, 1026, 1034, 1035, 
 1038, 1041, 1049 
 
 methods of, compared, 944 
 
 uses of, 940 
 Columnar carcinoma, 178 
 
INDEX 
 
 1197 
 
 Columnar carcinoma of bladder, 1033 
 of breast, 885 
 of intestine, 927 
 of rectum, 1036 
 of stomach, 908 
 of upper jaw, 743 
 Coma, diabetic, 77 
 
 diagnosis of, 688 
 
 in cerebral abscess, 719 
 
 in cerebral tumour, 715 
 
 in head injuries, 681, 683, 684, G87, 
 690, 691, 696, 703 
 
 ura^mic, 1014 
 Comminuted fracture, 420 
 Compound fractures, 419, 434, 199 
 Compression, cerebral, 687 
 Concussion, cerebral, 684 
 
 of the spine, 637, 640, 641 
 Condylomata, 128 
 
 of anus, 1034, 1045 
 Congenital abnormalities of testis, 1142 
 
 cysts, 182 
 
 dislocation, 540 
 
 fracture, 419 
 
 hernia, 970, 976, 987, 991 
 
 hydrocele, 1155 
 
 induration of sterno-mastoid, 823, 366 
 
 malformations of rectum, 1026 
 
 syphilis, 136 
 Congestive stricture, 1120 
 Conical stump, 1170 
 Conjunctivitis, gonorrheal, 120 
 Constipation, 995, 999, ioeo, 1012, T021, 
 
 1024, 1033, 1037 
 Contagion, 9 
 Contraction, Dupuytren's, 392 
 
 of scars, 214 
 Contusions, 190 
 
 of abdominal wills, 891 
 
 of bones, 417 
 
 of intestines, 921 
 
 of lung, 854 
 
 of kidney, 1002 
 
 of nerves, 326 
 
 of skull. 668 
 Cooper Rose's inflating bag, 771 
 Corns, 354, 171 
 Corradi's method of treating aneurysms, 
 
 268 
 Corrosive sublimate, 15 
 Costal cartilage, separation of, 445 
 Counter-irritation, 39 
 Cowper's glands, inflammation of, 119 
 Coxa vara, 393 
 Coxalgia and coxitis. See Hip disease, 
 
 611 
 Craniectomy, linear, 710 
 Cranio-cerebral topography, 701 
 Craniotabes, 524, 525. 700 
 Cranium, injuries of, 668-680 
 
 diseases of, 707-713 
 Crepitus, 421 
 
 Croupous inflammation, 34 
 Crus cerebri, injuries to, 700 
 Crutch palsy, 433, 345 
 
 Cryptoscope, 201 
 Cubitus valgus, 456 
 
 varus, 456, 459 
 Curvature of spine, angular, 650 
 
 lateral, 38 r 
 Cut throat, 825 
 Cylindroma, 159 
 
 Cystic hygroma, 31 \, 650, 823, 824 
 Cystine, 1095 
 Cystitis, 1076, 1100, 1112 
 
 in spinal affections, 634, 640, 643, 
 659, 1076 
 Cysto-adenoma, 831, 878, 172 
 Cystoscope, 1075 
 Cystotomy, perineal, 1079 
 Cystotomy, suprapubic, 1105, 1080, 1084 
 Cysts, 181-189 
 
 blood, 186, 825 
 
 branchial, 822 
 
 degeneration, 189 
 
 dental, 737 
 
 dentigerous, 747, 171 
 
 dermoid, 182, 649, 707, 784, S23, 874, 
 1067 
 
 foreign bodies, 186 
 
 hydatid, 187, 537, 715, 825, 861, 874, 
 958, 1067 
 
 implantation, 186 
 
 in floor of mouth, 784 
 
 involution, 870, 873 
 
 Morrant Baker's, 578, 185 
 
 mucous, 732 
 
 of breast, 872 
 
 of jaw, 737, 747, 171, 183 
 
 of kidney, 1067 
 
 of labia, 1141 
 
 of neck, 823 
 
 of ovary, 183, 184, 185 
 
 of pancreas, 964 
 
 of round ligament, 1159, 185 
 
 of spermatic cord, 1158, 185 
 
 of thyroid, 831, 83^, 825 
 
 of thyro-glossal duct, 823, 778, 784, 
 
 183 
 
 of Wolffian body, 1158, 183 
 sebaceous, 361, 707, 825 
 serous, 185, 825, 873, 1067 
 Czerny-Lembert suture, 930 
 
 Dactylitis, tuberculous, 514 
 Davy's lever, 1181 
 Decalcified bone, use of, 517 
 Deformities (Chapter XVI.), 378-416 
 
 in rickets, 525 
 Degeneration, cysts of, 189 
 
 in arteries, 254 
 
 in nerves, 328 
 Delirium tremens, 221, 422 
 Dental cysts, 737 
 Dentigerous cysts, 747, 171 
 Depressed fractures, 674 
 Dermatitis maligna, 867 
 Dermoid cysts. See Cysts 
 Diabetes, 1093 
 Diabetic gangrene, 77, 1094 
 
INDEX 
 
 Diaphragmatic hernia, 994 
 
 Diaphysitis, acute, 502 
 
 Diffuse traumatic aneurism, 247 
 
 Digital compression of arteries, 229, 236, 
 
 264 
 Dilatation of cardiac orifice, 807, 8io, 912 
 
 of oesophagus, 810 
 
 of pylorus, 911 
 
 of rectum, 1034 
 
 of urethra, n 27 
 Diphtheria, 34, 758, 841, 847, 852 
 Diplococci, 2 
 
 Diplococcus urea: liquefaciens, 1076 
 Direct inguinal hernia, 977 
 Dislocations (Chapter XIX.), 539-572 
 
 of spine, 634 
 Dissecting aneurism, 259, 253 
 Dissection wounds, 206 
 Distal ligature for aneurism, 266, 271, 
 
 274, 277 
 Distension of bladder with overflow, 
 
 1085, 1087 
 Disunited fracture, 438 
 Diverticula of oesophagus, 805 
 Diverticulum of Meckel, 921, ion 
 Dorsal dislocation of hip, 562 
 Dorsalis pedis artery, ligature of, 297 
 Drainage in abdominal operations, 968 
 
 in treatment of wounds, 195, 19 
 Dressings for operations, 19 
 Drowning, 865 
 Dry gangrene, 68 
 Duct cancer, 884, 879 
 
 papilloma, 879 
 Duodenum, perforating ulcer of, 921, 901, 
 
 8 7 
 Dupuytren's contraction, 392 
 
 enterotome, 1008 
 
 fracture, 490 
 
 splint, 492 
 Dura mater, injuries of, 677, 690 
 sarcoma of, 712 
 
 thickening of, causing epilepsy, 703 
 Durham's tracheotomy tube, 849 
 Dyspeptic ulcer, 777 
 Dysphagia, 811 
 Dyspnoea. See Asphyxia 
 
 Ear, affections of (Chapter XXVIII.), 
 
 813-821 
 Ecchondroses, 164 
 Echinococcus tasnia, 187, 301, 958 
 Ecthyma, 130 
 Ectopia testis, 1143 
 
 vesica;, 1072, 894 
 Ectrodactylism, 390 
 Eczema of external auditory meatus, 814 
 
 of nipple (Paget's), 867 
 
 of scrotum, 1165 
 
 varico-e, 306, 62 
 Eczematous ulcer, 63 
 Eggshell crackling, 534, 537, 712, 713, 
 
 74°- 747 
 Elbow-joint, acute arthritis of, 582 
 amputation through, 1172 
 
 Elbow-joint, ankylosis of, 609 
 
 dislocations of, 556 
 
 effusion into, 574 
 
 excision of, 622, 610 
 
 tuberculous disease of, 593 
 Electrolysis for aneurism, 268, 270, 275, 
 278 
 
 for cirsoid aneurism, 706 
 
 for hydatid cysts, 959 
 
 for intra-orbital aneurism, 275 
 
 for na;vi, 309, 732 
 Elephantiasis Arabum, 315 
 
 Graecorum, 146 
 Elliptical (oval) method of amputating, 
 
 1167 
 Emboli, 301, 72, 103, 254, 261, 262, 423, 
 
 302 
 Embolic gangrene, 72 
 Embryonic tissue, 25, 45 
 Emphysema, surgical, 439, 713, 827, 855, 
 
 923 
 Emprosthotonos, 109 
 Empyema, 858, 855, 656, 901, 906, 956 
 of antrum, 740 
 of frontal sinuses, 713 
 pulsating, 858 
 Encephalitis, 691, 692 
 Encephalocele, 707, 708 
 Encephaloid cancer, i3o, 884 
 Encysted hernia, 977 
 
 hydrocele of cord, 1158, 185, 980 
 of epididymis, 1157, 184 
 of round ligament, 1159, 185 
 End-to-end anastomosis of gut, 933 
 Endarteritis, 251, 39, 76, 142, 131, 132 
 Endocarditis, infective, 103 
 Endosteal sarcoma, 533, 712, 748 
 Endothelioma, 159, 788 
 Enterectomy, 93 r, 893, 924, 927, 928, 
 
 1003, 1004, 1008, 1016 
 Enteritis, acute, 922, 1005 
 Enterocele, 973 
 Enteroliths, 1073 
 Enteroplasty, 931, 927 
 Enteroptosis, 105 1, 984 
 Enterorrhaphy, 932, 928 
 Enterostomy, 931, 1015 
 Enterotome, Dupuytren's, 1008 
 Enterotomy, 931 
 Epididymectomy, 1149 
 Epididymitis, 1147, 1126, 1148, 119 
 Epilepsy, traumatic, 703 
 Epiphysis, separation of, 420 
 Epiphysitis, 499, 507, 518, 523 
 Epiplocele, 973 
 Epispadias, 1117 
 Epistaxis, 769.439, 671, 222 
 Epithelioma, 175 
 
 after lupus, 357, 359 
 
 branchial, 823 
 
 of anus, 1036 
 
 of bladder, 1082 
 
 of glands in neck, 825 
 
 of gum, 738 
 
 of jaw, lower, 749 
 
INDEX 
 
 1 199 
 
 Epithelioma of jaw, upper, 
 
 742, 743 
 
 External carotid, aneurysm of, 274 
 
 
 of larynx, 843 
 
 
 ligature of, 285, 243, 789, 
 
 802, 
 
 of lip, 733 
 
 
 804, 827 
 
 
 of nipple, 867 
 
 
 External iliac, ligature of, 293, 278, 280 
 
 of nose, 765 
 
 
 External popliteal nerve, affections of, 350 
 
 of oesophagus, 809 
 
 
 Extirpation of aneurism, 267 
 
 
 of palate, 798 
 
 
 Extracapsular fracture of femur, 471 
 
 
 of penis, 1139 
 
 
 of humerus, 451 
 
 
 of pharynx, 804 
 
 
 Extradural abscess. See Subcranial 
 
 of scalp, 707 
 
 
 abscess 
 
 
 of scar, 215 
 
 
 Extragenital chancres, 124 
 
 
 of scrotum, 1165 
 
 
 Extra-medullary haemorrhage, spina 
 
 1,638 
 
 of stomal h, 908 
 
 
 Extravasation of blood, 222 
 
 
 of tongue, 778 
 
 
 of urine, 1133, 1074, 1083, 
 
 1087, 
 
 of tonsil, 801 
 
 
 1105, 1118 
 
 
 Epi'vphlitis, 945 
 
 
 Extroversion of bladder. See Ectopia 
 
 Epulis, 737, 162 
 
 
 vesicae, 1072 
 
 
 Krethitic shock, 217 
 
 
 Exudation cysts, 185 
 
 
 Ergot, gangrene from, 78 
 
 
 
 
 Erysipelas, 94, 799, 1165 
 
 
 Facial artery, compression of, 237 
 
 
 curative action of, 98, 
 
 [Co 
 
 ligature of, 286 
 
 
 Erythema nodosum, 97 
 
 
 Facial cleft, oblique, 730 
 
 
 Esmarch's operation for cl 
 
 osurc of lower 
 
 nerve, affections of, 340 
 
 
 jaw, 751 
 
 
 operation on, 342 
 
 
 Estlander's operation, 860 
 
 
 paralysis, 340, 671, 788, 815 
 
 
 Ether, administration of, 1186 
 
 tic, 342 
 
 
 Ethmoid, diseases of the, 7 
 
 61 
 
 Facies Hippocratica, 896, 999, ioio 
 
 
 Eucaine, 1185 
 
 
 Ftecal fistula. See Fistula 
 
 
 Excision of joints, 620-627 
 
 
 Faeces, impaction of, 1016, 1017 
 
 
 for acute arthritis, 
 
 581 
 
 False joints, 436, 546 
 
 
 for ankylosis, 610 
 
 
 passages, it 25 
 
 
 for dislocations, 5 
 
 17 
 
 Farabceuf's amputations, 1171, 1174, 
 
 1179 
 
 for fractures, 423, 
 
 460 
 
 Farcy. See Glanders 
 
 
 for tuberculous di: 
 
 ease, 591 
 
 Fat embolism, 423 
 
 
 of breast, 888 
 
 
 Fatty hernia, 162, 993 
 
 
 of condyle of jaw, 752 
 
 
 tumour. See Lipoma 
 
 
 of Gasserian ganglion 
 
 339 
 
 Femoral artery, aneurism of, 279 
 
 
 of hydrocele sac, 1157 
 
 
 compression of, 237 
 
 
 of larynx, 845 
 
 
 ligature of, 294, 279, 280 
 
 
 of mandible, 749 
 
 
 hernia, 989 
 
 
 of maxilla, 744, 765, 766 
 
 strangulated, 1006 
 
 
 of noevi, 309 
 
 
 Femur, fractures of, 470 
 
 
 of parotid gland, 789 
 
 
 separation of lower epiphysis of. 
 
 482 
 
 of pylorus, 917, 911, 9 
 
 12 
 
 upper epiphysis of, 478 
 
 
 of rectum, 1038 
 
 
 Fever, 31, 219 
 
 
 of rib for empyema, 860 
 
 Fibrin ferment, 32, 219, 245, 422 
 
 
 of rib for hepatic abscess, 957 
 
 Fibroblasts, 25, 209, 227 
 
 
 of rib for sub-phrenic abscess, 902 
 
 Fibro-adenoma of breast, 875 
 
 
 of stomach, 916, 911 
 
 
 thyroid, 830 
 
 
 of stricture of urethra, 
 
 1130 
 
 Fibro cystic disease of jaw, 748, 171 
 
 
 of thyroid, 833, 836 
 
 
 of testis, 1152, 183 
 
 
 of varicocele, 1160 
 
 
 Fibroid, recurrent, 157, 880 
 
 
 Exclusion of intestine, 928 
 
 
 Fibroid thickening, 28 
 
 
 Exomphalos, 991 
 
 
 Fibroma, 162, 166, 167, 665, 707, 
 
 73 2 . 
 
 Exophthalmic goitre, 835 
 
 
 742, 747, 764, 875 
 
 
 Exophthalmos (proptosia), 
 
 2 75. 334, 672, 
 
 Fibro-myoma, 166, 189, 1111 
 
 
 683, 740, 835 
 
 
 Fibro-sarcoma, 157, 166, 885 
 
 
 Exostoses, 164, 712 
 
 
 Fibrous polypus, 764 
 
 
 Exostosis bursata, 165 
 
 
 Fibrous union of fracture, 436 
 
 
 of ear, 814 
 
 
 Fibula, fractures of, 488 
 
 
 of first rib, 275 
 
 
 Fifth nerve, affections of, 335 
 
 
 subungual, 165 
 
 
 Filaria sanguinis hominis, 315, 316, 
 
 1091 
 
 Expansion of bone, 515, 533, 537 
 
 Fingers, amputations of, 1171 
 
 
 Extension of leg, 476 
 
 
 chancre of, 124 
 
 
 in hip-joint disease, 617 
 
 deformities of, 389, 391 
 
 
INDEX 
 
 Finsen light cure for lupus, 358 
 
 Fission, 3 
 
 Fissure of anus, 1032 
 
 of lip, congenital, 723-730 
 Fissure of Rolando, 701 
 
 Sylvius, 702 
 Fissures of nipples, 866 
 Fistula, 56 
 
 aerial, 828 
 
 biliary, 894, 960, 963 
 
 bimucosa, 899, 925 
 
 branchial, 822 
 
 cervical, 824 
 
 fsecal, 894, 899, 921, 948, 953, 1004, 
 1006, 1008 
 
 gastric, 906 
 
 -in-ano, 1029 
 
 median cervical. 824 
 
 oesophageal, 826 
 
 penile, 119 
 
 perineal, 1108, 1116,1122,1132, 1133 
 
 pharyngeal, 828 
 
 recto- vesical, 1083, 1104 
 
 salivary, 789 
 
 scrotal, 1165 
 
 umbilical, 894 
 
 urinary, 894, 1073, 1108 11 16, 1132, 
 1134, 119 
 Flap amputation, 1167 
 Flat foot, 409 
 Floating kidney, 1050 
 
 spleen, 965 
 Fluctuation, 46, 48 
 Foetal residues, 151 
 Foot, amputation of, 1175, 1177 
 
 contusions of, 199 
 
 deformities of, 403 
 Forcible straightening of spine, 662 
 Forcipressure, 231 
 Forearm, amputation through, 1172 
 Foreign bodies in air-passages, 757, 838 
 in appendix, 946 
 in bladder, 1075 
 in ear, 814 
 in hernial sac, 974 
 in intestine, 1012 
 in nose, 757 
 in oesophagus, 806 
 in stomach, 903 
 in urethra, n 18 
 Fourth nerve, paralysis of, 335 
 Fractures (Chapter XVII.), 417-494 
 Fractures, early operation upon, 432 
 Fragilitas ossium, 418 
 Frank's operation of gastrostomy, 914 
 Freezing for anaesthesia, 1158 
 Frontal lobes, injuries of, 686, 695, 699 
 
 sinuses, affections of, 713, 761 
 Frost-bite, 85 
 Fungi, 21 
 
 Fungus haematodes, 66 
 Furuncle. See Boil, 350, 814 
 Fusiform aneurism, 257 
 
 Galactocele, 872 
 
 Gallbladder, affections of, 959 
 Gall-stones, 960, 1012 
 Ganglion, 363 
 Gangrene (Chapter V.), 67-89 
 
 acute emphysematous, 81 
 
 after aneurism, 247, 261, 263, 267 
 
 during treatment of fractures, 433 
 
 from diabetes, T], 1094 
 
 from ligature of main artery, 78, 282 
 
 from rupture of artery, 247 
 
 from splint pressure, 80 
 
 of intestine, 997, 1003, 1004, 1016, 
 1019 
 
 of lung, 861 
 
 senile, 74, 255, 256 
 Gant's osteotomy of femur, 610 
 Gartner's duct, cyst of, 184 
 Gasserian ganglion, removal of, 339 
 Gastrectomy, 916, 911 
 Gastric ulcer, 903 
 Gastrocnemius, rupture of, 366 
 Gastroenterostomy, 918, 905, 907, 911 
 Gastrostomy, 914, 810, 911, 907 
 Gastrotomy, 912, 807 
 Gelenkmaus, 606 
 Genu recurvatum, 398 
 
 valgum, 394, 526 
 
 varum, 398, 526 
 Giant cells, 142, 158, 227, 357, 498 
 Glanders, 145 
 
 Glands, affections of lymphatic, 317-325 
 Glandular cancer, 179 
 Glass wounds 201, 249 
 Gleet, 116, 118 
 Glenard's disease, 105 1 
 Glioma, 156, 714 
 Glossitis, 774 
 
 Glossopharyngeal nerve, affections of, 342 
 Gluteal artery, aneurism of, 279 
 bursa, 377 
 
 haemorrhage from, 244 
 ligature of, 292 
 Goitre, 828 
 
 Golding-Bird's sling for flat-foot, 411 
 Gonococcus, 115, 44, 585, 579, 895 
 Gonorrhoea, 115 
 Gonorrhoea] arthritis, 585, 665 
 Gottstein's curette, 769 
 Gout, 1088, 584, 600 
 Granulation tissue, 45, 61, 211 
 Granulomata, infective, 121 
 Gravel, 1087, 1096 
 Graves' disease, 835 
 Gravitation paraplegia, 638 
 Great sciatic nerve, affections of, 348 
 
 stretching of, 349 
 Greenstick fracture, 419 
 Gritti's amputation, 1180 
 Growth of bone, 496 
 Gubernaculum testis, 1142 
 Gumma, 131, 531, 715. -jjj 
 Gums, affections of, 735-738 
 Gun-shot wounds, 202-205 
 of abdomen, 203 
 of lung, 856 
 
INDEX 
 
 Gun-shot wounds, of skull, 676, 698, 203, 
 205 
 
 Hematemesis, 909, 223 
 Hematocele of cord, 1145, 981 
 
 of tunica vaginalis, 1144, 186 
 Hematoma, 191 
 
 of abdominal walls, 891 
 
 of ear, 813 
 
 of vulva, 1 141 
 Hematuria, 1090, 1096, 1052, 223, 1109 
 Hemoglobinuria, 1090, 78 
 Haemophilia, 245, 1090 
 
 joints in, 605 
 Hemoptysis, 223, 854 
 Hemorrhage (Chapter IX.), 222 245 
 
 during amputations, 1169 
 at hip-joint, 1181 
 
 from catheterism, 1125 
 
 from gastric ulcer, 905 
 
 reactionary, 238 
 
 secondary, 239 
 
 special sources of, 243 
 
 treatment of, 229 
 Hemorrhoids, 1044 
 Hemostatics, 230 
 Hemothorax, 854 
 Hahn's tracheotomy-tube, 850, 781 
 Hallux rigidis (H. flexus). 413 
 Hallux valgus, 413 
 Halsted's operation for hernia, 988 
 for scirrhus mammas, 887 
 
 suture, 930 
 Hammer-toe, 414 
 
 Hammond's splint for fracture of man- 
 dible, 442 
 Hand, amputations of, 1172 
 
 deformities of, 389 
 Hare-lip, 723 
 
 Head injuries (Chapter XX 111.), 667-704 
 Healing of wounds, 208 
 
 by granulation, 211 
 
 by organization of blood-clot, 213 
 
 by primary union, 211 
 
 under a scab, 213 
 Heart, wounds of, 862 
 Heat in treatment of inflammation, 36 
 Heat-stroke, 689 
 
 Hectic fever, 6, 52, 580, 589, 617, 659 
 Hernia (Chapter XXXIII.), 970- 1008 
 
 cerebri, 702, 677 
 
 en-bissac, 979, 1002 
 
 en-rnasse, 1002 
 
 fatty, 993, 162, 981 
 
 femoral, 989 
 
 inguinal, 974 
 
 internal, ion, 1001 
 
 interstitial, 979, 1002 
 
 of lung, 857 
 
 strangulated, 996 
 
 testis, 1151 
 
 umbilical, 991 
 
 ventral, 993, 893, 953 
 Herpes labialis, 732 
 
 in neuralgia, 332 
 
 Herpes, preputialis, 1139 
 
 zoster, 348 
 Hesselbach's triangle, 978 
 Heteroplasty, 710 
 Hey's amputation, 1176 
 
 saw, 678 
 Hilton's method of opening abscess, 49 
 Hip-joint, acute arthritis of, 579, 582, 507 
 
 amputation through, 1181, 618 
 
 ankylosis, 609, 610 
 
 congenital dislocation of, 540 
 
 dislocations of, 560 
 
 effusion into, 574 
 
 excision of, 624, 618 
 
 osteo-arthritis of, 601 
 
 tuberculous disease of, 611 
 Hodgen's splint, 476 
 Hodgkin's disease, 324 
 Hoffa's operation, 543 
 Horn, sebaceous, 361, n 39 
 Hospital gangrene, 83 
 Hourglass contraction of stomach, 907 
 Housemaid's knee, 376 
 Howship's lacune, 498 
 Humerus, fractures of, 450 
 
 separation of lower epiphysis, 458 
 upper epiphysis, 452 
 Hunterian chancre, 123 
 
 ligature for aneurism, 265 
 Hunter's canal, ligature of femoral artery 
 
 in, 294 
 Hydatid cysts, 187 
 
 of bone, 537 
 
 of brain, 715 
 
 of breast, 874 
 
 of kidney, 1067 
 
 of liver, 958 
 
 of lung, 861 
 
 of Morgagni, 184, 1158 
 
 of neck, 825 
 
 of spine, 665 
 
 of spleen, 965 
 Hydrarthrosis, 577 
 Hydrencephalocele, 707 
 Hydrocele, bilocular, 1155 
 
 congenital, 1155 
 
 chylous, 1 159, 315 
 
 of breast, 873 
 
 of cord, 1158, 185 
 
 of hernial sac, 972 
 
 of neck, 825 
 
 of round ligament, 1159, 185 
 
 of tunica vaginalis, 1154, 185 
 Hydrocephalus, 710 
 Hydrogen, peroxide of, 179 
 Hydronephrosis, 1053, 94, 1055, 1062, 
 
 1112, 1123 
 Hydrophobia, 112 
 Hydrops antri, 741 
 
 articuli, 577 
 
 of frontal sinuses, 713 
 Hygroma, 314, 824, 650 
 Hyoid, fracture of, 443 
 Hyperemia, 24 
 Hyperostoses, 166 
 
 76 
 
INDEX 
 
 Hypertrophy of bone, 530 
 
 of breast, 876 
 
 of gums, 735 
 
 of prostate, 1110 
 
 of skull, 711 
 
 of tonsils, 800 
 Hypoglossal, injury to, 343 
 Hypospadias, 11 19 
 Hypostatic pneumonia, 433, 471 
 Hysteria in spinal injuries, 640 
 Hysterical joints, 608, 399 
 
 Ichthyosis linguae, 775 
 Ileo-colostomy, 927, 928 
 Iliac abscess, 660 
 
 aneurism, 278 
 
 colotomy, 942 
 
 vessels, ligature of, 291, 293, 279, 213 
 Immunity, 10 
 Impacted calculus in urethra, 1120 
 
 faeces, 1017 
 
 fracture, 420 
 
 gall-stones, 962, 963 
 Impassable stricture, treatment of, ir3o 
 Imperforate anus, 1026 
 Impermeable stricture of urethra, 1121 
 Implantation cysts, 186 
 Incised wounds, 192 
 Incontinence of urine, 1084, 643, 658 
 Infantile hernia, 977 
 
 hydrocele, 1155 
 
 paralysis, 666 
 Infarct, 301, 104 ; and see Emboli 
 Infection, 8 
 Infective diseases (Chapter VI.), 90-149 
 
 gangrene, 72, 81 
 
 granulomata, 121 
 
 processes, 10 
 Inferior dental nerve, operations on, 338 
 
 maxilla, fracture of, 440 
 Inflamed aneurism, 263, 269 
 
 hernia, 995 
 Inflammation (Chapter II.), 23-40 
 Inflammatory fever, 87 
 Infra-orbital nerve, operations on, 337, 
 
 338 
 Infusion of salt solution, 224 
 
 for abdominal injuries, 892, 924 
 
 for haemorrhage, 224 
 
 for sepsis, 8, 102 
 
 for shock, 219 
 Ingrowing toenail, 360 
 Inguinal aneurism, 278 
 
 colotomy, 942 
 
 hernia, 974 
 
 strangulated, 1006 
 Inhalers, anaesthetic, 1186, 1188 
 Injections in gonorrhoea, 117 
 
 in hydrocele, 11 57 
 Innominate artery, aneurism of, 271 
 
 ligature of, 283, 276 
 Inoperable malignant disease, 160, 181 
 Insanity, traumatic, 704 
 Intercostal artery, haemorrhage from, 
 244, 857 
 
 Intercostal neuralgia, 348 
 Interma.xilla in hare-lip, 726 
 Intermediate haemorrhage, 238 
 Internal carotid, aneurism of, 274 
 
 ligature of, 285 
 
 wounds of, 682 
 Internal derangement of knee-joint, 567 
 
 iliac artery, ligature of, 291, n 16 
 
 mammary artery, haemorrhage, 243 
 ligature of, 287 
 
 popliteal nerve, affections of, 350 
 Interscapulo-thoracic amputation, 1174 
 Interstitial emphysema, 855 
 
 hernia, 979 
 
 inflammation, 35 
 
 keratitis, 139 
 
 mastitis, 869 
 Intestinal anastomosis, 932-938 
 
 obstruction (Chapter XXXIV. ), 1009- 
 1024 
 Intestines, affections of, 921 
 
 injuries, 921 
 
 operations on, 929 
 Intracapsular fracture of humerus, 450 
 
 of femur, 470 
 Intracranial aneurism, 274 
 
 inflammation, 690, 718, 719, 818 
 Intramammary abscess, 868, 871, 49 
 Intramedullary haemorrhage of spine, 638 
 Intrameningeal haemorrhage, 683 
 Intra-orbital aneurism, 275 
 Intra-uterine fractures, 419 
 Intubation of larynx, 853 
 Intussusception, 1018 
 Inunction, mercurial, 134, 139 
 Inversion of testis, 1143 
 Involucrum, 501 
 Involution cysts, 870, 873 
 Iodoform, 15, 590, 663, 55 
 Iritis, syphilitic, 128 
 Irreducible hernia, 994, 972 
 Irrigation of abdomen, 892, 897, 900, 903 
 of chronic abscess, 55 
 of pleural cavity, 860 
 Irritability of bladder, 1085 
 Irritable ulcer, 63, 777 
 Ischaeinic contraction of muscles, 433 
 Ischio-rectal abscess, 1027 
 Ivory exostosis. See Osteoma 
 
 Jaundice, 954, 956, 960, 962, 963 
 Jawbone. See Maxilla or Mandible 
 Jaws, affections of, 739-752 
 Joints, diseases of (Chapter XX.), 573- 
 627 
 injuries of (Chapter XIX.), 539-572 
 Jordans, Furneaux-, amputation at hip- 
 joint, 1182 
 Jugular vein, ligature of, 821, 243 
 Junker's inhaler, 1186 
 
 Keloid, 214, 162 
 Keratitis, interstitial, 139 
 Kidney, affections of (Chapter XXXVI.), 
 1050-1071 
 
INDEX 
 
 1203 
 
 Kidney, amyloid disease of, 54 
 
 
 Lateral implantation, 928 
 
 Kingsley's splint, 414 
 
 
 lithotomy, 1100 
 
 Kinking of gut, 899, 1013, 1016 
 
 
 sinus, thrombosis of, 720, 820, 103, 
 
 of ureter, 1051, 1053 
 
 
 106 
 
 Knee-joint, acute arthritis of, 583 
 
 
 Lavage, 912 
 
 amputation through, 1179 
 
 
 ' Leather-bottle stomach,' 908, 910 
 
 ankylosis of, 610 
 
 
 Leg, amputation of, 1179 
 
 contractions of, 399 
 
 
 Leiomyoma, 166 
 
 dislocations of, 567 
 
 
 Lembert's suture, 929 
 
 effusion into, 594 
 
 
 Leontiasis ossea, 742 
 
 excision of, 626 
 
 
 Leprosy, 146 
 
 subluxation of, 567 
 
 
 Leucocytes, migration of, 24, 227 
 
 tuberculous disease of, 594, 399 
 
 
 phagocytic action of, 12 
 
 Knock-knee, 394, 396 
 
 
 Leucocytosis, 47 
 
 Kobelt's tubes, cysts in connection 
 
 vith, 
 
 Leucoplakia, 775 
 
 1158, 183, 184 
 
 
 Leukaemia, 323 
 
 Kocher's method of reducing disloca 
 
 ions 
 
 Ligature of vessels, 280 297 
 
 of humerus, 555 
 
 
 causing gangrene, 78 
 
 of thyroidectomy, 833 
 
 
 for hemorrhage, 232-235 
 
 operation on the tongue, 782 
 
 
 Ligatures, 234 
 
 Kraske's operation, 1039, 1026 
 
 
 Lingual artery, ligature of, 780, 285, 286 
 
 Kyphosis, 386 
 
 
 nerve, operations on, 338 
 Lip, affections of, 723-735 
 
 Labia, affections of, 1140 
 
 
 Lipoma, 160, 650, 665, 990, 981 
 
 Lacerated wounds, 197-200 
 
 
 arborescens, 162, 576 
 
 Laceration of brain, 694 
 
 
 diffuse, 161 
 
 Lachrymal bone, fracture of, 439 
 
 
 fibrolipoma, 161 
 
 Lacunar abscess, 119 
 
 
 ncevolipoma, 162 
 
 Laminectomy, 644 
 
 
 nasi, 754 
 
 in Pott's disease, 664 
 
 
 of femoral canal, 990 
 
 Langenbeck's operation for excision of 
 
 parosteal, 161 
 
 rectum, 1039 
 
 
 pericranial, 161 
 
 on nasal cavity, 766 
 
 
 sarcolipoma. 162 
 
 Laparotomy for abdominal contusion 
 
 , 892 
 
 subserous, 162 
 
 for cancer of intestine, 928 
 
 
 Lisfranc's amputation, 1175 
 
 of stomach, 910 
 
 
 Lister's amputation, modified flap and 
 
 for injury of intestine, 922 
 
 
 circular, 1167 
 
 for intestinal obstruction, 1014, 1C17 
 
 supracondyloid, 1180 
 
 for intussusception, 1022 
 
 
 antiseptic treatment of wounds. 14 
 
 for perforation of appendix, 951, 
 
 95 2 
 
 dressings, 19, 20 
 
 of intestine in typhoid fever 
 
 925 
 
 strong mixture, 193 
 
 of stomach, 906, 899 
 
 
 Liston's long splint, 475, 617 
 
 for peritonitic adhesions, 906 
 
 
 Lithiasis, 1088, 1061 
 
 for peritonitis, 898 
 
 
 Litholapaxy, 1098 
 
 tuberculous, 899 
 
 
 Lithotomy, lateral, 1100, 1105, 1107 
 
 for rupture of gall-bladder, 960 
 
 
 suprapubic, 1105, 1107 
 
 of intestine, 923 et seq. 
 
 
 Lithotrity, 1098 
 
 of liver, 954 
 
 
 Littr^'s hernia, 996, 1010 
 
 of stomach, 902 
 
 
 operation, 942 
 
 for ulcer of stomach, 905, 906, 907 
 
 Liver, affections of, 953-959 
 
 Lardaceous disease, 53, 1092 
 
 
 amyloid disease of, 54 
 
 Larrey's operation, 1173 
 
 
 Local anaesthesia, 1184 
 
 Laryngeal paralysis, 843, 270, 27r, 
 
 2 73. 
 
 Localization of cerebral injuries, 699 
 
 809, 864, 853, 830 
 
 
 Loose bodies in joints, 605 
 
 stenosis, 842, 828, 852 
 
 
 Lordosis, 388, 614 
 
 Laryngectomy, 845 
 
 
 Loreta's operation, 911 
 
 Laryngitis, oedematous, 842, 93, 96, 
 
 444. 
 
 Lorenz's bloodless operation, 543 
 
 775, 784, 805, 806, 827 
 
 
 Lowenberg's forceps, 769 
 
 Laryngoscope, 841 
 
 
 Lower jaw. See Mandible 
 
 Laryngotomy, 847, 838, 839 
 
 
 Ludwig's angina, 93. 784 
 
 Larynx, diseases of, 841 
 
 
 Lumbar abscess, 657, 662 
 
 foreign bodies in, 838 
 
 
 colotomy, 941 
 
 injuries of, 826, 840 
 
 
 hernia, 994 
 
 Lateral anastomosis, 938, 928, 964, 1008 
 
 operations on kidneys, 1068-1071 
 
 curvature of spine. See Scoliosis 
 
 38i 
 
 puncture, 692 
 
 76 2 
 
1204 
 
 INDEX 
 
 Lungs, affections of, 854-862 
 
 Melanosis, 159 
 
 Lupus, action of erysipelas on, 98 
 
 Melanotic sarcoma, 158 
 
 erythematosus, 358 
 
 Melon-seed bodies, 369, 375, 605 
 
 vulgaris, 356, 777, 797 
 
 Meningeal haemorrhage, cerebral, 680 
 
 Luschka's tonsil, 803 
 
 spinal, 638 
 
 Luxatio erecta, 553 
 
 Meningitis, 691, 693, 720, 820 
 
 Lymphadenitis, acute, 317 
 
 spinal, 638, 659 
 
 chronic, 319 
 
 Meningocele, 647, 707 
 
 Lymphadenoma, 323, 171 
 
 Meningoencephalitis, 692 
 
 Lymphangiectasis, 315, 731, 774 
 
 Meningo-encephalocele, 708 
 
 Lymphangioma, 314, 171 
 
 Meningo-myelocele, 647 
 
 Lymphangitis, 312, 313 
 
 Mercurialism, 134, 739, 774 
 
 Lymphatic glands, affections of, 317-325 
 
 Metacarpals, dislocation of, 559 
 
 vessels, affections of, 312-317 
 
 fracture of, 467 
 
 Lymphorrhcea, 315, 314 
 
 Metastasis, 35, 785, 1146 
 
 Lympho-sarcoma, 324, 156 
 
 Metatarsalgia (Morton's disease), 416 
 
 of testis, 1153 
 
 Microcephaly, 710 
 
 of tonsil, 801 
 
 Micrococci, 1 
 
 Lysol, 16 
 
 Microstoma, 730 
 
 
 Middle turbinated bone, disease of, 761 
 
 McBurney's spot, 947 
 
 Miliary tuberculosis, 659 
 
 MacEwen's operation for hernia, 987 
 
 Mirault's operation for hare-lip, 728 
 
 osteotomy, 398 
 
 Moist gangrene, 68 
 
 MacEwen's treatment of aneurism, 268, 
 
 Mollities ossium. See Osteomalacia 
 
 270, 276, 278 
 
 Molluscum contagiosum, 362 
 
 Macrocheilia, 731, 315 
 
 fibrosum, 163, 169 
 
 Macrodactyly, 390 
 
 Moore's method of treating aneurysms, 268 
 
 Macroglossia, 774, 315 
 
 Morgagni, hydatid of, cysts from, 184, 
 
 Macrostoma, 730 
 
 1158 
 
 Malar, fracture of, 440 
 
 Morris's bitrochanteric test, 474 
 
 Malarial spleen, 965 
 
 Morton's disease, 416 
 
 Malignancy, characteristics of, 151 
 
 Motor area, topography of, 701 
 
 Malignant cysts of neck, 825 
 
 wounds of, 699 
 
 endocarditis, 103 
 
 Mouth, affections of, 772, 783 
 
 cedema, 82 
 
 Moveable kidney, 1050 
 
 pustule, 114 
 
 Mucous cysts, 714, 732, 782 
 
 tumours, 151 
 
 membranes, tuberculous disease of, 
 
 ulcers, 66 
 
 359 
 
 Mallet finger, 391 
 
 polypus, 762 
 
 Malpositions of testis, 1143 
 
 tubercles, 128, 135, 137, 172, 1034 
 
 Mamma. See Breast 
 
 Mulberry calculus, 1045 
 
 Mandible, diseases of, 739. 747 
 
 Mumps, 785 
 
 excision of, 749 
 
 Murexide test, 1087 
 
 injuries of, 440, 548 
 
 Murphy's button, 935, 918, 920, 938 
 
 tumours of, 747 
 
 Muscles, affections of, 363-367 
 
 Mandibular cleft, 730 
 
 Musculo spiral nerve, affections of, 344 
 
 Massage, 40 
 
 Myelitis, spinal, 639 
 
 Massage in treatment of fractures, 431, 
 
 Myelocele, 646 
 
 4SL 459. 460, 465. 484. 489. 493 
 
 Myeloid sarcoma, 157, 534, 712, 738, 748 
 
 Mastitis, acute, 867 
 
 Myeloma, 158 
 
 chronic, 869 
 
 Myeloplaxes, 158 
 
 Mastoid disease, 815 
 
 Myoma, 166 
 
 Maunsell's operation, 933, 1022 
 
 Myo-sarcoma, 157, 1066 
 
 Maxilla, affections of, 739-744 
 
 Myositis, 366 
 
 excision of, 744 
 
 Myositis ossificans, 367, 608, 751 
 
 injuries of, 440 
 
 Myxcedema, 834, 532 
 
 Meckel's diverticulum, 921, ion 
 
 Myxo-lipoma, 162 
 
 Median hare-lip, 730 
 
 Myxoma, 153 
 
 nerve, affections of, 346 
 
 
 Median cervical fistula, 824 
 
 Naevo-lipoma, 310, 162 
 
 Medulla oblongata, injuries to, 701 
 
 Nsevus, 307, 169 
 
 of bone, inflammation of. See 
 
 lymphatic, 314 
 
 Osteomyelitis 
 
 of lip, 732 
 
 Medullary cancer, 180 
 
 of scalp, 706 
 
 Meltena, 223, 1045 
 
 of tongue, 778 
 
INDEX 
 
 1205 
 
 Naevus, unius lateris, 308 
 Nails. See Onychia 
 Nasal bone, fracture of, 439 
 
 polypi, 762 
 
 septum, fracture of, 439 
 Naso-pharynx, diseases of, 722 
 Neck, affections of (Chapter XXIX.), 
 822-837 
 
 tuberculous glands, 319, 321 
 Necrosis, acute, 502 
 
 of bone, 496, 497, 500, 502, 509, 522, 
 1 169, 434, 43s, 83 
 
 of jaw, 739 
 
 of ossicles, 815 
 
 of palate, 789 
 
 of temporal bone, 8r5 
 
 quiet, 497, 606 
 Needles, 201 
 Nelaton's line, 473 
 
 operation on the naso- pharynx, 766 
 Nephrectomy, 1069, 1052, 1055, 1058, 
 
 1060, 1064, 1066, 1067 
 Nephrorrhaphy, 1071 
 Nephrotomy, 1069 
 Nephrolithotomy, 1055, 1058 
 Nerve extraction, 333 
 
 grafting, 331 
 
 stretching, 333 
 
 suture, 330 
 Nerves, affections of special, 334-350 
 
 bulbous ends of, 328, 169, 215, 
 1 170 
 
 injuries of, 326, 673, 424 
 
 tumours of,. 167 
 Neuralgia, 332, 261 
 
 of joints, 608 
 
 of testis, 1161 
 
 trigeminal, 335 
 Neurasthenia, traumatic, 640 
 Neurectomy, 333 
 Neuritis, 331 
 Neuroma, 167-169, 328 
 Neuropathic arthritis, 603 
 Neurotomy, 333 
 Nipple, affections of, 866 
 Nitrous oxide gas, 1185 
 Nodes, 511, 513, 520, 711, 61 
 Noma. See Cancrum oris 
 Nose, affections of (Chapter XXVI. ), 
 753-771 
 
 Oblique inguinal hernia, 975 
 Obstructed hernia, 995 
 Obstruction, intestinal (Chapter 
 
 XXXIV.), 1009-1024 
 Obturator hernia, 994 
 Obturators for palate, 797 
 Occipital artery, compression of, 237 
 ligature of, 286 
 lobe, injuries of, 700 
 Odontomata, 170, 747, 748 
 O'Dwyer's tube, 853 
 CEdema, lymphatic, 315 
 malignant, 82 
 of brain, 695 
 
 CEdema of glottis. See Larynguis, 
 cedematous 
 
 of scrotum, 1164 
 CEsophagostomy, 810 
 CEsophagotomy, 807, 810 
 CEsophagus, affections of, 805 
 Ogston's operation for tiu-foot, 412 
 
 for genu valgum, 397 
 Olecranon, fracture of, 460 
 Olfactory nerve, affections of, 334 
 Omental adhesions, 1010 
 
 hernia, 973, 984 
 
 tumour, 898, 899 
 Onychia, 360 
 Oophorectomy, for osteo-malacia, 530 
 
 in cancer of breast, 890 
 Operation for cerebral tumours, 716 
 Operations, general antiseptic methods 
 for, 16-19 
 
 general remarks on abdominal, 966 
 Ophthalmoplegia externa, 335 
 Opisthotonos, 109 
 Optic nerve, affections of, 334 
 
 neuritis, 93, 334, 715, 720, 818, 820 
 Orbital cellulitis, 93 
 Orchitis, 1146 
 Ormsby's mask, 1188 
 Os cilcis, fracture of, 493 
 
 tuberculous disease of, 516 
 
 incisivum, 724, 726, 728 
 
 magnum, dislocation of, 559 
 Ossicles, necrosis of, 815 
 Osteitis, 497, 499 
 
 deformans, 520 
 
 tuberculous, 514 
 Osteo-aneurism, 537 
 Osteo-arthritis, 596, 577 
 
 of hip, 601 
 
 of spine, 665 
 
 of temporo-maxillary joint, 750, 602 
 Osteo - arthropathy, hypertrophic pul- 
 monary, 532 
 Osteoblasts, 434, 496 
 Osteo-chondritis, syphilitic, 523 
 Osteoclasia, 439 
 Osteoclasts, 498 
 Osteoma, 164 
 
 of antrum, 742 
 
 of lower jaw, 747 
 
 of skull, 712 
 
 of spine, 665 
 
 of upper jaw, 742 
 Osteomalacia, 529 
 Osteomyelitis, 502, 509, 434, 497, 499 
 
 gummatous, 523 
 
 of cranium, 711, 714 
 
 of spine, 650 
 Osteo-periostitis, chronic, 511 
 Osteophytes, 581, 587, 598, 603, 609, 613, 
 
 665 
 Osteoplastic section of upper jaw, 766 
 Osteoporosis, 496, 498 
 Osteo-psathyrosis, 418 
 Osteo-sarcoma. See Sarcoma of bone, 
 533 
 
[206 
 
 INDEX 
 
 Osteosclerosis, 496 
 Osteotomy, 394, 397, 399 
 
 for ankylosis, 399, 610 
 
 for genu valgum, 397 
 Otorrhcea, chronic, surgical complications 
 
 of, 814 
 Ovarian cysts, 184, 185 
 
 dermoids, 183 
 Oxalates, 1088, 1094 
 Oxyuris vermicularis, 1027 
 Oztena, 759 
 
 Pachydermatocele, 163, 707 
 Pachymeningitis, 639, 690 
 Paget's eczema of nipple, 867, 880 
 Pain in burns, 86 
 
 in gangrene, 67, 71, 75 
 
 in inflammation, 30 
 
 in Pott's disease, 653 
 Painful scar, 215, 169 
 
 stump, 1170 
 
 subcutaneous nodule, 168 
 Palate, cleft, 790 
 
 diseases of, 797 
 Palmar abscess, 208 
 
 arch, hremorrhage from, 244 
 
 fascia, contraction of, 392 
 
 ganglion, compound, 369 
 Pancreas, affections of, 964 
 Panophthalmitis, following cellulitis of 
 
 orbit, 93 
 Panostitis, 502 
 Papilloma, 171 
 
 of bladder, ic8i 
 
 of breast, 879 
 
 of kidney, 1066 
 
 of larynx, 843 
 
 of nipple, 867 
 
 of rectum, 1036 
 
 of scalp, 706 
 Paracentesis abdominis, 900 
 Paralysis, infantile, 666, 379, 399, 401, 405 
 Paralysis of gut, 897, 961, 1001, 1005, 
 1010, 1013 
 
 of larynx. See Laryngeal paralysis 
 Paraphimosis, 11 36 
 Paraplegia, 641, 643 
 
 bedsores in, 80 
 
 gravitation, 638 
 
 in Pott's disease, 657, 664 
 Parasitic cysts, 187 
 Parenchymatous glossitis, acute, 774 
 
 goitre, 830 
 
 inflammation, 35 
 Parker's tracheotomy tube, 850 
 Paronychia, 207 
 
 Parotid gland, affections of, 785 
 Parovarian cysts, 184 
 Parrot's nodes, 523 
 
 Pasteur's treatment of hydrophobia, 113 
 Patella, dislocation of, 566 
 
 fractures of, 482 
 Pathogenic bacteria, 5, 6, 8 
 Paul's tube, 931, 942, 943, 1015, 1017 
 Peau if orange in cancer of breast, £83 
 
 Pelvic cellulitis, 93, 1074, 1083 1104 
 Pelvis, fractures of, 467 
 Penis, affections of, 1135 
 Perforating ulcer of duodenum, 921, 87, 
 901 
 of foot, 355 
 Perforation of appendix, 947, 948 
 
 of gastric ulcer, 905 
 
 of intestine, 925 
 
 of palate, 797 
 Periarteritis, 250 
 Pericardial effusion, 863 
 Pericranial lipoma, 161 
 Perigastritis, 906 
 Perineal abscess, 1132 
 
 cystotomy, 1079, 1075, 1085, IT14 
 
 fistula, 1108, 1116, 1122, 1132, 1134 
 
 section, 1131 
 Perinephritic abscess, 1058, 1052, 1055, 
 
 1059, 1062 
 Perinephritis, 1058 
 Perineuritis, 331 
 Periosteal sarcoma, 535 
 Periostitis, acute, 499, 500, 502, 711 
 
 albuminosa, 505 
 
 chronic, 511, 520, 711 
 
 tuberculous, 513 
 Peripheral neuritis, 1093 
 Periproctitis, 1027 
 Peritonism, 897, 969 
 
 Peritonitis, 893, 895, 947, 949, 1005, 
 1006, 1014 
 
 tuberculous, 899 
 Perityphlitis, 945 
 Permanganate of potash, 16 
 Peroneal artery, ligature of, 297 
 Peronei, tenotomy of, 371 
 Peroneus longus, dislocation of tendon of, 
 
 3 6 4 
 Peroxide of hydrogen, 16 
 
 Pes cavus, 412 
 
 Petechise, 222, 7, 101, 104 
 
 Phagedena, 125, 83, 66 
 
 Phagocytosis, 12 
 
 Phalanges, amputation of, 1170 
 
 dislocation of, 559 
 
 excision of head of, 415 
 
 fractures of, 467 
 Phantom tumour, 894 
 l'haryngotomy, subhyoid, 844 
 
 transhyoid, 844, 804 
 Pharynx, affections of, 802 
 Phelp's box, 65i 
 
 operation (talipes), 408 
 Phimosis, 1135, 971, 983, 1084 
 Phlebitis, 302, 103 
 Phleboliths, 300, 306 
 Phlegmonous inflammation, 35, 90 
 Phosphates in urine, 1089, 1095, 529 
 Phosphatic calculi, 1095 
 Phosphorus necrosis of jaw, 739 
 Phrenic nerve, injury to, 343 
 Picric acid in treatment of burns, 88 
 Pigeon breast, 525 
 Piles, 1044 
 
INDEX 
 
 1207 
 
 Pirogoff's amputation, 1178 
 
 Pistol splint, 465 
 
 Plantar arch, hemorrhage from, 244 
 
 Pleurosthotonos, 109 
 
 Plexiform angioma, 170, 706 
 
 neuroma, 169 
 Pneumatocele capitis, 713 
 Pneumectomy, 862 
 Pneumocele, 857 
 Pneumococcal arthritis, 585 
 Pneumococcus, 44, 506, 585, 639, 859 
 Pneumogastric nerve, affections of, 342 
 Pneumothorax, 854, 856, 901 
 Pneumotomy, 861 
 Poisoned wounds, 205 
 Polydactylism, 389 
 Polyorchism, 1142 
 Polypus of antrum, 740 
 
 of ear, 815 
 
 of nose, 762 
 
 of rectum, 1035, 1032, 1045 
 
 of umblicus, 894 
 
 of urethra, 11 n, 1120 
 Pons Varolii, injuries to, 700 
 Popliteal aneurism, 280 
 
 artery, ligature of, 295 
 
 bursas, 376 
 Post-mortem wounds, 206 
 Pott's disease, 650 
 
 fracture, 489 
 
 puffy tumour, 690 
 Priapism, 637, 640, 644, n 13 
 Primary arterial hemorrhage, 235 
 
 calcareous degeneration ol arteries, 
 
 255 
 
 union of wounds, 211 
 Proctectomy, 1038 
 Proctitis, 1027, 120 
 Prolapse of anus, 1047, 1045 
 
 of intestine, 893, 944 
 
 of lung, 858 
 
 of rectum, 1047 
 Proptosis, 8315 
 Prostate, affections of, 1107- n 16 
 
 senile enlargement of, 11 10 
 Prostatectomy, n 15 
 Prostatotomy, 11 14 
 Protective albumens, 13 
 Protozoa, 22 
 Proud flesh, 64 
 Pseud-arthrosis, 436, 546 
 Pseud-elephantiasis, 315, 61 
 Pseudo-neuroma, 167 
 Pseudo-paralysis, syphilitic, 524 
 Psoas abscess, 657, 662, 51, 990 
 Psoriasis linguag, 776, 
 
 syphilitic, 129 
 Psorosperms, 22, 174 
 Ptomaines, 4 
 Ptosis, 334 
 
 Pubic dislocation of hip, 565 
 Pudic artery, haemorrhage from, 244, 1104 
 
 ligature of, 292 
 Pulled elbow, 558 
 Pulmonary haemorrhage, 854, 857 
 
 Pulpy disease of synovial membrane, 586 
 Pulsating empyema, 858 
 
 exophthalmos, 275 
 tumours of bone, 537 
 of scalp, 705, 706 
 Punctured fracture of skull, 674 
 wounds, 200 
 
 of chest, 855 
 of heart, 862 
 of intestine, 924 
 Pus in acute abscess, 47 
 in chronic abscess, 51 
 in hepatic abscess, 956 
 Pustule. See Malignant pustule 
 Pyaemia, 103-107, 100, 301, 304, 434, 506, 
 509, 548, 580, 694, 711, 785, 820, 955, 
 1044 
 Pyasmic joints, 585 
 Pyelitis, 1055 
 
 Pyelonephritis, 1056, 1078, n 12, 1123 
 Pylephlebitis, 104, 300, 949, 955, 1044 
 Pylorectomy, 917, 911, 912 
 Pyloroplasty, 917, 912 
 Pylorus, affections of, 911, 907 
 Pyogenic organisms, 43 
 Pyonephrosis, 1057, 11 12 
 Pyorrhoea alve ilaris, 736 
 Pyrexia. See Fever 
 Pyuria, 1091, 1109 
 
 Quiet necrosis. See Necrosis 
 Quilled suture, 194 
 Quincke's lumbar puncture, 692 
 Quinsy, 799 
 
 Rabies, 112 
 
 Racquet method of amputation, 1167 
 
 Radial artery, compression of, 237 
 
 ligature of, 290 
 Radical cure of hernia, 983, 991, 993, 1005 
 
 of hydrocele, 1157, 1158 
 Radius, congenital absence of, 389 
 
 dislocations of, 557 
 
 fracture of, 462 
 
 separation of lower epiphysis, 465 
 Railway spine, 640 
 Ranula, 784 
 
 Rarefaction of bone, 496, 498 
 Rashes of syphilis, 127 
 Ray fungus, 148 
 Raynaud's disease, 77, 1091 
 Reaction, 216, 685 
 
 of degeneration, 329 
 Reactionary haemorrhage, 238 
 Recklinghausen's disease, 168 
 Recto-vaginal septum, wound of, 1141 
 
 vesical fistula, 103 7, 1083, 1104, 1164 
 Rectum, affections of (Chapter XXXV.), 
 
 1025- 1049 
 Rectus abdominis, injuries of, 893, 894 
 Recurrent dislocations, 396, 544, 548 
 
 fibroid, 157, 880 
 
 haemorrhage, 238 
 Redness in inflammation, 29 
 Regeneration of nerves, 329 
 
1208 
 
 INDEX 
 
 Reid's lines, 702 
 Rendel's mask, 1188 
 
 Repair of bone after caries, 498, 652, 654 
 after fractures, 425, 434 
 after necrosis, 498-502, 508 
 
 of muscle, 364 
 
 of tendon, 364 
 
 of wounds, 208 
 Resection. See Excision 
 Residual abscess, 52, 659 
 
 urine, 1085 
 Resolution in inflammation, 28 
 Respiration, artificial, 864 
 Retained testis, 1142, 980 
 Retention cysts, 186, 872 
 
 of urine, 1086, 643, 1112, 1130 
 Retro-peritoneal abscess, 901, 948 
 
 pharyngeal abscess, 805, 656 
 Rhabdomyoma, 167 
 Rhagades, 137 
 Rheumatic arthritis, 583 
 Rheumatic gout. See Osteo-arthritis, 596 
 
 spondylitis, 664 
 
 synovitis, 583 
 Rheumatoid arthritis. See Osteo-arthritis, 
 
 596 
 Rhinitis, 757, 120, 138 
 Rhinophyma, 754 
 Rhinoplasty, 755 
 Rhinoscopy, 756 
 Ribs, fracture of, 444 
 Richter's hernia, 996, 999 
 Rickets, 524, 382, 386, 393, 394, 400 
 Riggs's disease, 736 
 Rigor, 46 
 
 Robson's (Mayo) bobbin, 937, 938 
 Rodent ulcer, 177 
 Rontgen X rays, 201, 178, 422, 457, 512, 
 
 1063 
 Rouge's operation, 766 
 Round-celled sarcoma, 155 
 Rupia, 130 
 
 Rupture. See Hernia 
 Rupture of aneurism, 262 
 
 of arteries, 256 
 
 of bladder, 1073 
 
 of gall-bladder, 957 
 
 of kidney, 1051 
 
 of intestine, 922 
 
 of liver, 953 
 
 of main artery, 246 
 
 of muscles, 364 
 
 of nerves, 326 
 
 of rectus abdominis, 894 
 
 of spleen, 965 
 
 of stomach, 902 
 
 of tendons, 364 
 
 of ureter, 1052 
 
 of urethra, 1118, 1133 
 
 of vas deferens, 1145 
 
 Sacculated aneurism, 259 
 Sacral tumour, congenital, 649 
 Sacro-iliac disease, 619 
 Sacrum, fractures of, 469 
 
 Salivary fistula, 789 
 
 calculus, 786 
 
 glands, affections of, 785-790 
 Salivation in mercuriilism, 135 
 Sanitas, 16 
 
 Saphena, varix of, 305, 990 
 Saprcemia, 6, too 
 Saprophytes, 5 
 Sarcinse, 2 
 Sarcoma, 154-160 
 
 after fractures, 428 
 
 curative action of erysipelas on, 98, 160 
 
 of bladder, 1082 
 
 of bone, 533 
 
 of brain, 715 
 
 of breast, 879 
 
 of cranium, 712 
 
 of dura mater, 712 
 
 of jaws, 738, 742, 743, 748, 749 
 
 of kidney, 1066 
 
 of lymphatic glands, 324, 156 
 
 of muscle, 367 
 
 of naso-pharynx, 764 
 
 of nose, 765 
 
 of palate. 798 
 
 of parotid, 788 
 
 of rectum, 1036 
 
 of scalp, 707 
 
 of skull, 712 
 
 of spine, 665 
 
 of spleen, 965 
 
 of testis, 1 183 
 
 of thyroid, 836 
 
 of tonsil, 801 
 Sayre's apparatus for talipes, 407 
 
 plaster jacket, 661 
 
 treatment of fractured clavicle, 448 
 Scalds, 85 
 Scalp, affections of, 705 
 
 injuries of, 667 
 Scapula, fractures of, 449 
 
 winged, 343, 551 
 Scar, affections of, 214 
 Schede's operation, 861 
 Schizomycetes, 1 
 Schwartze's operation, 816 
 Sciatica, 348, 619 
 Sciatic artery, aneurism of, 279 
 haemorrhage from, 244 
 ligature of, 292 
 
 dislocation of hip, 563 
 
 nerve, stretching of, 349 
 Scirrhous ulcer, 882 
 Scirrhus, 180 
 
 of breast, 881, 871, 873 
 
 of pancreas, 965 
 
 of prostate, 11 16 
 
 of pylorus, 908 
 Sclerosis of bone, 497, 498, 512, 522 
 Sclerotitis, gonorrhoea!, 121 
 Scoliosis, 381 
 Scrotal fistulas, 1165 
 
 tumours, 1162 
 Scrotum, affections of, 1164 
 Scurvy rickets, 528 
 
INDEX 
 
 1209 
 
 Sebaceous cysts, 361 
 of neck, 825 
 of nipple, 867 
 of scalp, 707 
 Sebaceous glands, cancer of. See Rodent 
 ulcer 
 
 horn, 361, 1 139 
 Secondary hcemorrhage, 239 
 Semilunar cartilage, dislocation of, 567, 607 
 Semimembranosus bursa, enlargement of, 
 
 376 
 Semimembranosus, tenotomy of, 372 
 Senile atrophy of bone, 470, 529, 709 
 
 gangrene, 74 
 
 hypertrophy of prostate, 11 10 
 
 tuberculosis, 140 
 Sepsis, 5 
 
 in treatment of chronic abscess, 52 
 
 secondary haemorrhage with, 239 
 Septic arthritis, 578 
 
 intoxication, 6 
 
 meningitis. See Meningitis 
 
 osteomyelitis. See Osteomyelitis 
 
 peritonitis. See Peritonitis 
 Septic pneumonia. 84, 441, 781, 809, 827, 
 840, 852, 855 
 
 traumatic fever, 6, 827 
 Septic wounds, 196 
 Septicemia, 100 
 Septum nasi, fracture of, 439 
 
 lateral deviation of, 759 
 Sequestra, 497, 498, 514, 515, 1169 
 Sequestration dermoids, 182 
 Sequestrotomy, 509 
 Serotherapy, 14 
 Serous cysts, 185, 825, 873, 1067 
 
 synovitis, chronic, 576, 577 
 Seventh nerve. See Facial nerve 
 Shell wounds, 204 
 Shock, 215-219 
 
 anaesthesia during, 219 
 
 from amputations, 1168 
 
 from catheterism, 1125 
 
 in abdominal surgery, 892, 893, 902, 
 905, 922, 926, 954, 960, 965, 966 
 
 in burns, 87, 89 
 
 in intestinal obstruction, 999, 1010 
 
 use of saline injections in, 219 
 Shoulder-joint, acute arthritis of, 581 
 
 amputation through, 1173 
 
 ankylosis of, 609 
 
 dislocation of, 551 
 
 effusion into, 574 
 
 excision of, 621 
 
 tuberculous disease of, 593 
 Sinus, 56 
 
 Sixth nerve, affections of, 340 
 Skin grafting, 64, 707, 754, 890 
 
 purification of, 18 
 
 surgical diseases of (Chapter XIV. ), 
 35!-3 6 2 
 Skull, affections of, 707 
 
 injuries to, 668 
 Sloughing of flaps, 1170 
 Smith's (Stephen) amputation, 1179 
 
 Snake-bites, 205 
 
 Snap-finger, 391 
 
 Socin's operation, 834 
 
 Soft chancre, 1137 
 
 Softening, yellow, of brain, 696 
 
 Sounding bladder, 1097 
 
 Spasm of oesophagus, 808 
 
 Spasmodic stricture of urethra, 1120 
 
 Spasmodic stump, 1170 
 
 Spence's operation, 1173 
 
 Spermatic cord, hajmatocle of, 1145 
 
 hydrocele of, 1158, 185 
 
 torsion of, 1143 
 Spermatocele, 1158 
 Spina bifida, 646, 401 
 
 occulta, 649 
 ventosa. See Tuberculous dactylitis, 
 
 Spinal accessory nerve, aft ctions of, 343 
 
 stretching of, 343, 381 
 Spinal cord, diseases of, 665, 666 
 
 haemorrhage, 637 
 
 injuries of, 637 
 
 pressure on, in Pott's disease, 
 657, 664 
 
 total transverse lesion of, 642 
 Spine, deformities of, 381 
 
 diseases of (Chapter XXII.), 646-666 
 injuries to (ChapterXXI. ), 628 645 
 Spirilla, 2 
 
 Splay-foot. See Flat-foot 
 Spleen, affections of, 965, 54 
 Splenectomy, 965 
 Splenopexy, 965 
 
 Splint pressure causing gangrene, 80, 433 
 Splints, uses of, 429 
 Spondylitis, rheumatic, 664 
 Spondylolisthesis, 388 
 Sponges, method of purifying, 17 
 Spongy gums, 725, 135 
 Spontaneous fracture, 418, 261, 529, 533 
 
 gangrene, 77 
 Spore formation in bacteria, 4 
 Sprains, 363, 539, 628 
 Spreading gangrene, acute, 81, 433 
 Spreading oedema, 695 
 Sprengel's shoulder, 388 
 Spring-finger, 391 
 Stabs, 200 
 
 Stacke's operation, 818 
 Staphylococci, 1, 6, 43, 90, 103, 351, 352, 
 
 S05. 509 
 Staphylorraphy, 796 
 Starch bandage, 430 
 Stercoral ulcers, 997, 1034, 1038 
 Sterno-mastoid, action of, in torticollis, 378 
 
 congenital induration of, 823, 379 
 
 tenotomy of, 380 
 Sternum, fractures of, 445 
 Stewart's treatment of aneurisms, 268, 
 
 272, 276 
 Sthenic fever, 32 
 Stings, 205 
 Stomach, affections of, 902 
 
 operations on, 912 
 
INDEX 
 
 Stomatiiis, 772 
 
 mercurial, 135 
 Stone. See Calculus 
 Strain, 246, 257, 326, 363, 539, 628 
 Strangulated hernia, 996, 1008 
 Strangulation, internal, 1010, ion 
 Strangury, 1063, 1077 
 Streptococci, 2, 6, 83. 43, 90, 94, 100, 103, 
 
 160, 505, 578, 895, 946 
 Stricture of appendix, 947, 949 
 
 of bile duct, 963 
 
 of intestine, 926, 1016, 1021 
 
 of oesophagus, 808 
 
 of pylorus, 911 
 
 of rectum, 1033 
 
 of urethra, 11 20 
 Stumps (amputation), affections of, 1169 
 Styptics, 230 
 Subaponeurotic abscess, 705 
 
 hrematoma, 668 
 Subastragaloid amputation, 1177 
 
 dislocation, 571 
 Subclavian artery, aneurism of, 275 
 
 compression of, 237 
 
 ligature of, 287, 271, 272, 276, 277 
 Subclavicular dislocation of the shoulder, 
 
 554 
 Subcoracoid dislocation of the shoulder, 
 
 553 
 Subcranial abscess, 690, 677, 694, 720, 
 818 
 
 inflammation, 690 
 Subdeltoid bursa, affections of, 377, 574 
 Subglenoid dislocation of the shoulder, 
 
 552 
 Sublingual abscess, 783, 93 
 Subluxation of head of radius, 558 
 
 of knee, 567 
 Submammary abscess, 868, 872 
 Submaxillary cellulitis, 93 
 Subphrenic abscess, 900, 948 
 
 pyopneumothorax, 901 
 Subserous lipoma, 162, 993 
 Subspinous dislocation of the shoulder, 
 
 554 
 Subungual exostosis, 165 
 Sulphur in chronic abscess, 56 
 Superior maxilla, affections of, 739, 704 
 
 excision of, 744 
 
 fracture of, 440 
 Suppression of urine, 1057, 1126 
 Suppuration (Chapter III.), 41-57 
 Supracondyloid amputation of thigh, 1180 
 
 fracture of femur, 481 
 of humerus, 456 
 Supracoracoid dislocation of the shoulder, 
 
 554 
 
 Supra-orbital nerve, operations on. 336 
 
 Suprapubic aspiration, 1131 
 
 cystotomy, 1105, 1075, 1080, 1084 
 puncture for enlarged prostate, 11 16 
 
 Supratrochlear nerve, operations on, 
 
 337 
 Sutures, 193 
 
 intestinal, 929 
 
 Sylvester's method of artificial respiration, 
 
 865 
 Syme's amputation, J177, 518 
 horseshoe splint, 492 
 operation for restoration of lip, 734 
 
 of urethrotomy, n 29 
 treatment of chronic ulcers, 63 
 Symonds' tube, 810, 811 
 Sympathetic nerves, affections of, 350, 
 168, 271, 835 
 
 in shock, action of, 217, 891, 
 1023 
 Symptomatic gangrene, 72 
 Syncope, 216 
 Syndactylism, 390 
 Synostosis, 608 
 
 Synovial membrane, pulpy disease of, 586 
 Synovitis, acute, 573 
 chronic, 576 
 gonorrhoeal, 121, 585 
 syphilitic, 595 
 Syphilis, 121 
 Syphilitic affections of anus, 1034 
 
 of arteries, 254, 256, 131 
 
 of bone, 520 
 
 of breast, 867, 872 
 
 of bursas, 375 
 
 of cranium, 522, 712 
 
 of epididymis, 1150 
 
 of intestine, 926, 1034 
 
 of joints, 595 
 
 of larynx, 842 
 
 of lip, 731 
 
 of lymphatic glands, 125, 128, 319 
 
 of meninges, 693, 703, 715 
 
 of muscles, 367 
 
 of nerves, 326, 331 
 
 of nipple, 867 
 
 of nose, 753, 761 
 
 of palate, 797 
 
 of pharynx, 803 
 
 of rectum, 1034 
 
 of spine, 639, 664, 665 
 
 of testis, 1 150 
 
 of tongue, 775, 777 
 
 of tonsil, 801 
 Syphilitic ulcers, 66, 131, 132 
 Syringo-myelia, joint lesions in, 604 
 Syringo-myelocele, 646 
 
 Taenia echinococcus, 157, 958, 301 
 Tagliacozzian operation, 755 
 Talipes, 400, 666, 647 
 Tarsectomy, 408 
 Tarsus, amputation through, 1176 
 
 tubercle of, 515 
 Taxis, 1000 
 
 Teale's amputation, 1168, 1179 
 Teeth in congenital syphilis, 139 
 
 in rickets, 525 
 
 tumours in connection with. See 
 Odontomata 
 Temporal artery, compression of, 237 
 
 ligature of, 286 
 Temporo-maxillary joint, diseases of, 750 
 
INDEX 
 
 Temporo-maxillary joint, injuries of, 548 
 
 Tracheotomy, 847, 839 
 
 osteoarthritis of, 652 
 
 Tracheotomy, preliminary, 744, 780, 
 
 Tendo Achillis, rupture of, 366 
 
 804 
 
 tenotomy of, 371 
 
 Traumatic aneurism, 247, 249 
 
 Tendon sheaths, diseases of, 368 
 
 delirium, 220, 422 
 
 Tendons, displacement of, 363 
 
 epilepsy, 703 
 
 operations on, 365, 370, 372, 373 
 
 fever, 6, 219, 220, 422 
 
 Tenoplasty, 373 
 
 gangrene, 72, 78, 80, 81. See Gan- 
 
 Teno-synovitis, 368 
 
 grene 
 
 Tenotomy, 370, 666 
 
 insanity, 704 
 
 of sterno-mastoid, 380 
 
 neuroma, 169, 328 
 
 Testicle, affections of (Chapter XXXIX. ), 
 
 Transfusion, 224 
 
 1142-1165 
 
 Transhyoid pharyngotomy, 804 
 
 Tetanus, 107- 112 
 
 Transillumination of antrum, 741 
 
 neonatorum, 894 
 
 Trendelenburg's position, 1105 
 
 Tetany, 834 
 
 trachea tampon, 781, 808 
 
 Thecal whitlow, 208 
 
 Trephining, 678, 679, 682, 683, 690, 697, 
 
 Thiersch's method of skin-grafting, 65 
 
 704, 713, 716, 721, 820, 821 
 
 of nerve extraction, 333 
 
 Trigeminal neuralgia, 335 
 
 Thigh, amputation of, 1181 
 
 Trismus, 109, 149, 751 
 
 Third nerve, affections of, 334 
 
 Trochanter, fracture of, 478 
 
 Thomas's hip-splint, 617, 475, 662 
 
 Tropical abscess of liver, 955 
 
 knee-splint, 594 
 
 Trusses, 981, 991 
 
 wrench, 412 
 
 Tuberculous abscess, 50, 143, 662 
 
 Thoracic duct, wound of, 313 
 
 disease of bladder, 1080 
 
 Thorax, deformities of, in adenoids, 768 
 
 of arteries, 254 
 
 in rickets, 525 
 
 of bone, 513 
 
 punctured wounds of, 855 
 
 of brain, 715 
 
 Thrombosis, arterial, 75, 76, 79, 246, 255 
 
 of breast, 871, 872 
 
 of cerebral sinuses, 680, 694, 761, 
 
 of burste, 375 
 
 820 
 
 of cranium, 711 
 
 of lateral sinus, 694, 820 
 
 of epididymis, 1148 
 
 venous, 298 
 
 of hip-joint, 611 
 
 Thrush, 772 
 
 of intestine, 925, 926 
 
 Thumb, amputation of, 1171 
 
 of joints, 586 
 
 dislocation of, 559 
 
 of kidney, 1059 
 
 Thyroid body, diseases of, 828 
 
 of larynx, 842 
 
 Tlyroid cancer of bone, 537 
 
 of liver, 959 
 
 Thyroidectomy, partial, 833 
 
 of lymphatic glands, 319 
 
 Thyroid dislocation of hip, 564 
 
 of mastoid, 876 
 
 Thyroid vessels, ligature of, 288, 836 
 
 of mucous membrane, 359 
 
 Thyro-glossal duct. See Cyst of, 823 
 
 of peritoneum, 899, 895 
 
 Thyrotomy, 845 
 
 of prostate, 1109 
 
 Tibia, fracture of, 487 
 
 of sacro-iliac joint, 619 
 
 rachitic, 400 
 
 of skin, 356 
 
 syphilitic, 400, 520, 524 
 
 of spine, 650 
 
 Tibial arteries, compression of, 237 
 
 of tarsus, 515 
 
 ligature of, 296, 297 
 
 of temporo-maxillary joint, 751 
 
 nerves, affections of, 350 
 
 of testis, 1 148 
 
 Tic douloureux, or epileptiform tic, 335 
 
 of tongue, 777 
 
 Tic, facial, 342 
 
 of vesiculas seminales, 1164 
 
 Toenail, ingrowing, 360 
 
 dactylitis, 514 
 
 Toes, amputation of, 1174 
 
 empyema, 859 
 
 Toes, deformities of, 413-416 
 
 endarteritis, 142, 254 
 
 Tongue, affections of, 773-783 
 
 ischio-rectal abscess, 1028 
 
 Tonsil, affections of, 798 
 
 lupus, 356 
 
 Topography, cerebral, 701 
 
 teno-synovitis, 368 
 
 Torsion, 231 
 
 ulcers, 359, 66 
 
 Torsion of testicle, 1143, 1006 
 
 Tuberculated leprosy, 146 
 
 Torticollis, 378, 823 
 
 Tuberculosis, 140 
 
 Tourniquets, 237, 1169, 1181 
 
 acute miliary, 659 
 
 Toxins, 4 
 
 Tubulo-dermoids, 183 
 
 Trachea, foreign bodies in, 839 
 
 Tumour, congenital sacral, 649 
 
 wounds of, 826 
 
 Pott's puffy, 690 
 
 Tracheal tug, 270, 273 
 
 Tumours (Chapter VII.), 150-181 
 
INDEX 
 
 Tumours of adrenals, 1066 
 
 of antrum, 742 
 
 of bladder, 108 1 
 
 of bone, 533 
 
 of brain, 714, 720 
 
 of breast, 874 
 
 of cranium, 712 
 
 of frontal sinuses, 714 
 
 of gum, 737 
 
 of intestine, 927 
 
 of kidney, 1065 
 
 of larynx, 843 
 
 of lip, 732 
 
 of liver, 959 
 
 of lymphatic glands, 322 
 
 of mandible, 747 
 
 of maxilla, 742 
 
 of muscle, 367 
 
 of nipple, 867 
 
 of nose, 754, 764, 765 
 
 of oesophagus, 808 
 
 of palate, 798 
 
 of pancreas, 965 
 
 of parotid, 787 
 
 of penis, 1139 
 
 of pharynx, 804 
 
 of prostate, 1110, 1116 
 
 of pylorus, 910 
 
 of rectum, 1035, 1104 
 
 of scalp, 705 
 
 of scrotum, 1162 
 
 of spine, 665, 659 
 
 of spleen, 965 
 
 of stomach, 907 
 
 of sub-maxillary gland, 789 
 
 of testis, 1152 
 
 of thyroid gland, 828 
 
 of tongue, 778 
 
 of tonsil, 801 
 
 of urethra, 1120 
 Typhlitis. See Appendicitis 
 Typhoid disease of joints, 585 
 
 osteitis, 510 
 
 state, 33 
 
 ulcer, perforation of, 925 
 
 Ulceration (Chapter IV.), 58-66 
 Ulcer of anus, 1032, 1036 
 
 of bladder, 1080 
 
 of duodenum, 921, 87 
 
 of intestine, 901, 926, 927, 997, 
 1001 
 
 of palate, 797 
 
 of scars, 215 
 
 of stomach, 903 
 
 of tongue, 777 
 Ulcers, perforating, of duodenum, 87, 
 921, 901 
 
 of foot, 355 
 
 phagedenic, 125 
 
 scirrhous, 882 
 
 tuberculous, 66, 359, 777, 843 
 Ullman's operation, 934 
 Ulna, dislocation of, 557, 559 
 
 fracture of, 460 
 
 Ulnar artery, compression of, 237 
 ligature of, 290 
 nerve, affections of, 347 
 Umbilical hernia, 991 
 Umbilicus, affections of, 894 
 Unna's treatment of ulcers, 62 
 Ununited fracture, 436 
 Uranoplasty, 794 
 Ureter, rupture of, 1052 
 Urethra, affections of, n 17 
 Urethral fever, 1114, 1126 
 Urethritis, 116, 1126 
 Urethrotomy, 1128, 1129 
 Uric acid and urates, 1087, 1094 
 Urinary deposits, 1087 
 Urine, abnormalities of, 1087 
 Uvula, elongation of, 798 
 Urinary fever, 1077, 1100 
 
 Vaginal hydrocele, 1155 
 Varicocele, 981, 1159, 1067 
 Varicose aneurism, 250 
 
 eczema, 62, 306 
 
 ulcers, 61, 306 
 
 veins, 304, 300, 808, 1044, 1122, 1159 
 Varix, 304 
 Vasectomy, 1116 
 Veins, affections of (Chapter XL), 298- 
 
 311 
 entrance of air into, 242, 680, 826, 
 
 851 
 Venesection, 310 
 Venous haemorrhage, 222, 241 
 
 sinuses, thrombosis of. See Throm- 
 bosis of 
 wounds of, 680 
 Ventral hernia, 993, 953, 893 
 Vermiform appendix. See Appendicitis 
 Verruca necrogenica, 206, 356 
 Vertebral artery, haemorrhage from, 243 
 
 ligature of, 287 
 Vesical calculus. See Calculus 
 
 fistula. See Fistula 
 Vesiculas seminales, affections of, 11 64 
 Vicious union of fractures, 438 
 Villous tumour of bladder, 1081 
 
 of rectum, 1036 
 
 of pelvis of kidney, 1066 
 Vocal cords, paralysis of. See Laryngeal 
 
 paralysis 
 Volvulus, 1011 
 Vomiting after concussion, 685 
 
 after shock, 217 
 
 anaesthetic, 1189 
 
 cerebral, 715, 719 
 
 faecal, 999, 1010, 1023 
 
 in intestinal obstruction, 1010, 1023 
 
 in peritonitis, 896 
 
 in strangulated hernia, 999, 1005, 
 1010 
 
 persistent, after taxis, 1001, 1023 
 
 with moveable kidney, 1051 
 Von Hacker's method of gastroenter- 
 ostomy, 919 
 Vulva, affections of, 1140 
 
INDEX 
 
 1213 
 
 Wagstaffe's fracture, 487 
 
 Wardrop's operation for aneurism, 266, 
 
 272 
 Warts. See Papilloma, 171, 355 
 
 anatomical, or butchers', 206, 356 
 
 malignant, 175 
 
 on lip, 733 
 
 venereal, 1139 
 Wax in ear, 813 
 Weak ulcer, 64 
 Webbed fingers, 390 
 Wheelhouse's operation, 1130 
 Whitehead's operation on haemorrhoids, 
 1047 
 on tongue, 780 
 White swelling, 586 
 Whitlow, 207 
 
 Witzel's method of gastrostomy, 916 
 Wolffian body, cysts of, 184, 1158 
 Wolfler suture, 931 
 Wolfler's operation of gastroenterostomy, 
 
 918, 920 
 Wool-sorter's disease, 115 
 Wool truss, 982 
 Wound phagedena, 83 
 Wounds (Chapter VI 1 1.), 190-221 
 
 of abdominal walls, 891 
 
 of air passages, 826 
 
 of arteries, 246 
 
 of bladder, 1073 
 
 of brain, 694 
 
 of gall bladder, 959 
 
 of heart, 862 
 
 of intestine, 921 et seq. 
 
 of joints, 539 
 
 of kidney, 1051 
 
 of larynx, 826, 840 
 
 Wounds of liver, 953 
 
 of lung, 854 
 
 of muscles, 363, 364 
 
 of nerves, 326, 327 
 
 of pancreas, 964 
 
 of recto-vaginal septum, 1141 
 
 of scalp, 667 
 
 of scrotum, 1164 
 
 of spine, 630 
 
 of spleen, 965 
 
 of stomach, 902 
 
 of testis, 1144 
 
 of throat, 825 
 
 of tongue, 774 
 
 of trachea, 826 
 
 of ureter, 1052 
 
 of urethra, 1118 
 
 of veins, 241, 249, 680 
 
 of vulva, 1141 
 Wrist-drop, 345 
 Wrist-joint, acute arthritis of, 582 
 
 amputation at, 1172 
 
 ankylosis of, 609 
 
 dislocation at, 559 
 
 effusion into, 574 
 
 excision of, 623 
 
 tuberculous disease of, 593 
 Wry-neck. See Torticollis 
 Wyeth's method of preventing hnemor 
 rhage, n8i 
 
 Xanthine, 1095 
 
 Yeasts, 22 
 
 Zooglcea, 2 
 
 Zygoma, fracture of, 440 
 
 THE END 
 
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