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iL^f&amgi 




Dr . d . '« . ' Jaiinon , 




r 



A MANUAL OF SURGERY 
#or Stu^ente and f)»ctltioncTd 



A 



MANUAL OF SURGERY 



fov StuEtentd and practitioners. 



(fj^jCt^^ $IAA^^ 



•^ 



BY 

WILLIAM 5OSE, M.B., B-S. Lond., F.R.C.S., 

PRort^sai o* Climical Surokw ik Kisr^'a Collcce, LnM>OK, and Skhioh Suigiov 
TO King's Collicb Hospltau irc-. 

AND 

ALBERT CARLESS. M.S. Lond., F.RX.S., 

SEHroB Assist* NT'St'»^»o?i to Kiwo't CotLPCK Hmpit*l, and Tvachep 

Of OpEltATIVM ScJilGlKV IP KlXb's CoLLlGEj LoKDO>, ITC^ 



NEW YORK: 

WILLIAM WOOD & COMPANY. 

i8q8. 



1 »» 



»>r 



"i I 






TO 

LORD LISTER, ll-jj., f.r.s., 

PmidtHf ef thi Royal Society, 

THE FATHER OF ANTISEPTEC SURGERY, 

THIS WORK IS, WITH PERMISSION, 

Stdtrateu bp tift flutlfortf, 

TN GRATEFUL ACKNOWLEDGMENT OF THE MANY ADVANTAGES 

THEY HAVE DERIVED 

WHILST ASSOCIATED WITH HIM IN HIS WORK 

AT K1>Jg's college HOSPETAL, 



<:-23i^ 



PREFACE 



In prepanng 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- 
lilioner 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 ihat we have only been able to sketch in out- 
lint much that could have been elaborately described did the 
si^e 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 o£ surgical work that many 
of the traditions and theories of the past have had to be discarded, 



¥i PREFACE 

although at the same time we have endeavoured to preserve aod 
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 pT(x>fs of the sections 
devoted to Che nose and ear; to Dr. Silk, who has fulfilled a 
similar ofhce in reference to the chapter on anaesthetics; to Mr. 
William Turner for preparing the index ; and to Dr. Arthur 
Grifliths, 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, Longman and Co. ; and from the editors of the 
Lancet for the loan of Fig. 287. The various sources from which 
these are derived are acknowledged throughout the book. Illus- 
trations of instruments are mainly derived from Messrs^ Down 
Brothers, who have kindly placed them at our disposal, 

W, ROSE, 

17, Hahley Street, W. 

a. carless. 

10, Weldeck Street, \V. 
London, 

May T, 1S98. 



CONTENTS 



CHArTKH fACI 

I. INPLAMMATION^BACTERU - - - - Q 

II, SUPPURATION, ACUTE AND CHRONIC - ■ 34 

III. ULCERATtOS- - - - - " 5^ 

IV, GANGRENE - - - - - "63 
V. SEPSES AND INFECTION - - - - 89 

VI. TUMOURS AND CYSTS - - , - 133 

VII. WOUNDS ,----- 1^3 

VIM. K.CMORRHAGE ..... 210 
[X. INJURIES AND DISEASES OF ARTERIES — ANEURISM 

LIGATURE OF VESSELS . - - ■ 335 

K. AFFECTIONS OF VEINS . . - - 2gQ 

XI. DISEASES OP LYMPHATIC VESSELS AND GLANDS ' 305 
XII. AFFECTIONS OF NERVES — OPERATIONS, ETC., ON 

SPECIAL NERVES - . - - - 318 

Xin. AFFECTIONS OF MUSCLES, TENDONS, AND BURSj« - 344 

XIV. INJURIES OF BONES — FRACTURES - - " 357 

XV. INJURIES OF JOINTS — -DISLOCATIONS - ' 4^8 

XVI. HEAD INJURIES - - , - - 460 

XVII. INJURIES OF THE SPINE - - - - 499 

XVIII, DISEASES OF BONE . - - . - 517 

XIX. DISEASES OF JOINTS — EXCISIONS - - " 5^6 

XX. DEFORMITIES - . , - - 606 
X.\l. AFFECTIONS OF THE SCALP, CRANIUM, AND CRANIAL 

CONTENTS ------ 641 

XXII. AFFECTIONS OF THE FACE, LlPS, AND JAWS " 652 



CONTENTS 



XXlll. AFFECTIONS OF THE SOSE AND NASO-PHARVNX - 68l 

XXIV. AFFECTIONS OF THE MOUTH, TONGUE, THFOAT, AND 

(ESOPHAGUS - . > - - 6gg 

XXV. DISEASES OF THE EAR - - - - y^^ 

XKVl. SURGERY OF THE NECK - > . - j^g 

XXVIl, SURGBftV OF THE AIR-PASSAGBS, LUNGS, AND CHEST 763 

XXVIII. DISEASES OF THE BREAST - - - - ygi 

XXIX. DISEASES OF THE SPINE - - - - 8l2 

XXX- ABDOMINAL SURGERY - - _ . ^jj 

XXXl. HERNIA ------ go^ 

XXXII. INTESTINAL OBSTRUCTION - - - . 9^.2 

XXXIII. AFFECTIONS OF THE RECTUM AND ANUS - ■ 958 

XXXIV. SURGICAL AFFECTIONS OF THE KIDNEYS - - 982 
XXXV. SURGERY OF THE BLADDER AND PROSTATE - ' IOO3 

XXXVI. AFFECTIONS OF THE URETHRA AND PENIS - - IO48 

XXXVII. AFFECTIONS OF THE TESTIS, CORD, SCROTUM, AND 

SEMINAL VESICLES - - , . 1069 

XXXVlll. VENEREAL DISEASES - - . . IO93 

XXXIX. PLASTIC SURGERY - - - - . my 

XL. AMPUTATIONS - - , . , 1121 

XLI. ANESTHESIA - - , . . j 1 ^g 

INDEX -,.-.- 11^^^ 



A MANUAL OF SURGERY. 



CHAPTER I. 

INFLAMUATION. 

* Inflammation is the succession of changes which occur in a 
Vwrn^ 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 Dr. Burdon Sanderson, and 
no belter has yet been devised, although it is now necessary to 
amplify the term * injury ' to include bacterial invasion, the 
commonest cause of the inflammatory process. Formerly inflam- 
mation was looked on by palhologists as always of a destructive 
and harmful nature, but at the present time bacteriological re- 
search has demonstrated that it is often rather of a protective 
or conser\-ative character, being Nature's means of limiting the 
advance of noxious micro-organisms, and of finally eliminating 
ihem from the system. Many theories as to the exact nature of 
rhe process have arisen from time to time, and even at the present 
day opinions on the subject are much divided. Thus, formerly it 
was considered to he a * perversion of the natural acts of nutrition 
of ihe part,' accompanied by an increased amount of tissue activity 
and cell -proliferation ; but it has been cleariy shown by Lister, 
Cohnheim, and other observers, lo be in reality associated with a 
condition of diminished vitality of the part whereby the living 
lissue is in danger of destruction, or of such changes as will render 
it incapable of again maintaining its old functions. Then, again, 
some would look on it as a primarily nervous phenomenon, the 
injury 10 the peripheral nerves leading either to vascular spasm 
01 relaxation, whilst others claim that the cells of the inflamed 
area are first affected. The most recent communications on this 
subject are rather in favour of the idea that the primary lesion is 
one of the vascular walls, and would look on inflammation as a 
disturbance of the equihbrium normally maintained l>etween the 
vessel walls and the vessel contents, whereby the latter are 



lo A MANUAL OF SURGERY 

enabled to escape into the perivascular tissues^ and there product 
the clinical effects so commonly seen. 

The actual pkenottuna of inflammation may perhaps best b* 
studied in the web of a frog's foot. If this is spread out anc 
examined under the microscope, the following evidences of 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 only occasionally seen amongst the 
red, or here and there one may be noticed rolling lazily along in 
the inert corpuscle -free peripheral portion of the tube ; (h) the 
constant changes in calibre of the arterioles independent of the 
heart's rhythmical action, and influencing in a marked degree the 
flow through the capillaries ; and [c] the changes which occur in 
tbe pigment-cells, which represent the connective tissues of the 
part. These are mainly due to the influence of light, the cells 
contracting or expanding as the light is increased or diminished. 

If now acrystal of common salt, or some such irritant, is applied 
to the web, the early vascular phenomena contributing to inflam- 
mation may be readily observed. 

I. — The Vaaculaf Ch&ngeH In Actite Influnmation, 

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 Hyp«rsmia 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- 
tions. This is a peculiarly vital phenomenon, and opposed to the 
hyarostalic 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 Wood-now is diminished. This increased rapidity of 
the flow lasts for a while, and then the current gradually becomes 
slower and slower {retardation) j as if an ever-growing obstruction 
existed to the passage of the blood ', then a period of oscitlation 
w^ill 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 ihroynbosis or intra\ascular coagula- 
tion- During this period considerable changes have occurred in 
the behaviour and condition of the vessel contents. Thus, almost 
as soon as the dilatation of the vessels occurs, the leucocytes tend 
to collect along the walls in the peripheral inert layer, seeming, 
as it were, to &11 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 each other, and to the vessel walls, running inlo 
rouleaux^ 



INFLAMMATiON ii 



The second factor in the vascular changes must now be con- 
sidered, viz., SzndatioD, a proceeding which becomes evident at a 
VK)' early stage. Every element in the constitution of the blood 
participates in this process. The leucocytes are the first to pass 
through the vessel walls, especially those of the smaller veins and 
capillaries. The process is a strictly vital one, brought about by 
amteboid movement ; a small arm or outgrowth of the leucocyte 
ip^etiJifpcdium) is inserted between the endothelial cells lining 
the i-essel, whose cohesion has been probably interfered with by 




Ffil I— DlAGRABiMATTC REPRESENT AllON Of THE VasCULAR PHENOMENA 
OF iNFLAVHATION. (AfTER KeEN AND WhTTE ) 

Two thin-waJled venules are wen, and several capLilaries The red corpuscles 
aresiiU occupying the axial portion of the rubes, whilst the periphery' 15 
crowded wiih leucocyies. which in aeveral places are in process ol migra- 
tion into tbc auiTDunding celluJar tissue 

The inflammatory process. Into this arm the protoplasm of the 
leucocyte flows, stili further separating the endothelial elements, 
and thus the cell passes through the wall into the connective 
tissues without (Fig, i\. Arnold described definite openings or 
stomata m the endothelial coat of the vessels, through which he 
^bought the leucocytes passed; but further investigations have 
not confirmed this observation. When once the white corpuscle 
has migrated into the peri-vascular tissues, it may undergo various 
changes which have only recently been clearly made out. Thus, 



IS 



A MASVAL OF SVHCRHY 



it may dj« cr b« broken uf nt once, fretting fr«« Abrin f»rm«rit, 
an^ a«^*t in Ihc prociuciion of the innnmmatory coa^Lum lo 
be »liortly described; or, aEAJn* il %^9.y sertc as pabulum for 
tht Urgcr fibroHUsii'^ rclls which soon malec; Iheir Appcarftnc«, 
afi«nK^ apparently from the miilliplicaticn of Ihc connective' tififiud 
o:itpusc1c^ in the neigh bourhooa ; or, cncc more, rtomc of Ihc 
cxude^] cells lire likely lo ii\\i\ iheir way tiiK^L ai^ain into the cir- 
culAtion ihrou^h the Jymph^dcii, and others may l>e tfannformed 
into pus coTpti£<Jcs : whilst &till many oi them prior either to dis 
integration or rrnnsformaticn into pun corpuiclcs ha\'e a function 
10 fulfil in attAirkin^ anJ renmvinK iinv iIkkI iSs-mic whicti may 
csist in the r*i^hhaiirhoo<i of the inI1amni*tory focu*. whilt! a 
phagocytic function ((^-, micrabttlcat roving, vtdt p. 17) U aJw> 
5ub»crveJ by them, hi fatU the Icututytc* niay be looked od ftS 
the M:avcngei?t dt Iht* boity. uf nt iidvuTiced vuarJs. which, ai (he 
f^tst on*>«t of Tniichi<!f,are tl^iou'n out from th« \'«^^»Uas Nattm'A 
ftr&i lint; of defence HK&i^iit i^bi; imudiu^ forces. Lhdr chiuf dutj 
twIiE^ Eo tETiiiove aU ilamdi^i-d aud itii^iioLUt lualciialbi and tUe^it 
having limited tht si^read of the d<**iTnicnv* prorpss, th'-y in mm 
give place to th& larger atid moro useful fibiobla^lic ccds wbicb 
ftrc ihc active fliEcttta tti the process of repair. 

The rfj 4t}r^u^tfi piss ihrO(ip<h x\\v vialls of the capilUrirft by* 
pmce» of diAp?dciKi«, the rr^iilc of simple mechanicAl prf»ure; 
thif> u^naijy only occurs in very Eicutc attAcks. When once 
cxteri^al 10 t)ie v-CMtIs they arc broken u^ and their colourine 
maiicT diffused abroad, acd no fiuiber pari i& known to be played 
by them. 

The li/fiior sangitinij is also extraviuatcd. Thift i» merely an 
exaegerAiEOTi of a normal pioccss, .illhg^:^'h iiMially the lymphatics 
ale ml]y c;ipnblf nf irmovJnK all th'' fluid rxidrd. In pAthalnf^icnl 
conditions the amount of pUiima which pAtaea throuj^h the walls 
hi exceujve, and nhhnu^^h for a time the lymphatics of an in- 
Aamnl rc^'iun do i[icr^(>ed woik, yet Ihe Einnscidation is soon 
gri*at^T than thrry c^in dc^il xtiih. If the tliiid rscajies into thfi 
tis^uesi. It undergoes con^ulaliun liy tneetint; the neceMiiry coagn- 
btin^; media developed from the brcakintcdoiA-n leucocytes; mfiam^ 
nMatoT^ tymfk foini^ ItMially, whilst the jrruin Lubects in the meslns* 
of the tissues, con^tiiuiing :m inflammatory form of redema : if 
there ift a suftcimt breach of surface* the serum drains nway. If 
tl)e exudation take pbce from a »croua »urfaco— tf^.> pleura, peri- 
toneum* syDovl«] membrane, etc, — (he fluid pasws into and dis- 
tendA the cavity; it is ai lir«i sponlaneoutly coagnlable, but 
sooner or later coagxdation is Idcely lo occur, and then the clot cdr 
Kmph cither forms an adherent plastic ma»s on the surface OT 

fl<:i;iU Ur-f. in th-^ fluid. 

Looked at, then, dimply frc>m a vntcuhu point of view, 



/.VFjUfJfJf^J/O.V 



IJ 



w 



N 



W 



tti ftdfition, bow«ver> 1o these vaEcuI^r phenomena, which c^n 
rsuliJy tie cbstfcvod in a frog's web, there arc Qthcr?^ which cannol 
be so easily ol>Mrved, and which may be dciicnbcd as 

H. — Hw TUau« Ohuisofi id lafiajniniktiDD. 
Gnat differences in cpiniLun Iiavc been '\u cxist<:ijf:c sLi to <he 

may rtilt be potnu to be cludcbted, vet Ihc general opinioTi of 
patboloicitts is at the prcM:r]t d-iy litlcmbly wdldciincd. I-ormcrly, 
n Accord with Virchow's cdli^lar patholo^. il wd;^ held ihaX the 
tismtffi wcrr the all-imjHiriitni Hf^menr, itnd thai ihr imnifna* 
Dumber of celU '^hkh collect in on mfljjnE;d area ^-aE entirely 
dttc to the pFohferation o( the connective -tissue corpuftclc^. 
Uslei, jjt £ir kicl( as itt^S. maiinaincd the passive camlitititi ol 
the tUuif%: and wlier Cohnhemi-in 1S67, dweribed tlie irji^ratJon 
of the leutocylei> evenrlhing m the proce;is of tnl^ammaliiin was 
aatrib^cd to them. Since that date Scnfllebcn and many other 
Ineri-Trr?^ h4\-e wurKed al the Mune piobltiii, atiil a consideiable 
of fri**h Ught ha^ hiffr\ ihrown on the subject by «xperl- 
lt» consiating in ibe insertion of for«iga bodi«a into th« p«rv 
l&btta] cavity, and hj utlicia directed towaida dcniojwliaiirjt; the 
phagocytic funillott^of leococviesanJ iheJnfluencrrof clifrmiotAXts 
tp. I?})- >luch of the dirlicuriy ubich has »n£liroiid«d the queft- 
bon bAi anacn from a contagion bc"t\\ttfn ihe processes of iaflain- 
mation and lejtair. At one litn^ lepaLr wa:> All^ay!t looked on OA 
of an ifiAAmniAtory nainr^ : biii \\ is cvir1i>iiT Th»r !kU1i<^i)^h nr> 
l«6u>n is iho body am occur wiihcut a certain amoiim of inliam- 
m&tory reaction, yet the true procc^ of repair cannot be of ihnt 
a^lLire. A^ain, il isiniporiADl lodifTncjiti^itc Iil-Iuccei ihetli^n^es 
vbich occur in nciite and chronic forms c^i inliAiiimnnrpTi, and 
between ttios« met with in ^upcrhclal and deep pArts^ -. whils^t the 
btictchal ori^ or not of the process mu9t also be lAkco into 
Mxxnuit. 

In anjif inflammation there can nnw be no quMHon thnt the 
primary etiect on the lissuefi, at any rate in infj animation!! due to 
bacterial acti%'ity, is to paralyse them : they L^ecome iniiltrated 
■ritb Icticuc^tca, and with the pt^ldtlCI^«f exudation and ufrniciobii: 
multiplication, the protoptatin within the cells coufjulaiinj^ and 
reftuaBg to lalcc up the ordinary ^it^iins, constttutm^- a conditiC5n 
knKmn tt OoagvUtion Necroeia. This neciutit: tjssne is in time 
abambnl cntiittj \ry the IcfiuorvTes, or is ]i(inefn?d by th^r pep' 
toolxug aclivitv of the bacterid toxines, so that it is repUctrd by 
A flUUS of f^naJl round c^lla, nouri^ed by the riuidri transudiiit; 
ihfuu^b iheiii, and soinclLnicb kiLuun as Embryootc TiHJiua. Ac> 
rnrrfin*: !o th^ r^Jarivf inialtiy and vi^DMr of tfir inilivi.liMl and 
the haclvriat ihf* mAsf. may ir turn ''iih<?r tx^ rf'|jl,iri\l by Lifter 
tou&d cciU derived from ihc: conacciivc tis^uc^ {^i^telfa^tt). 




A MANUAL OF SURGERY 



I 



by means of which most of the leucocytes are absorbed, ai 
repair is brought about ; or the whole mass may be liquefied ai 
break down mto pus. In non-bacterial inflammaCions of supe 
ficlal parts the amount of effusion between the individual eel 
may be so excessive as to separate and disintegrate them, an 
thus CoUlqo&tlTe NMToalB may be induced, as occurs in the form; 
tion of blisters after a bum. Once more, acute inflammation t 
mucous membranes may be associated with active proliferatio 
of the surface epirhelium. as in catarrhal and gonorrhoea! affection* 
In chronic inflammations, on the other hand, active eel 
proliferation is a most important element in the process, resultini 
m sclerosis and induration of the parts. This, however, main!; 
aflects the interstitial tissues, and thus the true structure of thr 
organ may be impaired, whilst the connective tissue increases ii 
amount. 

TerminatioiiH of Acqto InfUmmfttloii. 

These vary according to the cause of the mischief and the 
intensity of the process. They may be described under five dis- 
tinct headings : 

1. BeHolution, 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 afiecied tissues, and 
when the vascular changes have not gone further than stasis. 
When once thrombosis has occurred in a vessel, the parts can 
never be restored to the status que ante. The phenomena of reso' 
lution will be merely those of inflammation in a retrograde order — 
viz., an oscillatory movement will first manifest itself amongst 
the corpuscles, and gradually the blood-scream will be restored, 
slowly at first, and more and more rapidly afterwards. The ad- 
hesiveness of the corpuscles will disappear by degrees, and it will 
be some time before the peripheral inert layer can be seen. The 
exuded leucocytes find their way back into the circulation either 
through the vessel walls, or to a greater extent viii the lymphatics, 
or else they may be disintegrated in the tissues and absorbed. 
The fluid exudation will be removed by the lymphatics. For 
some time after an acute attack the vessels of the part remain 
somewhat dilated from simple loss of tone, but this also gradually 
disappears. 

2. Org&niE&tlon, or Pibroid TUckening, occurs when the inflam- 
matory process is not arrested until after the occurrence of throm- 
bosis, but has stopped short of suppuration. The parts under 
these circumstances cannot be restored to their original condition, 
but changes take place in the c ell ulo- plastic exudation and in 
the connective tissue around, which result in its transformation 
into cicatricial tissue, and hence the details of the process w^ill 
be similar to those described under the heading of ' Repair of 
Wounds' (Chapter VII.). 



la 



SNFLAMASATlOy 



3- Svypantton i« always Aixt to tb« invasion of lh« a01^cted 
rn{uni liy r.fTt;*in pyoge^nic mgatiisinH. uhicli act m such a manner 
a» to di&intecTAlc ;uid Uqucfy no< only th« tis^es Involved, but 
.ilso in pftTl Inc extidilion iChapUx U.j. 

4, irU«imUon i» pio^luccd by ibc ttcliun c^n the surface of citbcr 
sJcin €>c muuini mpmtiraiie of iin irviljkni of such nuturt* ;uid 
tnicnsity » to dcvtroy it« vitality. Uiough wiihouc «vi<l«ui ^ougb- 
ins (Chapter lit.), 

I 3^ Oangnne k^ 4 )(?» luiuiuuii [esuTt of iiillAmmatioa. and I5 
idue tUht; T?> ih^ activity of the vinni or ih* Af^kness of the 
tiftfrww dttaciLvd ^Cbaplvr'lV,} 

CUnlcal Slffaa of InflAnuDAtioa. 

e«« mny for pructiCAl purpo^e^ bv Jef-crib^d under th« four 
Ingi ^i^'cn of t>ld by C*Isub, \i£., huiit^ p;»m, rvdnCM, and 
nt«Uing. with tht additiun of ii fifth, viz., impair menl of function. 

MtKL^An infl^m^d p:*n frrU hoi lo ihp lonrli, anil llie tera- 
PMtura. if l*ken by a SiLirfiLco thermomeCfr, wtll 1x' dohnildy 
tmi»cd abo^^ that of the siirrouidJo^ skin. The cau^c uf tlii.i ts 
ibc uiciv4iM^ jtiiiuunt uf blood iluuiui: throut*!! it. Cuhuheini lia% 
«hoihTi tlut nnrly twicr ns much blond r«7urnii from ,in infl^mM 
paw o| a dog ns from a ticnlttiy one: W'^itbt oLhert hAv^; d«iinon- 
itmttd tbal the tcmpcrftlure of na intiamcd Area i» never liighef 
tliai of ibr Itltii^l :(l Ibv ccntn^ of Xhn uiTCulirUiDn, j>,, in the 
H >»*«'warily wherr aciivr chrmkmland pathological chAn^eB 
OccuxnnjCt ft* ^^ ^Ji intJamod ti.«Aue, a certain uniourtE of htat 
Ti produced; but it l» rcUiivcly «o tnrmLlr>jn)ii] In ctikuitlt>' l)u[ it 
may 1>^ nrgJectwL Thr caus* nf ihe incH-^wd ipnipcratnTi^ of 
the blood is ool«d dicwbcrc (p. iBJ, 

Pfeia- lliis i^ due 10 th« irritation ot the pcHphcrnl rcn'c 
tcinnDoi^ both by the nicteased iUtcrial icnMun. .mi] by the 
IwrMure of t^tf* eiud^alion. no tbal tt t* much incrr^trd if, from 
tb« deoutv of Esuoul or librrju^ in^'tslmcnt!^, nvcllin^ cannot 
ttndily occur, f^.t in the pulni oi the h^tnd, or m the eye or 
teaticie. P;iS3jbly thr rKuJjtiun ciuy have name dirvt:! iiriinimg 
>r,iioc en tbi? rerT« lermir^^tk, 

Tb« uMfCial f«aiur« of inllAmmalory pum ie tluit it i:i alwAva 
tncreasca on ptc»ure, whether intrinsic — i.e., by incrcn^ini; iht 
blood 'prcssarc— or extriiivc: from tAlvriML ap^f*iiL'i«>k Thu^, if -in 
tnflftmcd An^K or band is allowtid to Uadq doun. ib« pain i« 
much incfOAMdi wb«r««t6 el^tvaiion of the p^ic cauuc? speedy 

The pain of itifpuraitMi 19 throbbing in cturAcit-r ; of a& intlamed 
«W0st m^mltrtK/, KC^iMinAf buminif, or ^Hy : of an intUmed 
ttrmt mtmbrtiK^ ntolJiiHf; : ol inHnmcd iow^ acnin£ or borinif. and 
ohta wor»c al night ; cvf An intUmed tettkUt vdiriiJTt^, When 
tfae organs of if^itdi UHit arr? intbimod, llnu^i^ m^y Iir llttli^ mmI 





9 



l6 A MANUAL OF SURGERY 

Gin, but much exaggeration of the special sense, e.g., flashes ol 
^ht in retinitis and noises in the ears in otitis interna. 

The pain is not always limited to the inflamed part, but is often 
experienced also in distant regions, either through a similarity of 
nerve-suppZy 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 diseast the chief pain is often felt in the knee, 
because the two joints have a similar nervous supply- Thus 
the hip-joint is supplied by the great sciatic through the nerve 
to the quadratus femoris, by the anterior crural through the 
nerve to the peclineus, and by a twig of the obturator entering 
through the cotyloid notch. The knee is supplied by the great 
sciatic through the three articular branches of the popliteal, by 
the anterior crural through the nerves to the vasti, and by the 
deep branch of the obturator entering at the posterior ligament of 
Winslow. In renal calatlm 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 
referred to the terminal branches of the nerves issuing from 
the part affected, e.g., the so-called ' belly-ache ' of dorsi-lumbar 
disease. 

Rddnofta is due to the hyperxmic condition of the inflamed part i 
it is, of course, only present when tolerably superficial regions 
are involved, and its intensity varies with the stage of the innam- 
matory process. In the early active hyperemia the colour is a 
bright rosy^red, fading rapidly on pressure, and returning equally 
quickly. In the stage of retardation the redness is more dusky, 
smce the blood is longer in passing through the capillaries, and 
so becomes more deoicygenated ; the colour does not disappear or 
reappear so rapidly, and a slight yellowish tinge often remains 
from exlravasated haemoglobin. When stasis is reached, and 
a fortiori when thrombosis, pressure will not remove the red colour, 
and, should such a state persist for long^ definite and permanent 
pigmentation of the part may remain. 

The redness is not always most marked at the focus of the dis- 
turbance, as 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 injec- 
tion. The same absence of redness is observed in iritis, owing 
to the excess of pigment hiding the dilated vessels; but in both 
cornea and iris, the inflammation may in rare cases be so pro- 
longed 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 is the last of the Celsian signs of inflammation, and is 
due to the same two causes, viz., the hyperemia of, and the 



tNFLAHUATlO^' 



1? 




idalKMi htCa, the part. Hrmvanmly thi* nmnitnt of nirn^'rAcdryn 
upon the ;kcitlcr>cu of the dii^lurbanc*, and ch» dieion- 
INIity of Ihc tBim«, and in rnc^'(--^urc it v/itii^i cr>Dvcrscly witf) the 
iijpuni of pain. Id -v>riit c4m?n nticrc tlit inil.iiiic-c) Ar«u iscavt'ivil 
l»y a thick aTnl firm la?tf:u. not only h llip tfnsixr p;iin very con- 
Oile«itble. inti •t^Kei]ioB may occur away Jjotn the inflanind aftn, 
t^.^ t>vci the IwcJt oJ Ihc [vmtl in palm-ir ahKcw, As a nilc, 
Ktirte the inlUninuilory ^Jiotlucta nmapF inl<i h\\ liwiut* ihfl 

PtQli)ecliv«» phrnom^n:! ^Jt rirfimi*M-[)> Simihu ilkEvlniltoni of 
Ehe cccnrrtfiK^ od a-dema at a <li*sl:mGc :ltl- to |v? seen in laHamm-'i 
tions of th(^ ^ok of the fool, of thi^ cyalirJ.n ^hcn ihc scalp in 
b^antmJ. aiMl in ta^r^ wf ^ulnr.iniul Mip^iuialitm tli uliicli, if there? 
b tio eKletTUl wuund an u-d4>iTijCc.tu5 ojndttiou of KCdlp i« &een. 
kDuwn a^ Poll's pLttfy himour- hwcrllirif; due lu intlammationi 
ibrm^h diniims^itni; ^t mvttem^ iIlk.'*i nol rntii^ly Ji^ipptsaE. 

Intpainnent or LoBa of Function )>.tii(jc^ri LrnpiDUnt LcjmoinitKni 
tpiin of intUiTiTTViiion, und h ttiiv not only lo thi> p^riLy«ing elf«<C 
oi lb« procc6^ u|H)ti llir function of ihc pari, bitt also In mcjk^urc 
,|o thr ^viit wlitch l?> oftcii L-liiitrtl by JLttcniplirij; lu u^u il. Thu« 
■n tniuinnl pja r^n ^tv hnt Ifnlp; a niiivl**, when inrtampil, it 
n^liiralljr kt.'pl at rpsl ; icUnilnlar or^anK* ''f -^^ thtrlivor -ind IciLincvi, 
I14VC tlicir timriicrv^, i( not Io<« /it h^n^t much tlintimshcc^ ; nrt<l 
iTuny simiUr inji>trjiLiiJnh nnj^hi l>raLl(h'i]' 

OensTftl or OoniitLtationaJ Syroptonui- 

The?Ev may Iv of a vticus chaiacltft il the organ aft'ctcd i& mi 

tmpoTtflTTt iMFfr, sulL ^» [lie kiilin^y^ ut lic>>il : liul y^xiiAi loiitlittuiLs 

J nvi h^f. Suffice ii th:4t the gfrneral ^ympiomkof 

, . lior. orfparT*,ootof litahmporti^nc--, rruty hi-wnUi-n 

ED one wuiil, s'u.i FoT^ti or pyrexih. Thr jjcn^ral tlinrAOtcri^tich 

^Uue^lirlf iir >I.»U" m^iy hi- J}in-ll>' lUird [>» Ik- :i ^wult-t m \r^^ 

of tPTuprr-itiirf, o<^ri>nnianie'l with a oorrrsnanillnR 

on in the rate of the hi-Arl hfAC nnd of ihc rcftprrAlion^. 

Tf il coaliniirrp for nny lirnc:, Xhc pnlicii becomes thin, cm.iciated, 

JMd lof«^ Riuwul^r pti^tri. The month ifc i!iy. and thi- loneuc 

futrcid: and in the Uler >^tA|f(4» wbcni ,1 bul iuui^iAapprchifadefl. 

tbi; )ip4 nnd t«c(h Ate usually covered vvith :^]rdc^ [or nccumula 

ikmi con»Miiic <A iii.^ii%!ut[cd niiicii^ .iiul fxid dchnM- Thv 

Hippmilr IK impaired, di^rstion is inipr itr^-t, ;tnd ihct IhimH). tou- 

ci'pcU«d : Any mocioa pciiwcd is eKor>e<liniciy affenwiv^. The urin« 

14 icAnty Add hiffh'Oonurcd. amd conUiiis an esiceatiof utfa aiuI 

ar^c», the pioducl^ of i;.\ci^-»ive litoiic change, -i* dcmonsliatcJ 

dinicEilly liy addin;; an p'^uiZ pait of ci^ld inlrir ;Lcid in a te->t-[t.ilH? 

U> «M1M! luine. nhem crvitaJ* o{ ritr'a.Te of urea wiJI fi>rin on thi* 

ti>pof the 6ukI. pvini; t\^ lo a ma» lomewlial rtwirnhli"<MiKaT' 

t-V^ly in apptvaiaiiLp. The *tKiit of a fehiilf palieitt is i.iftr:u Oiy. 

tnjt In' nn riH-Mlis iT<:'rr'i*i;mty *h.». 

In former day^> when Ihe pr;i<:ttG« ikl «^x<w«^v« UleetVm^ uav in 



vo^uc lor all InflftmrnjitionSi the nppcurnnce of the WW wiw cirr- 
lullv iLnird, Ah il was %iipi|Htsn(l to thniw vimr JikIit Hprn th« 

IiancnI'ft candition. W« now know ihal tht blood wWn dntwa 
rom tSc body <Igc> t^ol cnn^-uUt^ rapidl)^ in mntiy inlUmmalof^ 
effect ioiiK. ami hvnci' the coloiircil icirpuMlcMunninK iiilo i^hjIoiui 
or in:iw% liink. ]p;ivin^ the upppr |xjrl nf Ihn llctid ulniu^l colcW' 
le'i*. iiiul Uiis on dotting will U»mi 4 yetlowor • biifly coal ' tncijn- 
tiiidifttincticn Im thcdatKcr iimw btiUm. Inaamudi as there in rd A > 
lively rriuri" fi]>rin h\ Ihis uppei Miutuiti lliiiii in ibe lower, it will 
ronrracf more rendily. ^nt) thii't l»e(»:>me *cnpp*"tl ' or concave on 
it4 upper u^irfnL't.^ Such di^ngen, hovk«iver, occur m conditions 
other llifin i]i^aniinulion,/.x>t7ifttT^t:vcic cxcrci^fc, duTiitj,: ai^cl ttftcr 
jirc^'fuiuy. etc, J ;iiil1 wi an- o/ no clHtii.il in^Hiri. Tlie ml Cf*- 
piivl<'fc arf' not much afftfCl^ct hy limplf- iHlliiinmntiorift ; hot in 
vcpiic -tnc] iafcctiv4< cais^s they nre broken up And thr^ h:tmoj];lohin 
131 Hi.vst:minaTcJ through ihc plfiHiiti (p* <ji], Fx^m rcci^nt obfcr' 
\;iiiiiii\ il Aji|x^iiiN Ihftt [Ik* i^hiir r4]i~]^LiscW arr incrraqrej in 
numlvr in all inHAnnnntotyafTcction^i tihtch ^ on to suppuration, 
ctpcciully if the pLi^ t« pcnl up it: n CAsity. 

The tcmis ttiiit and lym arc? applied to the lerminAliotMi of tb^ 
felinle !ilalp, ihi^ fnrmn implying a npid dimipptMnuice «J ibc 
fe\'er, ftccompanutl usually by what U known ^s a • critical eva- 
cuation,* cilhvr horn itic 7«km, bou'cU, or ki<ijiey?i; the latter term 



I 



GuuM of Frrsr. 

The temponiurv o| ihe ttody, li ^« u^ll known, u coctrolIM hy n prtnclp^ 
hcMuowmifi^ rnnrfn in th« mpdnllA iw«inl fii:i«rt)ly bj- Ai:i»*«tiry <nnlf*« in 
ttip<imlH ai)(] i*< mnimiLinnl tiy tlw r^uiMi^iitiviii til ft^uiLiltriuTii l^tHtrn ihe 
amminL of hm lott Eiom the Hia, bv ihc breub. uid in olhrr dirKtioBih. *ih1 
th« frvouni cf h«B.t pFoducfd by the lluue fneUbolbm ouunJnjt in the vkam 
flvwr^lv, and «iiwiktly in ihc voluninry mucloi. t'^mU ii necnuirtlx 4lu* 
Ui<«nff I)? (wfTfunLhliimt. vii . » it«e«HUvd LoMof bwt. or tn m^Lntwd prmhic- 
mm Thrfnrm^it AM^vcely ivtimbl* propwlifon vlna wti UioknE \\\k jutlml^ 
(vnditiun, oiiJ hcjiLip \ot nctlnMOi locoiK:iude (hjii iwj it dur lu Inciaued 
Acuviiy in tike ticaT-lofminj; iiuun.vnpccliJly themuKl«>a fnci vrhl ch upUiat 
ih« Hpid rnijicUli.fri and |uu of iinn^ih under lucli firrunuUfiov*, and A* 
nibitrif* ijf a Ixrgn nmotjul <■! ciiTracTiwv in rht iiniii^ In ^il] probAbillty tlUa 
tnf-hwvrl Arhvitv u rliir m> tlu- rudi'-mrm ul rhr liriAi-jinaliLrlnf cmtm by 
«ciiiir i^Ti-VF^oiJi \foil} [Ipvelotut by the IixaI infljiirimiior>' jiivcrBi lliporf' 
■neni* ruivr abcivu ilml iIjc IjIjuh f(?Emciu. a> vdl as many of Om luuon 
produced by thflttclton »f mitru-cjrTfnmAfii*, if iri^f^tcd Into tbectrviiUtiidi in « 
purvMaU. potaaapi rnich a ivTksvr, ahhi^uKb it in i:[uil« anopvAqintum whvllK^t 

tn frc*/"! Ti-i thp lympirtiTu of Jrv^t' n mnv br ^lar^l jFUf-fly ihii (hpy ar* 
la lar^ jnn tluc lu tli* rn«:i |.if<*dui.nl liy ilic iiiLitisoi rtM|*rjiiati uiahi 
iliccumlituml cr11> cif itlaAdulat and (jlhcr i->rx-i'i>. H i> »ii1l iEntciiaiimhcEtitjr 
Kutfh chan^vi cm be «(|ilaii>nl hiciiplv t_\ ilir ]iyrahi4. 07 hlici[b«i ihiry 4ttt 
not duaio AlCaraimnn tnih«cnmpcHjiifnci| rhi I'lrxxl Tho pliAriornvna in i)w«' 
tion atv |*ririAt hv fTiM>?r*<iil |arKn|rit;uU ^ j<-iili> ni nrlfnirlv ^wMltnc,' -fcTLTiLkUr 
daCpn^niihon/ atliLiniroii^ irlihrkUK^r cm ind itrp chamcterliMl bv [hr<trj*ant 
Ivci'iiLLH^ itult , ^TLublc. mill imirc ui Ic^i hnullcti Tin: Ki-crUriK ixlU i>' ^Ijimlt 
arv inrrcAivcl in kite, and the pruiciplKtni becomm morJitdly grtnular, » ibat 



I 



tVFLAMMATiOU 



■J 






ttBClta»caa only faediBlEiiKuiiilwt) with Jifficull^. Tlw ^nuialtt w fttbu- 
kOtt* la chkiiicCtT. cleaHfu vt\^ C3:'mj>!(-Lcly f^rt tHc vIditioQ ef Ue^c wd 
dakil«r chviff* u aW «viil«ni in ihr Bhrm uf ih» c^riiac oiuikI*. whi^ 

llor digBitl\e \yi»icni vxoliiiiii auKiv oF Itin febrile numildiUclcMU. IcuMniucli 
I thib tnoctiDS 11 Uivdir irap^m Thr wliittry &nd buoal cUoda ar« 
abb tQvKcncc Ihe tx>nnJ am^vui of «il;vn, nnd nvTi<9 ihv noutli b«coniM 
9rr G^ilnc d^OiDoT^ ii inlorfcrerl wtlh *n <hc ume ivny Tha bile it not 
•InclCBilv pR"tQCi«l, uid luDc« tu f ii -cm u ]ki iy t n^jt pnrpiuTLira are dimlnlftbeJ. 
tf «l«n ibr n«lu»tl ActlvfiTtc And (Aihjtrilc fi^rwnn^ Hktick Ihc^ p^tl'inr rAnnm 
KD^cily- dict^i bu, and ii i.Kiii>iU|bttvil . (iih niuiJoiit ulso Ivcuiurr rtuotufrlT 
oAtfurfw {rom the »une cao^K 

Vmous tcnou bav« been applied tt> dilTorcnl ivpn iff mrgkttl 

ihjl th^Mt rirf^ to clintrj] divrrticit^k of Rinnifp^tAEion raihrr thun to 
pAibo)oi^ic«l di«tirictionsoldi»in(iKG, -iiid Onuch sometitnes depend n« 
ttiucb upnfi llic conf^lilulion of (be pMticiii as upoi:^ llic nature or 

use ol ihi- afTi^t'tinn. ily 8th«nlc inflftrimiirtiry fi^vrr (Gm-k, 
,iiircagthli(THiuntth;itc^m!ilionin which pyrcxb^nd all lift 
■ccomptAnyinc t^>inpcom!> arc ^cU mnrkccl. It nccurt^ innirily in 
Tcil3|f hc-ilLliy Aduh^H fi «>und o^iriMriAition* a.^. for cn^'unple. whrn 
jyoufi^ man iv 'iiidclrrily atU*:kail l^y atuir pmnimtinia, or wlw-H 
«a icutc abfcofitibfarmin^. JUtbukk inf^amnintuty fever (Greek* 

tfuof, wii1»ut vtrengtb) 15 diamcttnKcd by the tendency to 

exli^avioii au^ colkipne n%r^ucULt(-(l iht^fcwilh. Il t-% met Aitfi iii 

dphilitstn] 5^t]l>jnrt« ;ird rhntr? r\h;ii.iv(L*d l>y vidriiii; h^bil** but 

wi:iy al6J> occur -xt the close oi x loni; pcnod of pyrexia, f,g., in 

ibpc ibird ivcck of l)-phoid fever (-Uic typhoid nUtcJ, The 

tbiorptifio of ptoducU of puiiefaciitm aiiJ iUtt occLirrciirc cif acuit 

irer blood -polttontng aiH :itbo indiio? f<;vfr of this type in 

'Jlie t^mpt^riiUire in nut nr*ccu?riirtJy bi^'h, and. in 

the cad may become subnormal. The patient lies 

npon hb baeic, more or \<ns uru onsi/ioiis^ in a sUitr^ of rnultrrrini; 

dtlirwm; ihe hand^ are ref^l^^ss, i^'jri^t^mtly picking M ttie bed- 

dolbea i Ihe eyes may be op;.'0 iind \v'iEh nn uiinaluiul lustre, or 

hftll ckjc^. wlidsi the tuiij^uc IrcxuEnc^ di> diid biuMn frum the 

mooih nn| bring tihiir. Ri*^piiAt)on U shallow »nd rapid* snd ihe 

itult* qoidc asd foohle, '\'l\c exc:r#tA are oflfrn pAKKed into tho 
led* ftsd tbc akin ir^ hot jind dry al one morTH-iit, and then n^atn 
Ulcered *ith a clft.mmy i>ff':Tisivc pcrspirAlion. Should this slate 
td ihinfE^ continue, tkaih fmm toma or cKhaiistion U ineviiablp : 
ta (he oibcr band, ^ cbntif^e for the better may be heralded in by 
B iriticAl cva£UAt)Dii oi the bowcU, i>r a copiou-i action of the 
tki&. En «omr forms of Astlictnic: fevrr nervous jtyniptcniis pre- 
Et«unjteH fefiultinf^ in [he pr'irliittitsn of a vtate :ihic|i c^ti Kcarci?]/ 
It dittuijfuiabed Irom dediriiim tremcnt^. 

The recofiiution of tbe?e ilifTerent typt^.n of fovcr is most am- 
pr«tan!, in tbat the c<mslitLiliiJtrul or L'eneTJi] tfcaliiieul must be 
uided entirely by the symptoms manifested, ' 
~ a— a 



30 A MANUAL OF SURCEHY 



Oausm of InflunmAtlon. 

Pndisposliig O&tuet. — The conditions which predispose to in' 
flammation may hs conveniently divided into the local and the 
const it utional- 

The local caui^n include the following more important condi- 
tions ; 

1. Defective circulation, whether due to chronic anxmia, 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 gentrai or const Hutionat prcdispining causes are those which 
tend (o depress the j^eneral vitality, c.f^. : 

1. Old age, where the btrtly as a whole suflers in its nutrition. 

2. Weak action of the heart, distvirhing the vascular supply of 
the organs and memliers of the Ivxly. 

3. An unhealthy condition of the bli^xxl, as from {a) the addition 
of some abnormal constituent, as in alcoholism, plethora, lea*!, 
mercury, or phosphorus poisoning, septic diseases, clialieles, etc. ; 
(ft) the insufficient elimination of excreta, as in Bright^s disease 
or gout ; {c) the absence of some normal constituents, as in 
albuminuria or anxmia. 

4. The presence of some constitutional disease, dyscrasia or 
diathesis, as syphihs, tuliercle. rheumatism, etc. 

Ezdti^ Oaiuea. — The active agent in the production of any 
inflammation is the existence of s*>me irritant which acts for a 
shorter or longer peritKl upon the tissues. The different forms of 
irritants are inBnite in numlwr. but may i>e grouped under the 
following four headings : 

1. Mechanical or traumatic causes, such as direct violence, 
friction, tensi<in, pressure, etc. 

2. Causes which act through chanties of temperature, either 
heat or cold. 

3. Electricity, either as applied by the surgeon in the form iti 
the faradic or galvanic current, <>r through the agency of lightning. 
or the strong currents used for lighting purposes. 

4. Toxic irritants, under which may l>e included: 

{a) Chemical agents, such as strong acids or alkalies. 

{b) \'egetable irritants. *',t'- croton-oil, oil of mustard, etc. 

(f) Animal irritants, such as cantharides, and insect or 
reptile bites. 

{d) The developmeni of mirro-nrgaiiisms within or with- 
out the UkIv. 



tSFLAUUATSON 



M 



kucb in uniHirlAni pari in ctw iJevetopmiMii of djicaue 
ia«T (* itiv*^ u- This cariiT r>l tiirt-iiumAUuTL Tour chiHT 

I TW y^act uf lM«Ara*iw iFL^ j. 1 i iiv L-liAriiri>'ririxl by the erowib 

the ijiure- beairint; corkIh ubsncv irniTimlic-iiico o^ (he i£fu<4ih cnuiu Tbrre 

uAtatofli dill* rr> Itttt' rVM^lcpm^cv In ihif ImjAv an: a* folUfWt 

Fum. «n>ii^ fn>cn ihf. ,'Ukott*n Si>tMi*mu 



v;5- 




I 



« it?. s!^/«: 



[l.)TftNurfViE>ni, mHlvrKcln^ maliipTlcMluriliyt^cinEii&tioa. Ill .ain^Icor 
telfitadcocA, IV .tkn^Licio:] . V HtEf ptfK^'Kf Uif clintricoo^: VI..*i&pns'lo- 
MCd crcloaiv «ikci. VU , «r-:j|{l>^^ mau ttl vF)i*nitin\ . VIM . aucinj ; 
fX .men HTunfiiJin fumi, X . tni-illi \1 KphiW AWh hlnvl rnqiu«rli»% 

KtfiM^MjrCMlx tv panollk ulcrr of the coEnT>A, in JLtiri 1o funici of itii; 
tiftr^llh^ct mucoriypd (coffimoa enotitJtj.wluch mai Aldofc«fcun<l dov^l'^p- 
toff ia ili« Lnncdil fpn«Dnici^ri|^;nitiCj. or kn Ihv e«t«nial kndttpor) meoiut (nliv 

V"' - > ijii l« dRppnJttnt "n Ifin (mwrh in itii* tiwiim uf the my 

II i^ic VcMU ur BUatODTMtM fFiK (, H ) <{c\<Ih.^ hy a pijcw ol 
m wwiiHoQ 0* huJ J*>f TlH.-\)Lrt^ rnpnitil^li: U-t nmny Irrrnit of CfinnFOUtinn, 
If Itw Alcefmlic or %£wirt:K Imi i>]:iv nif ruiMif r)iiiivl |url in human pAlhdlogy 

III TW yr«<MW :i-r » HT^ir^ ixkirh rail Iv rljuHfcl filrhrrr oh ABlmftI or 
iitfvtftble, jUkI cixuJd Lr thetr rartit^ tint-n of inu9« ul luhtO niiUcAleJ 
ppMupUjML vhidi tiU} UiGi on l^uJiEic i.jic<Til uUh mcnibianoiig «n«clopea, 
■Ju qth cpOBtu* is vl^xb |i>£tji]ij| cje^^i 4re trolfu^tcd. They ooiuliCvt* a 



at 



A UaUVAL OPSUSGBRY 



In pulnkigy l» h y«l vol CttUjr worlMd oui. uni. livWd. w« kr* onj 
JoniBMftO to gtOfMH«di«ituyp]iEy*aT wnt IuHkuJI If St mppEiwi) ihAi 
tbv IvlbTwfny r«T)«IIv Uv of pi&JtviiHM lixiiKirliinc* 

AmiMbtr in? kiKtun lo occur in o-n'iJti tvttm oi oAxim. And abu m «riCQ« 

Wi«li«a of bestir: n l i J OCM. 

Malaria li protul^Lv due to tht dwv|opni(*nt of ■ proioiomi, th« Iftfiau/ww 

'rh« Pttmipfrma. whifh 'K'ciir mil unfmiucTirK' in LniiTtJil^, nrr mrmlT-n 

faLind in I'a^t'^ Jivak of ihc ni|:p]«, a/i'l ld h>inc (ojct of CiUcinc/mij trt 

ri94l1v U^iitt: pArullM, iind tf bc. whcih» ihcy have any oaumive cffwi on 

u'htrfi mi« Im7i nrtrthiirf^i rn Thi->v nTi^mnnm 

[V Tbe BsocvrU <ir ItliluBjroilM fonti a vm imporiA^ii and nuimuvui 
nljtu, and Liir in the pi^oaeut Jiy Lookf^ upoQ 4» rtii: ohventJAf cAuit uf fruu^ 
(ju-iiun. supi-urMion, ind monc of ihc infliimmftloiY <liw*K» Thoy ftPe 
clftMihcd uruvr tbd folJ^wiep dlffcmflt |^H]p<- 

I VlaroBOsel ijt Oafol iVkti j. III } Ar« rniinfli«h rir nvxl nllv, nuillipljrmfr 
fapidlj liy .1 |rrrx'c"* nf fivijnri ji ^ . dWiirii^n »nitt wtnal (ftrW) T^ipy m*j' 
rtiQAin Laolatcu, hvt as a jule air i.\)l|ec[cO tnto ifrtald Ot-HiiLii- tonaaLknu. 
Hml ill wLflHo^iicftte •ic Ecn^icJ iitiffitl"i-'^ii <tr vlusitct vocci iVin- *, VM 
when ilicy jin: ^ravpc<t like u buixch of K^^f"' vnuiill)/ e-c^urrlng tbo* it) 
LocoJJivd irll:inireAlio[iv , ilnftim\-£* at I'ha-in nicci {FifC 'p ^ I wiwp thty 
itpiTlnp in fhain«, ihp rhnrart^ri'dir 4~>t «pn^141mi■ mrlAinninhnnv ttififitPiti 
(hlK <!< IV \ Mfhcn they cccur Ln p^D, t^ , the jfonococcua or pneumucrVW 
LiicI vrUb fa i^i^ituirtiLi^ mv\ tmcuiiiuiriji it«pettl«'cLv- ^'hcii iltry j.tc citrupol 
inlii ifw;LftU vf fimr i>r riji^Ll iivliiuhiciU, lTir\ Arc imuhUv tctTnt^ t4irtnttf 
[Pic t. VIII J Ooc-iuinnnllv nriv nf rlir aIktv^i mnv (iccLir in iramt <iT 
coioiiicftthrny or etlatinnni tn rhorarlt'r-, and kri>wii ni jL Jiijif/'M (hi^ i VII) 

3 BiKfll! or roii-vliap"] luaf-tTrU ftl^ ;, X ) jrr tjiiiY.1 rn il^ form ctthor 
of Unjf AT ihntt AlamniiTk mjutr ii[i ni -i\\ nKK^^^^i"'^ "^ imlivliliinl rml^ imiL«il 
«id tt»«nd; or ihcy mciy liHimio (i^rvril and m> tbiri ipir*] rx-I^ «lii^~h mity 
brvk up inio the *0'«.f]«tl comma-9hA[mJ t^icilli , or tbcy niA>' ix-niM in the 
hcilj ljI (boir hofitAA iwUicd rocU «lihin the huImiadoc ot ihc cell* invKdul^ 
Thtiy mulEiply hy &m':n%, or by tb« fonyuLtlofi of «porat la Iheir Loterior, 
ThMv ijillnr !1-tv miiT^h nirin' nfmiKlAiil nrtii Ifwi iu;tily rinlmyfd than rhit nvwat 
rud* Thr vpuiv tnav ilevvlop in thr »nirt *ii ilw IndlJiut. u ia il» 0. 
4iiirjbrMo. or At ont «iic]< a» Lii thr to<Ldlk<l iliuaisElck-AhAiJAl B. ffU*r {Ti^ i<l4 

J, ffMllft (Fkf- d. XtJ fijrm nrli*cr«w - Ziko thrwda, potmtm^ng ftctiv* 
fctw«r of rnmitmitnl Thvy pml-aNv mvhiply Ity «]wr# frvmuUiori. *nd io 
romnn pjuhnl^vy *>rily "Cciir ir a fr-w cnndlllonv ™ch ^^ t*-niiTtrril fovw 

A lew IJifti HiAV te uiilaj hvrriUlu tli« lift bbLdry and iiiai> of activity 
vf tboc tr^rlAblc ini^-anUmfc 

EftbltftI, bbctcHn arv nlmtmt uTii>«rHil in iheir dniribuiionr EMrllt, air. 
uirl wntdr xr* ('ill nf ihnin, icid 4i>ipuciu1lv no in ixjpulQitunBJffhbobrhDoclA Th* 
fjtrnfr* Thf mimSrf r»f Ihr intiahil.inlv iW lintirr Th^? riimlvrf>f nrjpnHmi lA 
tbi? air On (hr hitfh Al|>f :k[v1 jn ItoUitcd Fif|tcc1al1v TnouniiUlioVEi. dllTrica. 
Eh«(? juc i.[JtEi;MJ-iEi«cti tc<A. -abiShV in llur *ii iit 4 i^iuwilcil ikUtplldJ waM 
vwviiia u( thmn aic prtH^iU. md llicnr ciFtfii iif ■ mint liviicrrou* Ifpe. The 
HuHicr c]f oiir hixlir^ uleI Thr intmmnJ CAna.]^ moitKvtvr. I«ciin wicfa lh«n. 
alih^Dxh in :i hnlihy irvluii^iml the toUd ovKan*. the l>lood and lymph, arr 
poctiCBUIv ITH Any cnnditlon of ifcnenil umdinm will fudlltaic tlwir 
oniruic* tniu the kyklem, ui [jcrtinin tinr^hirulil wi, wlU diinhtisih the rTSiiI- 
wiDc <jf ibc! 1u3y io ihdir p(e«vJLc* oJiiJ, KtiiiL). and b*ntr iny tbi: inJividLiAl 
opctj t<* [Hn rxfurnrifkcr of dlywaJnEBCtiTg diB<aaaa> 

HfibUitj. Tho axv' An tA & ^nnip incApablt of lUiive tocomoiiitn. 
BlihouEh th«y mantlt«r, tn o:>Tnmi:iQ vfUi ^1 nUnnic »cin4ivln|E puiula. 
' Brownlu) mr^vcmctiEv M'»i I'tju-llli and ipieilln hjtvn tn juldltlon ihc power 



4 



ISFI.AMUATIQII 



aj 



'Tile v^jAci iJiA>cM«.llr^ EiALtninui luukEulviiiK L^ciL^jmniJk- 
TvD mctbuil* hAi« \iccn ineulKriirri iiUh«, vir . fiuUm^ iom ilic fbtniiLiJim iff 
^JoayoM., In «omi- x^rirrtin nnnilcir pinn i^ prownt, vijf,, onnotll ni :ichnin 
>r mw« tw^i^inei enUrf^l jnf1«ni]riwf<] vith now viTilily anrlfrnm lhi< nnhm< 
ifmfF fr«li i^mmikon* arr prcwlutfiil l^jlublv *omf Klrtirno Jinnoiirrd and 

Bmlli of flrsVdL^-Tlio 4cii\Jiv nnil ilf irl"}iriiriil oi luu-tcrii juc phyvi*" 
bipcal ptundmana. (AiriecJ out in oco-inlinr^ t>iih ihr cni^^f^I ln<" i:oi'«min|E 
ummI Afkd v*gctkblp life, Md wuiniijE ccnaJm <]«]^nir<- ct-nditicnn to t« 
fmvAit TIkF lubulura or find-iiofl dlflrm vtith ih« parrtcnicir iipcfW?c, and 
It* naiolu tit tiitit (rtrwili vjix\' in lilm Hinflni-r \4 rr* (hi-Jf i-nvlrorLm*^nT In 
loAoliMkal cotidiLLntn. onr divide Ihrrn inin iwrj uir^i ulHvir't, ,u^:j>rt]iit|( 
ID whcuHsr Of cui (ha> tan devcit^ ui ib^: Iwiae li>^ii«* Thr f-aiki>t>it\e 
DV f^mvlic bftcUfi* <Aik do lb. firodjcin^ vhj&i niv Vna^^n a? ^m^iK'^' 
Jmmhj bill wben Jin or^ptoltm C4n only d^vGk'ii i\\ ili-ifl Tii^AV). »ij<:h u 
MttMVft <if hlfrufjh. nr in miulAtiunt nf IiIhitI. lan^irrL oi imv (if in itoilic n"n- 
Hnoi nain'si (niirri'il. ti U c^l^rtl ■ inm'pMit\'*fmic. •di|imphyri|-, "r t-Afriim 

■■ncuf ihc |Mtbi>Kv»ii Uf^uiJiiiA 4Je t^fublcof Lontlnum^ their ddtvlopm«nt 
B(lad tiaaiKA^i ^ £aciittt[»'c kjiprf>filiTb»-' Eiud i}us prujxu-t'r laooit <jf ^rrat 

r, is tlul it ppfmTU uf intton*TVtf difluuon M ihu vrru*, (he Tffiftiii. 

LI. a»l n^lijifnLnr nvtPtnA hinUi irr hfwonik- rhnmrMri/r^l In- ihm 
Thf oKcuicv fc^ atETimphpric: lir in ihpir di?wlo|irnmT luhMuijih 

OA fm ia. jvul indeed, miuiEc fui ihcir ili^vcl-Jpincnl- ilic atlua-l fir«e»ijc 
<J fei* ftir. tiMj ATv ifirm«] oMtfsti •if'-lt^ If H[ivr<var, i1i«y K-vic ihc 
wyiTOf 40|iiinr^ ih# ^iv^fth lli'iv n<rr<H fmm Ihc iiiilnHM [i>HMm Kiirrfmnil' 

■M ttm* wlilch rttjiiir* ii» Ltjni»|ititrff ^inuitil ihcin, Frum whkh mvifcn If^ 
nrkSv culwM. uid luch urbnll.ii FlnLir^h hnc in njini^rn nr li^ilroi^en, 
14. itw tiadlhiB of IcUnut AW ImcKnA ^^nsnmp oivcvn. MI1I ip%< e^ * 
Uifcr or mftl^ udqudI of cortonic *ci<i ; Sui >ri cbidition Oi^rtain ^pociJ^l 
Owipoiifcd* fcrt prudaciied a* (he roiiili ol iliclr k«'*">Ii, and ar (ho rvpenw 

ad mnr orcanisfiMtFr tltrif ^nriducti arr c«i))nM<T[<( ivpiuiu^iiiu ]Ll1>LirnJn m 
*f hqvBlVuw <c«l&iiae, a cturiicierdLic fipdlure in ihc action 01 ihc fyuffrnn 
<f^ t'lmJIitiiHL) bft^crin. «u 'i^hcr^iac [he 1i<iucbLciiou ol ihe lisuts Mvhich 
MOn Ift «uppimboii could nui i.jtiT4Je^ 

TW nnt nnjHirUni pr«liu:rv Tiowvwr. »( b>cUriAl nfUvtiy itrr rtic u- 
nDed fnlBM or pr^vniMii hnrlin rhr nr w OTCP and vEltm<)f which tlmrrminfi 
ite ffrf*Ft1 iirai«iibor nioii uf iht tntectiie di»a»?« Two ^mi tlanv-i of 
iMtaa c»iii, ^i« (<] 1I1C fS'-'UM-ttf in L^diivcik iilkiilutdv gr^ukic htues 
liiilt *p vn the hbenooi sjf i.rnfnuDiitui byJruie (NHjH'.>| ; thcv jnltu ffuoly 
«tA add*, vil can bw ctvdnllitnl (^uUxvnn, putFTiu:in vul «cpfelu iire 
^■mtvini 0I thr4p prttilnrrt In^n^Irrl rnln AEtlmEik lh<iv pr^Inr-o il*ifiiiiti> 



Knac ivmptms- a^ locally may Icoil 10 the fomuiirkn cif m ativos U1 Thv 
UM-t9mmmi afe Iwdlv* i^hldi hAvc ua\y Unj m:ui;:iJ9c>l more icceniTy, 
ttti uc MCTPfd 10 be vf Ihe oaXurv ul ^WiurmtKi . piuLkiblr mca< «f (he 
iiIkIi<v prccwapk rnaU in eHd iiroditctirrii of (hvMt ■ub*(iuic«a- 

ColmniM ax«rN. bf vhieh tnv% ria hv rrv~ouiii««1, ar* aliu d«v#lripiir1 by 
*inf •ar*Mt" -h* l« (^ith^r^ protfii« ttuurwceore oJ the riinrlmt irn^la 

Katkoit of EiMBlPttUa, -Tbev aic In tbc lOAin EhnT^toM ; 

1 MtiPo^tfu ^dMAifuH. — llijfh pu'^erkTjf (hr micfi»cciEB Are ooedcd for 
iba ^*«r%. aM ww wiLh ihim ii i> 'jfim di^cuh tf? rlcttirmiDc Ihs chonULeri 
■rf anj paflicttJar fcrm of microtv undvr ri--viniTiatirkn Minutir diifortncaa in 
ika mtt and «happ iru>' aaiti. an>l the ivlattv^^ pLrrani^iTrrif in rhkint. e^luOi*f\« 
tic . IfUiThenMcitonindlfferRQl nulntnjf refliftnti Ti^n :hin dfrcctt^m.pcrhaiJW, 




A MANUAL OF SURGERY 



tht mosr importaDt fact tooscertaia. Into the vaiioua methoda of d«mc 
and staining bacteria il ia impossible to enter here. 

2. Ciillifatioa on various nutrient media b of the erfaieai am 
determining the exact nature of any special organism under exannoaC 
this purpose the cut surface of a raw potato after sterilisation of th 

suits excellently in many caseft 



.5>. 



such as meal infusion, milk 
serum, are not very saiia&cb 
similar materiaJs, solidified by 
tbn of gelatine or a^ar-agar. a 
placed in lest-lubes or on plaM 
most suitable nutrient bases. ! 
the life-history of any mlcrt 
important to note whether or i 
develop in contact with the a 
may be accompiished b>' th 
nutrient gelatine poured into I 
some of which are aUoLv-ed ti 
the vertical position, and orhe 
slant The former are inoci 
puncturing the horizontal sur 
an infected platinum wire (stab 
the latter by streaking it along t\ 
surface [streak cultuTei. (Fig 3) 
3. iKiffulaUfn e>:periment^ a 
the most reliable means of i 
into the relations of micro-nrg 
any particular disease; but it 
always fully recognised that an 
nor necessan I V affected in the 
as man, and therefore a bac 
must also be somewhat of a coi 
patholr>gist The importance 
means of investigation has I 
phasized by Koch, who has ii 
the following four e?uieniiala in order to pro^e the infective characl 
particular disease : 

(i.) The organism must be pieaenl in exery carf of the diaa 

in the tissues or in the blood, 
fii.) It must be possible to cultivate it for manv generations a 

the body, 
(iii.) Its inoculation into a suitable animal musr be followt 

appearance of the specific disease ; and 
(iv.) The organism mu&t be found in the tissues or blood of t 
infected in this manner. 
The question of Immiuiity from infective diseases ha-s F>een, an 
receiving the greatest attention from bacteriol ovists Three tiilfei 
of immunity exist, viz. : 

{a) Natural tthrHUMity. by which is meant that certain individuals < 
are capable of resisting the action of microbes, which can devel<)p 
thus, rat? are unharmed by anthrax bacilli, and goals by those of 
This condition also obtains in the human subject where certain ii 
seem lo be immune against particular diseases. 

{b} Aequirtd immunUy is that condition in \^hich an individual is 
the danger of contracting a specific disease owing to his having- alread; 
it Thu^. one attack of any of the ordinary eKantbtmala or of ^)-p 
rule, protects him from rarther danger from that sp&ial aflccll 
casiunally, bowe^'Cr, this immunity wcms lo wear itself out, and stfcui 
may then occur. 



Fio. 3. -Sfan AND Streak Cul- 
TORES FOR Bacteria. (Aft£K 

TlLLNANWS.) 



'ATWS 



4 



' dcrv^aci] 141(1 tJcTitM^i*^ tiV k^-iclKC ViULuuk \Aiitit iiAVC bcvii 
tovAect ihiAofc^eei. of which Ifcc EulMwinK nn; th<: mo.^i importaai . 
I tiwrnh ti nn with 1fc« wdfie diMut in lacti a w>n in-l m ^ucIi n nirici ibti 
till M|i>P* can iwlih' wnmr it t^i Thli va>* fr<nn«rl> fn'pplf>k'«£l a* a prt- 

j^« vltb aa MtasoAlcC ur imklLfiQ] uiuv whiUf. wii;Ki nu hi^ulk I'^p (uilichl 

ufttftmAl iJiieuc, hjo k( >iieJi jtn etTbct (Ha ]li» cimhtiliilicHi .i- Uj pmlrtt Iiiin 

it TliU l^ui bAflR u««l ifith rCxfJ miiltn in (hr prf<«tiii)ni] rif ftiilhmv 

(iii,) It UfTTTi^mbl^ itui mtflt 'I'ririnitin* hav* ihi' pr^^r of df. 

aM^riolfOf inp ^ikh^ntm Kypr. vhich LTc c&pahlG oi inDiliMinj: td^n 

rt. ASd Ll li ihc ureal jifli i>( b*f.lcrti:jli»tfihl* M iiu»U(^ !4ur.h tub- 

ccd wun]«lf o0Ui»iAt thin «'il>fi4u», and na» Shu tinp1n>vi af* « 

iMtvnt ift vrwraJ (fiJioum u well v Iot proi«cli^e puipoM* (iv ) 

Iban «ith iha oriA of Hdnr 'ki^vr diflMU* !■ pnaitily a motnii ol pn- 

or rurc u m Thr ctiw til Liccinatton (ft pfevnni tnihU.pi>i alititiiij^ 

lit CfTiAtn niTkJLini of <litjkie ;im iii whHhKr iir noi ihr twci rrtmllrLifiiK Art^ 




Ueditliig or AatiMptk Tttvez of tlie Tisaatts^'-lf wc arc «ur- 
(w^l uilh> 4mi if nur lifrfiK-s ft\rn nTf inv.iHrcl by, ft> grr-*! n 
fiarilk of eni^mici^, nuinv at uhich couM under mlt^Nc cicctim' 
AUKCA produce jcTAv^c Qi:va-^e9, Xhtstc must he present within us 









h b bdoc cU»liiie<rftted- 



puCcal DAluitJ ft)L-Hii^ of tc^isEJii^ iWir iii:e!vity, Ami such is 

tomoitltdiiiliwrpnc nr j;L-rnnc-iili*l |iciwr.'r nf ihc lis>.i»i.'ji> Tlieiis 

<an hv ao numocr of JoubL ih^t bacC^riR -ir^ di'^fiiroyt^d in ttio 

'Aud^; Mmc an: ponnhly excreted by ihi; ktdncw, hut of tlii» wu 

koinr but liltlc. Tl>cit ATtr two m.kin ihrnrrric^ it^ <o Nrilurr^ 

IMeic^ nf iV*tm>-iii|! oe prrvrnlini; Hv -iriinn of T>aclrnq in thr 

ilnl», *U- M » ^ Ifctcrhtiikoff'ii ihtfory of PlLigasTtMUi. whtcli fnairi' 

'Uin» (hal itit- Idicocytr*. 4od iitsrt tlit lars^^r n>vind ctll» derived 

fn«a Ihe coiijncctivc- tissue con>U'^lcv di-Ntiitipd elsewhere ii» 

i|hmli|ait4, h^iw Efv> ptiwfn of Mlcinf; ihfei th«-ir ^ulKtnnnp rht- 

Ei(3nlw«^ and of iherp drvficyin^ thcni ljy a protMs trf difCCRlion. 

idcn ia bascfl on eIk' rvauh^ oi micro-Kopic cxomin^ition, it 

-«!£ lukiAtit) «disy- t«» iltnuinsliiUf^ llie pnaenit «if l>aclt(iii 

rtfalfi tbi^ (king Ifitcocyl^ (Fi;;. 4), :i1lhough o|>pon<?rLU to thiv 

ry frU||;K;i7<4 XhM it it only lli« dcait or^anrftms wbkh are 

iftJlow«il and dc-Jtlt wtlli in this n^y. \» an iictportant outoome 



A MANUAL OP SUftGFRY 



of ilik docirin^ hatt arisen ilit? k\en of Obtmlotaxli, a i^rm Intro- 
diicud to intljtatc th*-' iillraciivc or rcpubivc power exercised by 
tbc bitcU'iui upon thr leucocyte*- Hy /o»V«\'chtmiuUAiiiHme4nc 
llK'.LftrdCtioii wTieietiy leuctnyt^^s ^rv ^Lilheml tuwuids^ny tissu^^ 
in which bftcl^ria have com tm-noed lo rl«vt»lop; th* organisms or 
ihcir proilucta M^tim \t> h;iw a jiowcr of cnusmj; acltvfi tliapedesia 
4nd cxu^Ation of i)i|<i!»ni;t, m a ic^ull uf which Lhc spicHil of ihc 
mirmhfr invA^inn U limirrd. And the inflAinmniinn ihiiK r:jut^ 
ya protective nil hfr than d^MfUCtive. Positive chumiotnxU is to ha 
inokod oTi, thru, iK^ Naluf c"^ dtfcnce ncain^l nn jictivc and vifcorooft 
nticroliit: Alt^irk* Nftittirt \Av:\\\io\A\v>. ou Ihc utiiri hkuil. is the 
t*-nTi applifd [o ft condiTior in nhirh chn Icuc^tscyifs an- HpfKirenHy 
ii'ptrUt^cl by [he orR^iniamfi, nn accoimt prob,»bly of Ihcir virulent 
nature* Isoth phenomena can be »ecn \<ixy well hy inoc«l.iCirn( 
(he LUTHeii (if *m pinimAl AJtU thr AiptrpiUnt tne"* ''^ ^*^^ <laiic 
l»y Lr*lif-r ; the ipoi of inocwlfttinn locitit opa'^ut and [lull, owing 
lo th* dt?\<!lfipmcnt therein of the mvccliuni ot the funKUSi anJ 
the nccio^i.i CAUHid thereby; atoimd thin iw an nreji £if clear 
lihupjI lisiue which i* nwrnJiic. Imt fipc from leuiitn-jle?* owiuil; 
In netfarivechtmjoiiixiv. C»iii*idr This, aj^'nin. i« -a circle of inftl- 
tr;tl«(r lisMio. .It tirtft ol ii whili^b yellow coJout, and finally brMk- 
ii\^ duwn into pus. the reMill o{ po«:tive thennutA\i>> (Jl More 
fvcfmly ihc tli*fOfy nf ph.iyoryiosis ha^ l*rn very vigorously 
Attacked, itnd It hav be^ii maintaicied that lUi.- chief gennicicUl 
p()Wors of (he body ivside in the blood ^nutn und it» «:on'4EituentEt« 
CettAiii hpecla^j ^IhiLniitKms ^ub^[allLra have \>ei^\\ i^tjlntcd, and tU 
ihf^p the n»me rtt Prot#ctlv« AJ1>msJllA or AlftidliM has Iwcn ^vea. 
FrohAhly ili«r* is tnith in tioih iIi^m th«ori«s, the two diricirient 
pnwors being called into play under varyiog circumstaitcc** 

V4rl«ttos of lofluom&tloD^ 

Muiiy (emis are uwd thnitJilly Co indir^iip ilit dilTei«nr nuni- 
feiitatioiw of Ehe influminaiory process in tli« body, and to th«M 
we must now dtrcct ationtion* 

A O&t&rrhiil ijitliiEiimaCiuii i^ uue uJTecliui; iiiui:ou6 tUCtnbraoQS. 
evidenced rlinionlly by the nrcurrenr* of fedT>e*is. and a burning 
or scjiMir^' pam, which is moat mart^^d in the v^r\y or dry fitace, 
when ihcrcc i^ Uit little discbar»;e, and is inucli dimininheil in Ute 
Uiei *U^i">, whrn tbeir is frer scrrt^tion of nuitus, min<»'pn'< or 
niiv. P.iilwihiKirally. thji pmocis it accompanied, Mi arrsll active 
inltAmmatcirycharfi^e]^, by hyptrr^rmia and oudatton. In (hu early 
AtMf^ the muriji^enmirt ftinclion of the mcnibranc is Ahrof{nted, and 
any eAtrAv;i^uUf rxiiiLtuon |ia.vtr% into it% Nub^l^mcc, c«mMrK it 
to lietomt- vrtolk-n. Pro! if juration of the trpithclium toon followSf 
resulting in (he increAsed formation of mucui; and 0.% tho mcni' 
limcc become* more and more inftitraied with leucocyte*, these 
Ate added lu llie di>chttr|;t;« Aiid it i» IiaAHfunued inLo tuiu:[i-pu«. 



I 




tHFLAMUATfOS 



ST 






or pvcn ftruillv pus. Small ulcers may form from tbe km of ttie 

flUpc>6cUJ rptlMtuiij, bul litis i?» ;iii exLvptiuii r»t)m ihtTi thr^ 

niU. Mirrofirrpir -'vanurt/ition of thfr (li«chiii|,'4* r^vtr^K pii» ctll^, 

i^lrttcncytcfi, nnd q>ithclin) wlis in v^novH CT.in<lition^, some con^ 

dmn£ KlotnilrAof mucin, und some of ihi.' noiiitul type. Tbiv 

of lufl^mTnAtion may |ic c^ii«^d l>>' linf icn.i, Imt U uflti: fine 

II !hr action of lorjtl initanti^ nrio wh.il k known ii* ' tsiWing cold,' 

A Oroflipoui lor ploMir) mflnmmalion i^ one t^hnmclcrizrd hv iV- 
ixRiAtion L>f .1 hint I'lbiirou^ ialfic mcni1>rAiTr> ll n)ay <M.tu\ wi it 

iju* MLr£Acr. ^\ ihr plri[i;i, ywrilonrmn. or sytiovml mcmhT^ini' 

A joini, in llie (firm i>f plastic lympli, which Tnny orRanuti? into 
vlhcsioos; it M also sccti id open wounds allowed <o (^r-int^Intr. 
lad it <icojr^ in llir ^iKcoli of tlic lungs in lulj.cr pneunionia- On 
miuxTti4 nvmlnnnn. <iich :k^ the rnnjiinctix^i or lli^f of ihr 
pluryru, it occasionaily forms wbilr fiiiky nu»»ps, uhich tan 
tTtdiiy i>c dtUchtd, lcAvi;ig nn injfxilcci surfftcc below, with 
nervly a pciiiil »r iwu of lufiiujiTli^i^e. mu\ ilu Uiwv of hubnt;mcr, 

-V Dfflllterltlc inf1:t)TiTiialion i« one ftiit- tri j\ ^p^d;il or^^anism— 
tU BjkUIu^ <iipkihf9%a a.nd ifc evidenced try thi^ lormiitioti of a 
'ittcibrsnom rxudntioiii Aith which arr^ in cor porn led Ehc aupcrficiiil 
kjivim uf lb« BjiiLlhv^ium. ?t[i rhiit k lAnnoi lrr< ifiTii>vt<d Aitlii>u1 
k«vtii^ a mwr surfncv, Tho bacilli devek>p in ^hi^f^l^v mcmbruie 
iftd pirndticc lAKin-*^ which by ihuir abf^rplion ^vv rJsv to ih^^ 
cEXkfltlutional a>M]ptoini uf the disease. 

The trmi PfaiecmanotiB i^ ni^w bitl rrirely emplnyM. h wh4 
[imnvrly uM*d lo indn:itv un inlljinitnalory coxidnion wlien ^11 lht< 

ktoiUAud lat^riUtiAl ajc Inm^ whkb indicMc thai 

nn mf^mrd or^^norgbnd ihc pTor**« i^ rrspmivHy limit^-d, 
c<btr Id ibc ActiLk! and iictivo fiub^.mci^ of \\\c ort^LUi. i^r lii lh« 
sjpporttnc ftfxooA ttjsii<:- 

A JMactfttie inlUmin^Uton \^ nne which cumplerely Icavta iix 
<nsiTul fftcus, and without ^ipparrnt rcm^n altftckt mmr oihrr 
pirt ; thnfi, after miimpt the tctticl* of ovary "i^'^V become in- 
Ruwd, whilst aIeci Lip.i roiomic%« cspcci^dly fho^ anccling pelvic 
ttfanv parrrtttK r occa<iion.-illy *-t'ii, ijiiitr imh-ppndfjjlly i»f 
, Mtnia, At>«c««%rt forming in the course of pyaemia .irt* nut of 
^^ Ibii aaturc, ahbcugh Ihcy arc frvxn now^ tr<siuciitly to called; 
^■ittey vc really cnibc^c in orifin- 



I 



TrMtment of Acute Inflamouhtlot:. 



It is only po«ihl** hor^' Vi li^vil ^^-i^h the Konirral principles which 
pvSe ua in ihcircuuncntof i]it1ami^iAt:)ryAt1dciionAk The method 
of applicalioit of ih*"Sr tn tiifftTpni parts fjf thr txjily will Ijt 
4ncrihKl hctpafter. 

Tbc liM&i TrcaimoDt may he iiitlkaied uniicr four headings: 
Htmtvf iMe tAiitine mau, \i cvidctil, and any contnbutory 



28 A MANUAL OF SURGERY 

causes wticre possible. This is not a difFiculc matter where the 
lesion is a gross one, and the exciting cause tan^ble — f.g., a foreign 
body imbedded in the conjunctiva or cornea, or a piece of dead 
Ixjne lyinR at the ix>ltoin of a sinus. Inflammatory tension from 
pent-up effusion is readily relieved by an incision or an abscess 
opened. But when dealing with inflammation the result of 
bacterial activity, it is often diflicult either to localize the cause or 
to eliminate it. In certain cases it may be practicable to totally 
excise a local focus — f^g.^ a malignant pustule — but unless under- 
taken at an early stage> the surrounding parts quickly liecome 
infiltrated, though this may not be evident to the naked eye. We 
have then to trust to the germicidal action of the tissues^ supple- 
mented in a few cases by the use of some special antitoxic serum, 
and also by such general measures as iniprovinf- the health by 
good diet and suitable drugs. 

2. Kttp the inflamed part at rest. Wherever inflammation exists, 
steps must be taken to ensure l>oih physical and physiological 
rest as far as is possible. Thus, an inflamed joint is immo- 
bilized by a splint ; an inflamed mamma needs txith 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, whilst an inflamed retina must be put to 
physiological rest by txclusion ctf the h^ht. 

3, Reduce the local bioed -pressure and hypera'mia, and thus diminish 
lx>th the exudation and p^iin. Elevation of an inflamed limb may 
secure this end, and is a most essential element of the treat- 
ment of all inflammatory conditions of the leg, for it is a well- 
known fact that the emptying of the veins by gravity in an 
elevated limb leads to a reflex contraction of the arteries. The 
main artery of a limb has also been tied as a meuns of reducing 
the local lilooibsupply* but such a severe measure can l>e but 
rarely called for. Local blood- letting by leeches, punctures, 
scarification, and wet or dry cupping, may lie recommended in 
suitible cases, and may give immense rehef. It is unnecessary 
to mention here more than the fact that a leech can withdraw 
alxjut 2 to 4 drachms of lUofid, and that it shoidd not be applied 
over a large subcutaneous vein, or Ui parts, like the scrotum or 
evelids, wlicrt' there is much sul)cutaneous tissvie of a loose 
texture, in which extravasjitjon readily occurs. The Weeding 
from a leech-bite will usually cease spontaneously, or at most 
after the application of slij-ht pressure. 

Cold wisely utilized may be of the greatest service in combat- 
ing inflanmialion by causing contraction of the arterioles, and so 
reducing the hypera'mia. It should only l>e used inthf early stages, 
and never when suppuration is threatening, as. althongh it may 
cause local depletion of the blmjd vessels, it at the same time 
depresses the vitality of the part, and so may do more harm than 



tftFtAMHATIOti 



W 



^^^^L A^im. it ^ould t>c \^ii&\ wiXb the ^r^'ticst <^^tc in old 

^HBple, fiom ic^i i>f ciunin^' slmj^hinji; cf tiic liin. Tlirri? ^rc 

^^Eariitits methi^iU of npjilyiiri:; \i. :is hy irFAn« of jn Ecip'|>if{ ; or hy 

^Hnih'^tion from a vituel suaptinckd ovi;r the p>iiE con:jinmf( iccd 

^HvMcr or lottoti, froin \\)iicb itripsiof lint flc^rrnd ti» envelop the 

^^pAaiTict) Jirca ; Of 4 piece of tiDt nrung uut of cviptrfiitia^ l<jEuin 

^^fai^y l« pbcvsl directly oit thir fxifl, Aind timilMilly Tent-Avd ; or, 

^B>Ttt«r otill, lli« icvd «%aer may ^c run rhrou^h :i colI (if Itati^ii 

^P^ipC9 ftinoivn aA Lcitcr's tuix's)* fitted ruefully over the intlflnitd 

iq^iuu- L'u(k-i jiiyiinutri^tLiirL^'A ltici.i.ild iiiu?t In.' Luutiiiuou^t jiid 

•or inieniiitieiit, as oTh'^n^iw ilir iiti^^nij^fing perifnT* of iin.'Pmia 

and hypvrjrmiA will h^vc ;i hjinaful JuX\\^ ihun a b^ndlkiAl inliu- 

^K H«ii/. rh|>f'i'ul|y ^^lirii i uniliiiti-il vrilt iiioisltiri\ i)« vcriy Urt^irly 

^HiswhI in ire^ilng inf1;imm4lory jtfrctionK, nnd aci« in -i dUm^ln- 

^BuLly op^fVutiT w.ty to cold \>\ riil:t\iM^ the vosbo[s and 1it;tii<iK^ 

^B Iku icducti^e thr ICLiMivi .inJ ppiin. ^lAMflline rxud'ilion rind 

^V ngraiKin* and dicnirLisliinf^ (hr tcndr*nry tn «Usi?^ JE alsi^ f;ivniirfi 

^P rite Activity ^ind Mt;4Jity of tht pari l>y iacrcjnm; the v^itcLjtar 

wpply And laciiitaim^ lyniphnlic id>soiption. Wheal suppurntuMi 

nthriaiicnLDj£,lhe ^ippticjlion pI warmth and moiNturr h>i5tcn-i i\\c 

pima.. [*'or MilxriitiLnniiiii Itrsiunn. hot forn«ntaniiii!i, Enrdirnrpd 

IV not utith opium or MUdoan;!^ or spon^iopFiUiK? wrunj; out of 

bal ynttcr, or simply dry lic^tcd colton-wtwl, may be empfoynd. 

^H ^Itai :^D jiluct^-t in focmini:. lu'lhini; E:4n lie mtirc Mx^thiiig ^md 

^H WMltcFaiTA' tlian a 1in«twd-mpal pmillicfr. provided that r hr? :il>>ict-s4 

^V i^not allowed ii» Imrut into it- 1 hey Uiuuld never be applied to 

^K ofoi wottmUiTi ulrac^Hsc-iimlL-Mthe bttrr arc in a vcryunheallhy 

n lUIc ftittu didViw i-ellulitis. jiiil llicii the pauUiLT sliouKI he 

wmWkI mor« or l^ss «4epiic by rruhinj^ it uith lioE cnilvjjic 

I iniaa (t in yoi)- Tl]« honicic pi>ultic4- nr fonicntntton in mu&t 

L atcM ID iiUDy siipeffiLi^ indLtTiiin'irory aJ^c^CJoll^ dur^ tu >L'psi*^, 

^K iltfl.aail vraoi of ^ttentb^m. It licnsjsi^ in the :(p[)hi.^airin Id ifie 

^y pn of A pctlitMi nf hofftcic lirl unmk^ init iif n hot t^inr arid ^Ki^ 

ova (t m ao), knd covered ■<\\\\i oiled Snilk or i.iiUiipcKhn tissue. 

4* /Vrt*<P* fif Mtm tjf frtih i'Jtir^^t i*/ tiritfjlivfl tri in/niKta, Mull 
cfc iImmp (•[>■' to pnirrfnriivi* rh.inpn-^ in An in>[*ri diw'barninK 
^MUid. Some of l^ir nkrlhoilb jml ;tp«-nlK for mAintniniTig atopMR 
Uc de»cn1>td in CI]:Lpl<r VII. undnr the t^uhjcct of the tn^atmrnt 
odmxiundis :tnd tUi mil nt^ml Ut tir diJittiNicd heie. 

Thr- Central Tr«atni«iitof intlammaTion vane^i-onsidfrnMy with 
iWnomblion i>f ti]<: p;tiicol. aiid as- to whether lie u s-tiunf; and 
boJlhy.OTivCkikly. TIiom: who are dfpicnsed in health, or who 
tmy Ik npccrMi trjdily to Iwcotne mi from the cuntiimaiite of the 
Uviie ttalCt will need to be cairfollv supported by ;i tonic plun tA 
fr£4imenl, whdfit nX the •^me tjnie atienlion raufd be dircict^d to t \w 
Hiiuiiuciodi <4 toxii- bcdiea by suitable pur^-ativea, diapborclici, 
4ud diuretics, Qianine may be ^iveji ^ilh ^ivaX beiiutit, ^^ also 




30 A MANUAL OF SURGERY 



dilTusible BtimulanCs, such as ether or carbonate of ammonif 
whilst the recovery of patients lying in a typhoid &tate of exhauf 
lion will absolutely depend on the admmistration of nourishin, 
fluids, combined with stimulants and bark at short intervals. 1: 
the sthenic type of inflammatory fever, 'antiphlogistic' meaD 
may be freely employed so as to reduce the general blood -pressure 
and remove irritating matters from the system. In the majorit; 
of cases a smart purge, followed by low diet and abstinence fron 
alcohol for a few days« will be all that is necessary ; but in othe 
instances where the blood-tension is high, as indicated by a larg 
and full pulse, and the local signs (pain, etc,) are well marked, i 
may be also necessary to administer such drugs as antimony, aconitt 
full doses of acetate of ammonia, colchicum or ipecacuanha, t^ 
reduce the general blood -pressure, as also to obtain diaphoretii 
action. In a few cases — tf,^., acute menin^tis — venesection may b 
needed, but ihis is an agent httle employed in the present day 
In some forms of inflammation, due to the specific diatheses, suit 
able drugs must be employetl to combat such tendencies — e.g. 
salicylate of soda or salicin in acute rheumatism. 

Oiironlc luiUmmatioii. 

The phenomena of chronic inflammation are much the same ii 
essence as those of the acute process, but the manifestations an 
somewhat diflerent. Hyperemia and exudation occur, but tb« 
tissue reaction is much more prominent. The main diflcrence: 
in the two processes are as follows : 

1. The hyperemia is less in amount, but longer in duration 
owing to the fact that the causative irritant is similarly less intense 
in action, although spreatl over a longer interval. The local 
manifestation will therefore be less obvious ; there is not so much 
pain, which is mainly of an aching character, and less heat, whilst 
the redness is more dusky, and the tissues tend to become pig 
merited. Considerable loss of tone in the vessels, especially iht 
veins, results from the prolonged distension, and thus there is 
much greater difficulty in restoring them to a normal state. 

2, The corpuscles do nol tend to adhere together or run intc 
rnuleaux to the same extent as in acute inflammation, and mjgra 
lion, though it exists, is on a limited scale. The exudation i* 
much more fluid in character, containing comparatively litth 
albumin or fibrin ; in fact, in some chronic inflammations oJ 
serous membranes 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 (issues, which in the former are in a 
much more depressed or passive condition than in the latter 
They become infiltrated with round cells, derived more from tht 
connective -tissue elements than from the leucocytes, and henct 



k 



cnr^ruzAtion U much mpTC niarkcil here tli^i in the ^ict^tc form. 
Tluui:^ Hrfttturtkm. llii^n. U .1 uitid^ kf^s iJintniiinil fcaliirt inf ihr 
call)' Kt^ifse ci chTiMiic iiiBjiTniTiati^t^, i^Uhou^h Att a sv<:(in<I'iry 
chiuiiec, ospocially in tuttcrcuUr unci •syphilitic dittMBo», il la 
□lien seen- 

Tli« OftOM* :trF slmllAt In c^i^nidei lu lhti*<ti proclurirtg th<^ :irij(e 
mixchiftf, hut shf-hl«r a&d nior« prolonged in their jkction, ;ind 
tt«9 tend lo produce ti^^e pioIifcrAtiun ruthcr ihttn ti^iir iJc^tiuc- 
tiuc The mtnl ^tliikiii^ poitil ui iIil' Atioii^i^y i^ tlii: Uj^c p^til 
pUyvd by diMlwtIc r-f»rnii[ jfins or rnrmtjinnonfl] prrdifipnsitinn**. 
llo«l of ihe manifKtalion!^ met ^^ilh in NLir^ic^il ptnctice are due 
to lyphitb. tul>et<lc, tout or rhcunirtli^m, ftTi<f one jihould nover 
tifUt such A iflv \fcilhcaii <*ircifuUy ii^cidiriij^' as u> ihc n<j.ssil»lr" 
™u<Tir^ of ^Ofnr t;irh lainT, 

ThoEvnltood chrome intlnmnuiion v^kry ct^nsiclvnldy according 
to ibc p&rl of the l>0(i> nlTcclcd, and aIui with chc prrdispos^jn^ 
falhclir tJ,ilr, and WT' rjii ,U Thi> pUf i? only r[>]|ol1ii/r ^t ff^wdlii^f 
pcrtJit wnrthy of irang tiotiwd t>y (hf *ludrm. 

ii ftmplo chronic in flainmu lions the vtraX beccmcA inhltrmcd 
vdoUrv^* nuitily fmm prolifctation ot the connective t)smjc». 

Tlin, n Inner iv thii.'kmi?c1 :uid coDdf^ii.HeiJ 111 cfituiiiL- usItntiN, 
v^ilit in chrunic pvnotitititi :& nt^- iiibp^Mosteal d<?pL>9]t of boner 
ta^occiK. Gittiid* become laxsvf and indurnlt^U, mainly by hyper- 
[Itiu of the connective ti^Nue. nhiUl if the nk'm is ixivoIvchj h 
mj either became iricreawd and ibirt^erieJ in hulk, ;l^ i:l chriinic: 
bjftttropbic ccifrratii. or it ma,y entirtJv loie lU chai:icten-.tK 
ductufe, and \k CDrvcrt4^ii inio ^ninuljilicir] 01 fdiro-cicatnciai 
ti^DC uith 01 withijut jti i^ilrtvpiiiu;.' idtt'jjlivc 5lii*:e. Tiue 
■ppnnUoK) oocu» bui rixely. ^dchougti ct-nitin t^periik Dr^anisms 
<f ■ km vimlenctf may ocaisioiT^lty k:L(l I0 ii« d(rvvlopm«nt, 

l« chronic Tobarcvd&r iutljimTtidiiuu the tissue of the part is 
lodicpd by pvdpvt»leiii;iloiJsf.'(^niil4[ii.]r tissue* scAtli-Kicl throui^b 
vudi h«» And ther« ^re dcliniif luliorTlf^^, whjrh may run 
f>(dh«r aimI k«d to ihc ionn^tlM>n of crLtJti.ilin^ toci; ItifAe in 
>VE) Duycilhri le^ull n\ siipifLiiAlLiru c<i LikcMticm, or may ujider^M 
L^ikifiraiinn, an<l thi^ir f »tf nsion Iw hniilrd hy .t ntlrmsing procrr^ 
Muind thofn. A difTLifip o\'erj^owih forms ibt- earliest ^tj;{i?, ^^nd 
Ektt 10 often foiloneti by dciEruction of the mvolved Iii5:sues. nnd 
poaBoblr t^ittf,AnjfAt\iiti of ihe partst with or without luppumtinn. 
In CTironk: Syphilitic inllammuiitin (tertiirj) the imv-i miifkcri 
Iniwc 14 an ro^Asion of any of iht; connisctive Ukkuc^ by :i 
lluUr oudaiion and hypcrpUrii.i, u'hicb may he diflus^ or 
; ii (be fnrTuei, ({cnen^l vilcioui of the pari iefiuh>. «^„ 
«tany'1iard lerliary teuicle ; hi (he lalltf. a j^uinrn;! i* 
fctfiloped, which unuiUy under^'oes cenilrvd du^vntraEion diid 
l«i3bs irivtniE e^t to a i^ximmy lli»d. and kavm^ a btUhcry- 
baking ilcnigb behiud. 
In alf Ibew wtetkes of chronic Inftamnidtion a mvUed prn- 




lifM^TiHiti k :klu'4ys diutit] itt thr timira intinu of ihr nnrrifit of 
the inHamrd ^itta. Ehir retuli of nn a.t<ociAl«<l rAnwtiV tmiartfriiut. 
Oonstitutictiuil it^mptomi ^ltl- Iml hlllc vvidcni, I>rv^>n4l \honc 

ait fine, nr in '^|>Tir ifiniij'rs <Irve!opT-(T trront^iirtly, 

Thv Tnatmont ol ciirunL- inllMzniti;i1roii i* uiitiuilJy Trucb more 
prolcnit^Hl flinl lUHicult Ihon UmI d iicutc C7i!ic:*s bt^f^aunc ol tlic 
cuoHtitutioiiii] tlystiijjim tvljidi FJviftt^ m.> fieniiemly liclimil it. 

1. The *"iwrw nifuf hf rjw^TW whenever pn*yWe. Dea<I or (US' 
«af>«(f 1ion« inu&C b« iab«n £iu-:Ly by op«fiilioD, if Een«bk. aihI 
Itiliuf cuJ^r mMcriAl mu»\ [k j^oi nd of by tbe knife or aliArp afiooo. 
wliiKt il ih ofcini ilfHiiflblf fi) Mjppli'irifiiil llti?> by (litr MiliM«(]uait 
af»pli'"--aiion of pure carlwlic aciii, A chronic ub«:r»4 h hjthle li> 
incKvif^c tbo aclion of the ofit^inal imtitrt ihrou^b Ibc tension 
cn^'rmlcu'd by it» presence^ AOii licncc lE AbouM be ileuU ivilb j^ 
CAiiy AS [xiviifkir unilfT rb*^ Ktricti^M .tnii'^-jitii pk'Cmutkitis, 

2. Ktff Iht pari ut rrxt. Tint h jutt .is mucb -in i'uenlijij ss 
ir ibc trc^tmcul c>f ^truti: inHnmrnnliLiTi. jomlii nu^E be imiTiu- 
bib£ff<l ; xht. ^ptnt- iiiktM hnivr ihc wticbl lAbni fri;m it b> suit^bfr 
appliiino^, iirjwtltr Mill, by mauil-iirin^ fbr ri^njinlrni pnwiion: 
Mcrctnry Rlantlii miiM not In- jctu-dy cxcKwcd* anci kpusc otpahs 
nixut be protected from irritntiun* 

J, C^flifirtr irn^jVin is one of tbc meat u»fu] fninis of licAl* 
mtrnt for chtonJt in t1aniri.it t>ry tiHidUtonv Ii h ^ippUed in 
nnany ililfctcnl wav%, --Lccoidinic to tbc! cbftT:LClct of tbc dijv^sic 
jind the port involved, Thu», friction t^-ith the n,iked b^nd, or 
with St inn) til tin If ei til irw-a linns, pnithites n 1iypei.r-niic i-miditioa 
of the «kin. :iud prr>;Tiote« IocjjI d;.-inily in the Miperficial psutK 
wbicb m^y rraet betiefiL-iaHy on deeper straclareu. Scucrtt dre^mi; 
may \< siraibtrly employed ; il consists in ATiipprng up tbc pnrt 
{f^.. il joititj in strips of lint fovereil wttb line, bydrar^^. tu. [con- 
raining' fAff JO per c*nl. of f^mphorj, ;4n3 xhvn encjrclinff it 
finiily ivJch Hi.];ip phk'^lor, spr«ad prefcrcibly mt chamois IciUncr, 
b^itinr p^tiTit i^ Atiulhti ubcfd! iLppbcjitioi>, ^v^^3t NiMcr^ ai*: riiuBt 

^,4bi,ibli- in siii(;ibli- <au-s, Tltr mox^. a uouiid pindunril lay 
buminj;; a ^pirit^joiifi w>liili4>n of i;a]Cp«tr4> dh Ihe ntdn : Ihc tsauVt 
ih^' mAinicTi-incc of ft rn^' stirfiicc, however produced, by tbc coti- 
Man; pirscncc ■>f wnic Imtmit. Mich 4* the inwition of a br,id. 
cir ibi- iT^ip nf uiv-in nintmeni ^^i -t drrwilntj : and ibr spton, a doiibU 
thrcAi knoited nl c-.tdi end, pusucd for some diilancv umlcr th« 
:ikii>, .ind dntwn from end 1o culI ibily- iill ihc^c ,\tc hut little 
i)M?d mn\', ^ihiimigli thry miubl W. LK.v^.*iionully cinjtloyctl wilb 
:kdv:im.i|:e, The;4ctii;d ciuiteiy is the must wverr form nf conntrr- 
trriunt. and in espcaally useful m M>me variecic?s of chronk 
Jnfl-immiitJon of Un:e» :in*l ]oint!i. Various tbroriea hax-c licru 
Hu^l(r?iled loesplaiu the mflboil of iittioii of cuuuler-irrilstnt?^ but 
(hi.'re i» ^till si ^ood deal iid doubt on tbe subject. 

4. f^iffssuft is n inofti importanl elenivrt ni the treatment id 




INFLAMMATION 33 

chronic inflainmatory disorders, and probably acts by artificially 
bracing up the vessels of the part which have become relaxed and 
atonic from the prolonged distension to which they have been 
subjected. It may also act by inducing the absorption of the 
inflammatory exudation. Firm bandaging, and especially the use 
of an elastic support in suitable cases, is the most satisfactory 
method of application. 

Gtmral or constitutional treatment must be also adopted to meet 
the specific diatheses which are so commonly associated with 
chronic inflammation, e.g., mercury or iodide of potash in syphilis* 



3 



CHAPTER IL 



StTP?nRATIOR AND ASSCESS. 




WaBN Ibc bilamomtor^r pructiss results ftuE^ tin- in li.'ii of corlAin 
cucro-OTifunsms, known asmt^g^mV, lii|tiL'f^i.[uiii i^j^ ili;: Inflnrnt-Ll 
ttSKufT and of thi» exudation follows, the hquefteri m;itcrutl hcini^ 
LnowD fts pujit and llic process whicb Icaas to its forinftlion ft* 
nMwtitvM. Any louillz^d c^jllcciion of pus is known m tin 
dMTdJt, and of such two ^eal v^irfelles ^e descrilird— the aciilr 
And the chronic. 

Acutd Abflo«u. 

Etiology.— ^A large amount uf experimental work ha» liocn 
iLndertHkeri Ut awrrain tht rtrlulions <tf tincff^m to Acutd suppura- 
tion, imct from Ili« m^Lss of evidt^nce— mainly concordant, bui 
occa«icnaJly conflicting — the fDllowin; conclusions may be 
ilrawn ; 

(o) Thai hoftrrui art ^rf sent tn all mutf ahscusfs, pJlhrr in thr pnt, 
Ot in the abscess nAll, or in both. Qgslon of Aberdeen wa% ibe 
lirsl to proclaim this fact, nnd it is now gcnemily ncccptcd. Tbc 
failure to discover organisms in a few c<isc& is quite poN»blj due 
Ui imperfect obsCT^'ations, or to the fact ihat rbry have dini eiut 
owinp; lo theit low virulence and the Activity of llie KurroLindinf; 
tJ£iuc9> The liver is one of Ihe commoncnl stcn lo find Mciile 
pua ; pofaibly tlie bile may play stmin piirl in Us (Micnncnci:. 

(ft) I'hat ftiw^b hattcria can uach thf infamtd arta tit ktr from uyUk' 
ail ttu hody cr from nitltttt, 'I hvi farmf^r method ib the* more 
common, and is illuitrutcd l>y tli« obscnali^n:? of Gorrc and 
ButkhAtdt. wlifj tubbed ijujtuie^b uf Sinph^IoAtitin pjra^atn 
iiutnts into rhr/ st^in of th<-ir arm a » and produced acute suppura- 
lion commencing in suporhcial puMulc^ and fnuBhing ae boils or 
cATbuncles. The suppurAiion occuiTJng in v/ound» ia moM 
commonly due lo infeclion from wllliont, Init [h^re can he no 
doubt \\i9.l eiiil&-mfktu?H occurt^, by mpAn« of whtrh fln abncess 
CAti be pToduced by infection from within the body. This can 
only happen when the vitality of ibc patient h considerably 
deprcKned, and namet focal mndkion ri:i*i^ favmirable l[> liticirrial 




SVPPURdTtQK Attl> ABSCESS 



35 



I 



dcttJopmcnt. Thus, Riven -i blood-clot <ir infirm n^Aluiy srmits 
t!jiudaiion in an itpbi-jilihy dcprr^^tO indivkhul, whotR g^i*rmScid;»l 
power is low, vuppuralioa it likv]> ro en&uc iratn .tij to- infection, 
the oriE&Dtnnd hcm^ prcviuualv prc-cnt m the blood : f<*., ihe sup' 
piuadon vrhicliv<xu%[t>»:ill> fulluw^;! Mnjplc fi^iclutr i>r fi^ijrialoiim. 
An at»ceK« Ihuj* |iro4)ii«^d may 4* lertTiw] iin idiopathic mferhvt 
ofafflv. OccasionaUy ih« microo^s may be otrriod either tn maue 
ttmigima condition)* or in 11k subtitfince of a Mnall ponion uf 
olood-clut, ai au emtxjlus, fiuin one pml tjf t!ie bndy wh^tr an 
fnl»ct«>d wound <\r injnryf-xiftU to some otiwr part, tliutori^mftlinu 
an tmMif mft^itM Jibitfu* Pysrniic abKi«fia«6 ure of Ibia type, and 
9tstiiiaj rc4ulc» Buy occur aftti ^ononbLea, and artor typhoid .ind 
iithrr fevers. 

(f) That cniina^ irfitattn^ rhmuaf prndjitu of ifmtutd fitrngn 
Mut U^., silvcr-witc or i:lnss tplinlcnj) di> net prcdn^a fupf^unittoH, 
except Id tbc rarcAt of ciuc», by aaEoinfcciiort. TJuf** j^ i^JC<^d 
^linicr of k''<"i ad inch and » quarirr Ion.?, ;ind Jiyin[;b and a 
hiHwi<lB,tb« ftfsuLC of the buTf^thig of a sGda-w:tteri/rr^p wa& cut 
out of the iic<k of ii hotel porter text months nhcTJalmA calcr^d ; 
it hadcAUvcd no Tuppuration. Iv ^ pifftfy ^j^ s/i^j^jiCTfi^r) id ; c bfcii 
nude aiiJfcilprilKHi tr^dni-ciil ;irid*l'iM;i*H'ilTnis. in tthjrh ibe 
vub«tanccd^ie^rv?iy ic^ed uj^ jn WtBin glass cap&uir vvn-i im 
ptimtcd ifeciiffM ^cfl|^|^JVTft:':l[:ji^ an Anim/il, .nni after a 
drlny tcilfill^jAyUlir iKWou^li ht^kUBl^^if dm vkDucid ujis >el (rvv by 
a Wow- ^^o MipjmTatitjn en*;t«fl, iilihounh a reruin amount of 
ptjtty liific fibimuui material wut found at the Mie of operation ; 
t-wt the tissue -licjutfying properties of bacterial fcime»l£ bcinjj 
jbv^al. DO tive pua wiia fuuud. On tbe other hand, injrrlinnvof 
Ibe ptomaines produced by bncivria {t.g., cadav«rin, putroficin, 
ricj have re^ull^d in fuppuration, the tiaauc"; being hquehcd into 
true pu^ by their activity. 

In oonrWirm. ihrifrf've, a1lhon>;li suppuraljui} may 1>e pxperi- 
RMrnlally Inducrfl in animaU under t^peci.'il drcvirnsUnccs, apart 
(fom micro-ofRJinisn'kS, itt ihah for all ordinary cimdiiions suppHTtitian 
^cr* met x^Kf aidfifr^m Ihi fre.*eHCt .titJ vttai tulivityo/ sfai/it t^iuterm. 
The cau*c, mer, cd an amtp ^i>*M-p.ss m;*y for practice? iinrposes 
b* grouped under the three following headings: (i) llie itidi 
vidual aficctcd 15 very ponr.ibiy in a dcpr<-^$«d ond unheAllhy 
viale, an4 the Kermicidal properties of his nsMies *iie defeLtivf- 
(3) A Icital nidus muit exi%T, which Is in a «)ndition of dt^prc^t^ed 
vitUtty, from mjury. cold or othervviiv ; and (3) this jpal must 
become iniecte*! viith pyo|jcnic ort^aninmK liroujiht to it eiihtr 
liom *ithJu Off nithtiul the iKwiy. 

BaitoifatUT- A* alnwJiF rtatr^> the- pi^f '*i all ncutc Ah«cnK9 cooi&ins 
faiHiaf( «q[UKMnf, tb« CMluni of uhicb. bowctvr, vartc? v\th <ir\:unutiuice^ 
Wltcvvapfianlkfi occun in ^b^nnd* in ^hictt [here u but Inile piitr««cilik 
ttitctfa]. Of arlu4 Idlcfiathically, il alnwiV Munyv ruulu fmm a chrrci In- 
factkoa ttilfa [Jfieur rogiovf Uitf |iuvti(i>(]LidLiu f^th'^^uJi: tui^irriA 1 11 luany 
A>GUIad Hptic v^iondtf. bonivcvei. non-pfkibii^cenK bnctcHii are alw prewnii 




A MANUAL OF SURGEHY 



lesdioff to putrebction of tho disdiarge. The most important Pj«|«k 
Orfmnlnu are u follows : 

I. StafkyharaiLi pyogrmti aurem h that most commonly found in all fad 
of localized suppuration. It can be readily cultivated on nutrient gelaliH. 
■gar-agar, or blood serum. On pUte cultures it forms in two daya goHos- 
yellow colonies, as also in tube preparations. It is very resistant to cheinicaJ 
and thermal reagents, requiring se\-eral minuiea' boiling to ensure its destruc- 
tion. It produE^ea no gas and no slifiking odour in its growth, and is capable 
both of peptonizing albumin and of liquefying gelatine. It ia a facultatii« 
aerobe (p. 23). 

Z. Stafhyhcoaiti pyogrmn albtii, 

3. StapkyloatcfUi fiyogents cttreus. 

These two form* 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 alms is a little alower in rendering gelatine Auid, 
whibt the aiotis is apparenll>[ not so \-irulent. The latter organism is very 
similar to, if not identical with, the Staph, epidnmidii aibus. which is widely 
scattered over the sitin, and is usually found m the small abscesses developing 
in connection with teuse stitches. 

The staphylococci are mainly associated with the formation o( localized 
abscesses. Thus, if a culture is rubbed into the gkin of the forearm, a plentiful 
crop of boils, or perhaps a carbuncle, will result: if injected beneath the skin, a 
aubcutaneous aticesa may be formed, or even a typical carbuncle, if a suf- 
ficient numbA;has4jeen iniroduce^and if they are unfiltered so as to retain 
their toxinea ; if the peritqc^ ^4w~^ infected, suppurative peritonitis follows, 
provided that a ?umcient qDaotitT of the organisms is present ; if a joint, 
suppurative arthritis. When injecli#inio ^e blood-stream. there ia but little 
eSect if only a few are introduced ; but ^b^^^AyJBiultiple abscesses in any 
and every part of the body may occur. A ii^yiftftiil or more frequently true 
9cptica*mia; if, soon after the mjection If an amount not large enough to pro- 
duce general in^tion, a bone or joint is Injured, acute infective osteomj^litis 
or arthritis will follow ; whilst if the cardiac valves are arlihcially damaged, a 
typical ulcerative endocarditis ensues. All these conditions may be produced 
artificially in animals, and. from the similarity of the symptoms and the 
microscopical appearance of the parts, we conclude that similar conditions in 
man are due to exactly the same causes, except that the infection is not arti- 
ficial, but comes either from without as a result of local injuryn or from the 
blood 'Streain. 

A. StteptocoiCits pyogenn is an organism of great importance in patholog\-. 
as It is the main exciting cause of mAay inflammatory conditions. 11 is prob- 
able 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 temperature of the air, 
and not very rapidly even at blood heat. It does not liquc^ gelatine nor 
produce any colouring reagent, but has an energetic peptonizing power in the 
absence of oxygen. It occurs in chains gf varying lengthn which may occasion- 
ally bifurcate. 

The Stttptccotcui pyogenti is mainly associated with spreading inflamma- 
tions of the cellulitic type, whilst it is a &immon cause of pvsemia. and even of 
acute scpticiemia. It has also been found m many acute focalized abscesses 
in empyema, and in some forms of suppurative artliritis It is probable that 
the streptococcus of erjsipelas should be included in this group 

5 The BaciUas toll iommuim is an organism to which much attention has 
been directed of recent years It is ideni.cal with the microbes formerlv 
known as the Bai: pyv^ /"''''''* and the Biic iu<t>i atrogmc^. U esisis 
normally in the Lnlestmal canal, eiitendmg from month to anus, but most 
frwiuently in the duodenum and cok>n. and pn>lftMy pUys a considerable part 
inlhe normal process of dis.ntegr^t.ou of hxxl-slufts So lon^ a.-, ji ^m^ns 



SUPPUJiATICS ASD JBSCSSS 



J7 



$ 



v1thintbwbnw«1.irivHrfKttvinnix«nn 1w unanwUlcmbte bo pui fnW or 
ihnniRh ilie ka:ati£al will, ai a luuli at toty lov or dWDadaa Irt tn vlnUty 
Lif abraaiian u^ tu Muhkc, it ih lUblc lo bctimie iji[c(i)cly irjiu]«it< prodadriK 
nsppumiiv induimiiiiicn uf the ni<»( jlcu(c i>pc^ <>r «ven iiecTuut- Hence h 
K Ifaa rnoti oomnca <ouH erf IGUI* ^uppurnhv? pfriioraiiH in all au« whan 
tlia ialKtkm anH« frota tb« bo^«L wfatlsi IL icAlbo rnamly rtiponuhli' ^r ih* 
imuloaol ab«B*« in the r^fli^hhourhitorl of (he tube, u in apppndicKU, 
MVte IncUo-nctil MC^urstliun. etc One rf iln dimi chanuwrbllc tcdim^a l» 
ItiW Tien vben cnllitJited in a t«irt-lubv— it praducn & muat uSeiuive nml 
p«Drtr»li:^t odoor. AoiDoirhAi linulu' lo ttiii of docMnpoBiof !«<«* ; »tich ih 
A^ c«tk«d ifi cho ptjt pri^ducfid bv [he oniiuiiun 
ft The B*itl2¥i fy^Myitfiis u (cciiloiutlEv rael w«h in voundi. producinu 

(Bftfcw c«M whnrll luMbm kiicnvD lo pv-r nw lu um]i.'r^l irtrcttion 
T Tht rnnmtnxsms kaJ Afjil/ar fy/Ariijfi tany ^w i,'iv« nw lo suppurukm 

*.hrj piKUaKKUA Bod typhoid it*vt f^ppiii-MW , tiui thcv tic MvA specially 

viralent. jmd Uw •baotua juv viuaUj ofa fcubucuia t^^. 
A Tb*Cd*JUitf[irf muu jiIh bBinckndttl in thii caiivory, 

FftUiaJldClcal Aiutamy of An AbupGMi, — Tfir? |>hen£iinr-nH nssoc!- 
abed u-ilb ihp f<.iriEKLltL»n l>I tr ^icu^t; ^ibnccsft are merely n fuilher 
3ti|;c of thotic dctuikd ;ircvioualy a^ ch^nictcH&tic uirillamirm' 
lion. Tbcf VEftf)Crb» uf ihr aiTrfcEJ^Ej Jitru liecciitic^ JislvaUirJt diiU ibo 





Fig. 5,'Diaumii op ah Asscto* IJ( Faqckh or FotiHMio«' 



W 



In Itip pniptim' tlv vvwiUara twn 'IiIjiTttI. bLii in iri'.- cniirr tha tUiamrt oi 
tktftax b lodiiiinruibablfl, tvinu iv|>lued U>'iU(e1bi]af infihtoliuii unJcr 

Tuious i^cmeiit^ fjt ihc MlxhI jmoqa thrtiugli the? wa11». As tbc 
orginUm^ cjevelop, llie vaicular phenomena of retardaT^on and 
atAaU loUowud l)V itirombosift occur nuccc**]velv, whilsi Ibe 
cxuiJatkio ci ccU& brtoHU'h vj jiiral Ihat Ihc ctigiii:il tissue of the 
pin diHuppears, AUvt piiv^iii^ lbn>ii^>i a -<t,i^tf of ajft^'iibiiun- 
oftCTous (Fig- 5)- ThU removai of Ihe mlilliiift*i lUsues, thoagh 
dlM in part lo th(f dcfoclivo blood-^npply brouj^bl .'tlKnit by th« 
pccsftkUte of ibc ciLUi.lrttioiT dTid llie VflscuUi thiumbo^is, b mainly 
ciUHd by ilwif li^iirf;trTif>n owiii^ tci the prproni/inK powci of llic 
hwrttfia prw*nt. The- nowly forrm-'l tU^Lu> ropbcinj^ tlitm c^n- 
■MS akcr«}y of a nuuoj rnunLJ lc-II^, (Ik- ^cutnki porti^Q ^i which 



38 A UAIWAL OF SURGERY 

is also liquefied 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 usualW a 
tendency for it to increase steadily in amount- It may then tjcd 
its way to the surface and point ; it may burrow alone fascial or 
muscular pianes ; or it inay, somewhat less frequently, become 
circumscribed, 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 breaks down and liquefies 
as soon as it is formed, whilst granulations spring up from the 
floor and sides of the cavity, endeavouring, as it were, to 
^6bliterate the track the abscess has taken. Thus, a definite 




w 



^mwy^£^f 



Fig. 6 —Diagram of the Later Stage of an Abscess vmicH has 

JUST BURST. 

The walla of Ihe caviiy are lined by granulation tissue^ except at the eitreme 
margin, \tbiUi the pans around are hypenemic and in6Urated. 

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 (Fig. 5), one meets with the following zones 
in passing from the centre to the periphery: {1) The central 
collection of pus ; (2) a layer of breaking-down embryonic 
tissue ; (3) embryooic tissue showing a trace of the original 
structure of the part in a state of coaeulaCion-necrosiSf and with 
Ihe vessels thrombosed ; (4) tissue of the part infiltrated with 
leucocytes, and with the blood-slream either stopped completely 
or retarded 1 (5) hypersemic and slightly infiltrated tissue of the 
part, gradually shelving off into normal tissue. In the /fli^r stages 
(Fig. 6), where the inflammatory process is not spreading, the 
following zones may be described : (t) The central focus of pus; 



SUfrVJtjtTION AND ABSCESS 



9» 



by«r or 



ibli 



normal 1is;iue som<9whal 





ti^ue: (2) a layer of fibi 
litflve j^ndiuUy mcr^in^ into (4) 
aililir«|cd iLDil hypvf^mk. 
The "l*iilr*i? AfBB and STmptomi of an Ncute Abscesi nuy b« 
~ uiukr tltrcc bciultnfi^ t 
be Jtvit/ Jiftu coDAist of a locfilisfid puich of inflamed Uaauo. 
cad b> 1h-'»i> p^in, mlni^-ss adlI '<wd1rn^, which lait«T is ai 
hard And bnc^ny^ hui wK^n pus forms the contra b«C0Tn«« 
4<A, elAatlc, and tlucxuntmf:^ ^hilni nupcrficial fi^dcmii is more 
aukcd. And ibe pain tnor;; tiirnhbini; in chAr^ictcr. Nataratly. 
tbr- Ammjttt of ihin pain drprmk <-ntitety upon theilpiisiiy of the 
Afr«ct«d, And Ihcfiupply of ficnfiory nenxs t(> the p^n. sup- 
tion beneath a. dcnnc rcn^ttinfc mcmbmnc. such a^^ the pnimnr 
teinit a)vrAy> intmicly painful, [f left to itself, iui abscess 
cm lAler poiniH and buT<clv. Av H imrrF^s^^in si»p,ii eierls 
preisuns in oil dircctioct, and caturnUy seek^ Eo find an exit from 
03 cnviTOomcnt in the direct ion oi Icii^t rc^iMAnc^, and so may 
cither finJ its «ay Ic ttic ^mface. ot may biiiiow utong muscular 
md faaf Ul plarv«, or into Adjacent ravitit^v This ih not merely 
ft medkomcil, but ai^o a vital pn>c«i4, a^u ^ilroady d«scrib«d. 
nikai Ibe m» reaches the surf-icc. it usually opcn^ by a flimpie 
process vii iiWrnrbn. jtllhinij^h n Imt^ ^li«<f>« may ca^sf^ sl^}llgh- 
ngoC tlitf sup^rrkbl ccv«fmf,' l^y cutting ofT Ihe supply of nt.ttri«nt 
nattfial from b«low. 

z, Pnatat tfnU are maialy due to the mechanical influence of 
Ihe MvrlhTTt,' upon »(urroi.in(]iTig smicttifes- Thv mosi rvideni are 
Ifaooe due 10 th« iTTit^ktioa <ii [lervvtj, as a rcsulT L>f wLiioh neuralgic 
pan niHy be prc^nt, or tho patient riAy refer the pain Co some 
dblaut uiuflcLted legion, lu MJiiie ua^cs, \\hurc bloodvessels axv: 
intols^, the tissup ftroiind |h*»in diKappi'arfl, nnd rhfry are left in 
Ibt ab*c«6« cavity as t^nnds, i^urroundcd hy ji-r^mjlation tissue, 
Thrombons nnd ihe MjbM>quent obliterAtion of the vessd may 
refull, or ncca^iooall^ ulciriation Aiid h^^moirli^ii^e [idcerative 
pedan^ritia), Tisbri may br hid open by the prcisurp of an 
abCB^M^ whdfil joints may be inviided, leadia^ to f^ubsequent dis- 
orguUatkon, and bon«--« may l>er^^jme carious ^^ even necro^d, 
eflrrtft arr moTR commnn hi chiimit rh^n in aciiir- abscesses. 
■ 3. Th« gtitnui tff^'tt of the formalton of an aeute ab^^esii ar« 
imply those of increaMd fever, aomi^timc!^ amountmf* to a ri^r. 
A rigvf conR«t!i of a definite scries tif plii^jioiiifiua, ihr re^iuU uf 
mnr stimulaFm^ inl^tierire re^irliini^ Ihp Ih^imoKenic oeTitTe* of 
tho BiedulU* detetmminii a sudden mcrea^ of activity. It is very 
flniiaf in nature to an iittack of o^ne. hv\i\K uahdredin by a lecl- 
ki(f of intense cold and discomfort : tlie rcniure» are pinched, and 
teeth chatter, Th^ sWfn, however, feeh pungenTly hot , and 
temperature of iIm body rapidly rise$. The eerisation of cold 
U fNirtly due lo Ibc contact of air at a niaintjiined normal tempera 
wilb tix di>. hot, uri^-i spiling «kiu, and also possibly to the 







40 A MANUAL OF SURGERY 

condition of supeHicial anxmia which is present. After thi: 
stage has lasted a variable period, the patient gradually bejpn; 
to feel warmer, the face becoming flushed, the therrnQmete 
ceasing to rise, and the skin beginning to act. Finally theti 
is a rapid fall of temperature accompanied by profuse perspira 
tion, which leaves the patient more or less exhausted. 

Fnt Uld its OonAtitiiezita. — Normal, or as it was formerly call«i 
health}', or laudable pus is a thick, creamy fluid, having a specific 
gravity of about lo^o, an alkaline reaction, no smelt {unless putre- 
fying or under special circumstances), and containing 85 to 90 per 
cent, of water. If allowed to settle, it separates into two layers, 
the upper or fluid part, isquor puris, consisting of liquefied tissue 
and serum, whilst Che lower layer contains the soUd elements 
present, viz., dead and living pus corpuscles, fatty and granular 
d^brisi perhaps micro-organisms, and possibly a few red blood 
cells. All the pus cells look alike when examined under the 



m ®^{«) 






® 



Fig. 7 — Pes Corpdsclhs hefope and afteh Treatment with 
Dilute Acetic Aciti. 

In ihe former ihe protoplasm is finely granular, and ihe nucleus not very 
evident ; in the latter several nuclei are clearly shown. 

microscope on a cold slide ; but if placed on a warm slide, a dif- 
ference is soon noticed. Dead pus cells (Fig. 7) remain rounded 
in outline, coarsely granular, 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 otserved; 
the proliferation of the nucleus is always an evidence of degenera- 
tioD and approaching death. It must be clearly understood that 
both the living and dead cells are derived from the same sources, 
vis^., principal^ from the extra vasated leucocytes, but also possibly 
from proliferation of the fixed connective-tissue corpuscles of the 
part. 

Aa already stated, the pus in an acute atscess contains bacteria^ which may 
bcBt be demonstrated in the followinp v;ay : A drop of pus is placed between 
two cover-slips, which are each evenly coaled hy a thin layer of the fluid by 
sliding one over the other. These are dried by passing them through the 
flame of a spiril-lamp. only sufficient heat being employed to set the albumin 
without destroying the corpuscles. A drop of methyl-violet solution is now 
placed over the pus film, and allowed to remain for about a miDiiie. bong 
ibcD washed away by a stream of distilled water. The slip should be a^n 





iloitljr. ml noQiod k Caiuds balsam Tbe uucci tnW) bv (buml mined 

|v. ^h<lM AlbuidikvB} and itllj cr&nnks 4/« not toiourvd al aH, ur bul 

ay (Fig. *J. The a^ma^cfpoiti of Uie coc«l v*n& with the eharaciir of 

■aippUTaiMiO- If Cbe *b*oei« iii tDc«lU«>l . Ih^y wiU usually fc>OArrftnjsd in 

_ lan J«Ui(<iv]acaco. l-~i|f i. Vt ^. If fhr uipj-iurincm ■■ of * «pEWhj)g ijw 

«rl]MNi|B totaiWd i«ry arulr Tbrj <ri11oc4:ijriii i.-]viin« |iirr|iliJCrKr(. Pic i, V ). 

Vvmis terms arc ttpplicil to difTcrcnl tjiiiisuf pMa which hiibo 
unlBf i|MKial drcuni^it&iictSi. Whrn pus l\ nuwA with iilorHl. it 
bl«raMdWBl««S(fihcnfbr UDgUllMOUAr. ^vhcn ihm and ^CT\t\, it ifi 
litwina; cord;, when mixed with c»rdv fhrciU, oa :k more vtsiiJilly 
«m in chrojitc soppi4i<ttian of a tLtbcttuUr aaiurc; mQCC-piu» 
■hrn Tnixrrf with imiriis, anumfi 
torn ind^mnutory conditjons ^ 
BOCOu* mcmbf aucs. The occur 
loDce of sOaking |ius Ap^ti from 
pMrrfection h^t^ Iwn jirmdy «x- 
ptaosed AS brrnf* du? ici the AciKily 

vi the B^Uius ieii it^nmMnih 

Tbt? Dbcnoal* iif m atuie 
abacets* ai a ful<f, pmt-iit« no 
6iiailti«>> the Mnfte o( Ructuji 
lioD npcrvmni; id Ihc xnidiiL of 
i& arflt Dfpviously iiil^amwl and 
tnwnv being qiiiic charucc«r' 
■tic ; out when The pus is pboed 

J»br undw musc«U iiiid>^Al p.^ , _ p,„ ^^^ ^^^^b Abs«». 
^laan, vtry «(eluJ i»\an»iTiMlitin viu.wiho Conrirvcus Mitt C«c«i. 
nay be ooMed in of<l«f to dc^ter- 

«»inc ihc cxisicncc ol An ab^cesa. Tlic surgeon nimi noi be 
aii^kd bj ibc wasc of fluciuuliuii oliUiui^O acrtijis ihe fibres of 
J mdvl'*: nonr i*i noiiced^ howe\<er, by palpating along the 
course ctiit% hhfcf^, 
Tr«4tBMai of AcitU Absctu^ — Wlicn an Julliuncd nttn is 
rmniC lo KuppLinilr« liir fonnAlion of |>vi4<.iiji bt Iml rarely 
In iSe e-irly Magf^, cVviiinn and Test of th« part, 
:f wilh Ilk) jipplitution of cold anil c\JLpor«tinjj; Ititiuns, may 
matctunes succeed in ^compllshini; xhtt., .is ^l&o |>us^ibly the 
adnuiUKiralion of tiulpltide tif i^lduiii in pilU, wiih i]i:inin^ nnd 
iron. The liypodemi'c injection of powerful antiMipiics — /hT., 
pure ctubolic scid liaa alH> beeu employed to destroy tne 
pyocnuc urguibdis iit iita. 

Ift a fcm' rpgkm?* of llie Jx.idy. pus iTiay Ijp txhufthtd aftrr its 
lonwatiOii. Ihic onlv when tLitLi:a«d in a canity of highly -absorbing 
pVHrcfBt MCfa as the ant^'fior chjmU-r of the tyt (IijpopyrinJ, or 
pevlups some of Ibc seruiui l^i itif:^. e,«., ihe |h:r]ti'neHii. In the 
(onntf lh« proc*^^ of flb*nrpiir-n niay rpn:(inly he oliserved under 
ibe inflliMice of a Mmple Icc^l an<l ^I'fieruJ Irealtnenr. 

A4 a Tu\t, liowcvcr, one rncoura^es suppuration by applying 
hoi fumeuutioiM to ihc pjirt, aad then as buoii as pus i!> evident. 




■4» 



A UA^VAL OF SUMGEttV 



an indcioo i» made to fv/Knate th« matter. In some ea9e« It Is 
acKUablo TO anticipate suppuration hy a ire« iaduOD mad« und«f 
antiseptic precftuti^^os (e.^.. in Acutc pcrioititb) ; this haa Ibc 
tienpfidiil pffecf [>f relievrng [**nsion. and often cuts shori Ihc 
mllnrTiiiiEktory proc«ftft, la ircisinf- an ubacess, care must he taktm 
ih^t tho opoEiini; is lar^ vnouj*h to provi?nt re-acctimulaiiofi. Ih^il 
It ia placed al a spot suft.iblt^ fur Jrairijjfe, jis far as pOMtble 
ffOTTi Miurres of Mpiif <oritHHiiT)iaiiiii, and in wirh a diii>r(iiin thai 
inov^tnenlfi of th^ pari do not cli>«e it. The anatomy o( ihr region 
iaciscd musl 1^ remembered, jiikI impoftunt ^truauroji .^voided. 
Ill lir^iljuif wLllt dtr'p A|j?^cs^'b nt iUii|^ctous rE;G;i(>n?*i Sliitatl'i 
m/ihiii m;iy Iv .idvantaReoiislv rmploy^fl- If rnn^^iHi in mrrdy 
dividing th::^ »Jiin nnd ^uperhciAl f-irucluTc^ And then ThnD^ing a 
dircclOT' inln rhc Abscess cavily ; a pair of >ii^ti^ or drcuinj; forceps 
IS rjrm~ i>jihficv] alf>ng the f rrxivi^t and on forcibly Kcp^LT^uinfC the 
bladf!^ n luflit'ipnt opening is made to insert the miger, wbf-re 
practicable, and sut^scqucntly a drninaicc-tube. 




Methods cf cp«nlns Various Abncoruofl. 

AldUftrr AbMin. -Cut in ibr in^diaj] liiiu q( Iho adllji (^#BnI>» tl:c Uicki 
IroDi abi>w downvAfda. and ux Udioaa nicUicd. ihui ugipiiiE the ihrM 
main taarca of cUlukc >ii . the villAt> venela ikUrvc. the kni^ thoracic in 
inMA. and ih« ftdbacMiular vcmvIk bvhind 

tnralflfti BnbO^Make a t^rl^c^al incitifm fn-irn hvliw iipw>Ttl4. tbafOtMkl 
^Ijimrint: ^ti c( n^aijui a will or IjinR floun Wlipn he lii^ lh« inca&op wsi' 
iUid 5u .vjLLiiiiuliir^on It prcvonuu 

laUBUftumitry Ati«c«* —Cut in h diinliui] iitiJUiinic Uvm ihe nippte lo 
j>rcs^ciiT lEkjiJF^ i« rhr cjiWioptioKiu* ductal ^nd pfH4 n 1in({cr in BOiu tocfCft 
up all ^hc diUci'rl 1ip|>il1i^ 

&«tTaphtrjiif«&t Aha«nM lT»d*p alors 1^* po*t*nor hnnl^of iHc il^nuw 
Tila5toLd for ilxml.in inrli dra^ Ehfll musrte ahiI tlif conitkd iheAlh forwlrds, 
open tiv H]||i->n > uii^ljLp], j>Li>hi[iK ii dlia.Ltrf ju^vArvl■ \v Xhv middle line iimuc- 
dUlelv ill U<"ii i]f ihr InLii^Vfriw) pfiAttiWH 

P«M« AbttOtt** or IlUo A1»«M« - IlKOH ibc .tb^omiiuiT muT^IciB jimt intenul 
tci ami ^n ihr- i^mi- W-pl i« thsanMhor iuptriof fpiii«, anrl oprti Ai Ihai «pM 
In 1 frw c^ifc* If nihiy Iw i/lt'lubl^ in npen In ihp loin tt'T^^^^t' meihod] 

toipjima - Open aUrui an Inctk in rrniii (jI lIip ndd-uLllAiv Uu& tn Itic Aflh 
ctuial [E)(cfa|mtc, rcm»\iti^ Buh|iciifjvmlly * i^rticm uf tlic Afdi tH-»xlh ribo^ 

IhUo Mala] abi«H«. Place Ibo pAtttnt le^anbf: 4vr^ ihe hull of « cbur, 
fir in Thr lilhi>Enm)- pntliloa II ■!■ aUGHthclic! ttcinnloy«l. And tnciv vf»rlLC4llj 
and ver^ fr»ly u Ut fnun Ibe lUtut u pou|ti]c . hoUlng niA> ennue vrltbool 
(j^fiiniC Ibc icLluTij In vmiv triwi vrtwra tb« kkin iit undcti&iiwJ. a crudU 
iociHuti fth^urd 1x in[b1r» (liif i«»i)lEiniE cutnvrs of vkin hvltiK cvtTKn-oJ, 

In (vpeninji a PbIdut A1»mm. <arc muai be laUn not lo vound llw MipOT- 
AoAj palmar Arrh i^r iri ^iuha) WojkChei it ii but aco<3mpli»h«d byMMTOf 
iheliiii^i' immivlurrly III a liTiri^i^h ibaeemrr of the meiJifftrpal bone*. caf rhif 
furwufd^ rti Ehr? Uj4k ul ihc firiNer : ihe up})rrr limit of ihtn IncUlun Hhould not 

A WhiUw qbnukT W. nprinrtJ in thfl middle line of thv fin^crr by a hnif* h*U 
with ii^ bciclt ti-i^vbr^S tno wrifli. ojid it often hoppcnt ibat ihe notiert^ il 
cciOKlouiH, LintA^uti^ly jutUii ae hU uwn opvrahoa by wuhfir«wtag Vh luuid. 
ih« sdteiaHlly oamptAElng thn Inctiinn ^ rarp muti. of courw^ b* afean not 
. o 1«c the knit* limwi c» or or (ov deeply. 




SVPPVRATiON ASD ABSCESS 




^: 



ll ra a(!\-)?u%Mc Iti senily i*qucc£c an ab^i^fx after opcninc it, 
^pHJally wlirti NluiigtiK jitc prc-vrtt, nr whf^n il Iihr biiTTowrrt ; if 
«b« ai%-ity is br^. it Aliould be explored ^Wth the fing^at. All that 
Is lW«dM Subn«4nien11y, if there i% no compIicHition, s-udi n& the 
pmeiKe of deaJ or di^jiaed t>onr. i% Icj ^u^ahkc: foi dr^icin^e. a& 
D^ itisenKng a di;trn;tgi*-ti]T>e, ur :i slip nf protr^i:tiv<.'» Ami to eicludr* 
ttprig by :i carrfully apjilied :Lnltu«plic drc^i^in^; in other c;kseK 
it may w d^^iablt to pack iba <;avit> with tl'^U'^f^ soaked in 
•a iodoloim riuiihitni. Tlirrc m often a toii^idei^iljle loss uf 
blnnd rtming ihc first twenty-four hoiTr* from Ihe yielding of 
h* capitbh«& in the abfiMss wall, uwinc to the uiLddeEi leltei <ti 
sion ; Ihii lht» usuali^ tfrascs of it^eU. or yictds to moderate 
rr. H"ir» iwv /■( *v*^ Awn eviuuiutd, no n^frt i\ fnrmed %J thf 
is ktp4 Auf4\f, th# diw^h^rje twhc merely ^efons, and tii© 
«tMiti<l rapidly closing; and henlinf^* Lndor such circumstunccs 
bttCtcrim arc ixit bund aFIct Iwetily'four hoLirs. bciiii; dc-strtivcd by 
llie phofpxylOi. Plk whirh tiinks on its pvAnmiinn, >f nnt in 
open oormmunicatioa with thr^ inioMinalcnn.'ki, will to^ :i]l smell in 
a dfty or two, the wound purMim^n nornial <;ourne' In some crises 
iJieoriffuviJopeninjr Al thc^poL whi;ur ihc ab^sces^ pointed may uoX 
give olkienr dt^iinaK'^ : a mtmtfT-apfmjtg should thrn lie m.idr hy 
puibiag the fincer, or a probe thtoui;h the ih'jiocs^ wall amongst 
tbe tbsue*. tiuiciDjic it prntrude bcncAth the ^kin At some de- 
pcadctit spot, ADd cutting down iip<m the fiUk^iT or prntjc in this 
fbreclion. 

VVbcre actitc diffuse suppurftlinn is present ttilh some tendency 
to Ucu^hiDj^, the appliciition of \v.irn;th and nioi^tiirr m^y with 
ijvuitufie Iv LTiDlintied *iftrr uicisinn: ;* iMJTiiric pfmhice(m;ideljy 
m^nffiD^ bocLicic lint out of toiling bortc acid iolion. i In JoJ, or 
« carbolK Ib^teed poultice (made as .-ui ordinary poultice* but with 
boC carbolic lo4iuii, i hi jo, substituted foe water), wdl lie found 
Mtxnn ttvlul- A clurcujil pottllice, dit>«te(1 wiih icjfloform, i*i 
oocssiOBalbr sdvjLntageout when the pArtc are \-ery styptic, at, ufttiT 
extntvasAtKHi of uiine. 

ChrosJe Abwon fj>vr. ,' OoLd or Oougastive Abseesa), 

A cbronir ah^ice^i may be defined aa a colleciion of piw which 
iamvi Uoit'ly witboul Anyii^'ns of active intLipinmtion. Ailhmi^h 
Jew ex^mplc^ mny be du<' to inf(x:tioii with pyot^emc microbes 
(o chriwif pyemia, yet iht vast majority aie luliei culir in 
^ ; and, indeed, wh^n a chrontr Ab»ce9« \^ «pok«n of, it miy 
lAken lor f^nt^ ihM it i;^ tuborciiUr, un^^S14 otherwise 
ftAIevl. Wherever tubercle car be depodiiedi a chroinic Abscess 
may lorm ; hut ii I'lrrur^ most commoitly iit cooneciion with 
ftopqi, joints, find ;ymph-tlic ^l.tmU, 
Into the deiAiU oi iho^c Evtu'^^itivc Affeciions it it4 unneccniiary 
mter heir ; fiufiice it to »t-tte thai the Ab^eMi oiitc* fr^m the 
ktion of a lubrrcular foqu^ without pain ur indAinm;itory 



44 



A MANUAL OF SURGERY 



redness; that it forms a soft Auctuating swelling, gradually i 
creasing in size, and pmssibly by its pressure effects beconm 
painful ; ihat it tends to come directly to the surface if there is i 
dense fascia to prevent it, but that, being usually placed deepl 
there is a great tendency to burrow along fascial planes^ ai 
hence to become superficial at a spot far removed from i 
original source. Thus, an abscess arising in connection wil 
tubercular disease of the dorsi-lumbar region of the spine nu 
travel in many directions : it may pass backwards, and be opent 
at the side of the spine as a lumbar abscess; it may infiltral 

the superficial fibres of the psa 
muscle, and travel down ihe sheat 
to the groin, pointing either abo\ 
or below Poupart's ligament ; or ; 
may find its way into the pelvi 
and escape either by the side ( 
the rectum, or through the sacrc 
sciatic foramen into and along tb 
thigh, and has even been opene 
at the side of the tendo Achilla 
{Fig. g). The lar-reaching extei 
of these abscesses, the impossibibt 
ofdealingadequately with the hnio 
.menibrane, together with the ii 
fective nature of the disease, an 
the commonly inaccessible pos 
tion of the original focus of tl 
mischief, render them most difi 
cuh to treat, and fully accoui 
for the dread of opening thei 
experienced by surgeons in pp 
antiseptic days ; for should tt 
Fig, 9— Psoas ABscEsa due to cavity of the abscess once becon 
Disease of the L.>Pt^ Lumbar ^^p^^^, there is but little hope ■ 
VEPtflBR^. (Afteh Albert! '^-f - -^ - j .l 

' punfymg it again, and the resu 
The method of exlension alonR the -jj ^ increased discharge ■ 

psoas tendon and m|o rhe lh]Bh '" ^ *■■ , ^ , , ^ . 

IS well seen. P^^^ absorption of the chemic 

products of putrefaction, aggravi 
tion of the original disease, and only too frequently death fro 
exhaustion or blood -poison ing- 

The/u5 contained in a chronic abscess is usually characterize 
by containing;, in addition to the ordinary constituents, masses 
curdy debris of variable size and amount, consisting of coagulat* 
fibrin with degenerated and fatty pus cells entangled in the meshe 
If the abscess is one of long standing, an abundance of chole 
terine crystals may be present, a fact recognised by the naki 
eye by the glistening sheen, or greasy appearance impart* 
to the pus ; microscopically they appear in the shape of rhor 




SUPPURATION AVD ASSCSSS 



<5 




E. w^ih f>TW oorn«<r noccticd out. It i* Lmu&uil to find 
or IviciUi iTi th^ pu« of a chronic nbscetis, not even 
Ike flpecifvc ovKwuvn of tubercle bfricg JisccmiMe, and tbi* in 
spil« of t1>fr Inn ihait iimciihtioit r:»f Am]iia[% with ihe |.^h r(-siill<G 
m 1ubflrCitlo«i«r Proh>bly llie hacilli h«v^ b*wn hfoken up by the 
soppurAtivc process, bui the moro rc^i stunt bporesiire still present. 
Tbc micTnttff^ appt^ramt of a luhoiiMilAr abactSi rfnf! ib f|Liitfr 
rrrislTc. Th4! raviiy U lined hy a Uy«r pf gruy, yellowish- 
«y, or pirktfh, pulpy ptanuTaEicrn tUftU*, containing miliftTy 
pcrhnp^ undcr^L^ing c^i^cntion^ and );n9Wn as (he /lyiv^rji/ 
r, lif^ctilour And vitality are ^cpc)id(-i>l upon ihe ctironiciiy 
of the prorrwi: thff InHRrrr llur aliscpss is ITl fotmiilH, thff 
vftficuLu' Ihc membrane, owmp lo the a^^ocu-tted sclfmfiU of 
sarroundinj;^ *tfuclurc-t Icadirp to comprcsiion of the blood- 
vomIiIi whibt it hoi l>irrJi Alii^dy meiilioneJ Lh^it end.irtfrrllih 
alwrn^nt Accoonfantci ;i chnwiic inflAmm-'JtiiJn, and help* tn tender 
thepartafion vatjculox, TbU lining mem hronr ts hut loo:^ly<oc 
nected l^■tth n l;»yer of fibro-cicalricial tn.-iteri;i], which forms the 
uulPt p4it of thr wtflK it"tl from whith it uin u*uid!y Iw re^iLlily 
detftcted by tht finder or -.i «b:irp vpoon Thi^f, in turn, grailii^y 
tfhehres ott mtc tlie nonn,^] |ir,£u» Ahieh ■:urrouncls Ilic :tbtice>KH 

HatunJ Core. — A tuli-rcuUr iiWcsa doe^ nut nct^e^iirily di^i- 
duiT^ ilseii. Ucrd?i)triially in th« (leitd-housu one iMv?4fts with .j 
muftof potty like coQfiiftency lying in front of the ttpiae in th«bod^ 
td ft p^tieiDt *lio has been cured of spindi disease. This is cvi- 
ib^itly ibe (lesitrCiilcHl remains ol uchitittic dbsci^ss. iIjc^ ]1iii{l partluj: 
luiring been absorbed, ^nct i1t« solid elenrt«nts left behind, ^nc^p- 
nUed* and perhaps inliltrated with Umu «ait«. Such d£bn& cin 
baooiiio tfao Mat of rccurre^nt inll;tmm»lory miacluuf when ihc 
odntal divKuiVf ha^ 1>«tii quieaLvriit (m years ; an ubsceui may 
nMotnly form »nd com^ to the 9urfac:p, bring th^n known as a 
wirfaif ahetu. Frohsbly n Urifo Amount of cho[ssterin« will bi^ 
bttsd iu&onj;^t i*" <^cntrfit>. 

Booltvof LoDC-oonttEUiedauppuriktioD. — When a cbrumic ali«Ci;ju 
• Op«wd uiUMpticaJly. :tnd m;iLnui[Lcd in .in aseptic condition, 
■ppiiration t^ nt a rrdc. of r^hort duration : the wound mny 
Tcsuii) open for inonlh:^, h^ii the dischtirgc w'lU be merely 
«ftXH, ntid nn ron^ittuion.tl rt^siitts will Iw m;i[iifrslt^d- Thr 
l«apMAtitf<a »maiii« nonnsd, and thr f^^neral health Li unini- 
mtoI, if tw other diivcASc t^ prexnl- liut tet such nn abw:^^ 
I«x»nw M^tic. and llx: condition of affjiits is at once ch^uii^ed : 
lb« dbtthan^c Iwonme* pumlent, fi^vi-r supervenes, and gritr 
nKtral chatif^cK occur, which moner or \m^x mxy liNtd 10 xhe 
pitMDt'« death from exhautlton. Lmg-Cffnftnmd svppartttim, ihai, 
u aimia^ an evidiMt of uftii, ^nd fiuni it two couditioiis may 
iriw, viv^ hectic finier and Urdareous liisenKf. 

HiKtlC Ftvtr Q^uiy be defined as » chronic taprs^miA or condi- 
lin at Uood-poboiuiig, due lo tbc continual absorption of amnll 



A UASUAL OF SUSGSKY 



ii 



u 



01 tnt* ptonaiMtpfOduced in s«ptic wciundf, and 
with not only nhcr opCDkic chronic ab^cc^^ar^, but alsj m septic 
syphilitic or ran(«vou*t dj>im^. It h t:hni:it.lcruri\ hy n f^i^thtt 
(liufnut elovj^tion of I«Tnptifature, vjhich ront a tolerably lyptcal 
<x>ur#. It coitimcflctrs to rioc duriu^; th« aitff&oon^ the p<Aticnrft 
fiice becoming lluatictl (hectic l^tuli of lYat ch«ek9)i the c^cs hri^bt 
and spaiklirk^, llkt? pupils ililmrd. and tbe paiifnl fccUog l^cttn 
.-iiid fetrang«T. The pul«t, how«v«r, U smal], comprQ^blci and 
ttn or twcotvbcBts quicker thfto it»itouldbo; thotiDnio>'^^^^^"i^ 
icd At the cdifc^ And lip. ThU condilicii comlitucs lUl laic in ihc 
nighi, h\ wbirh timt' iht' tcmperatiirr may ha\^ rispn four ur five 
da({rcrai. It ihcti commences to EaII as rapidly a>i it h;)d ffjrmerlj 
risen, o^nd usually drops to Ihc^ romiul, or even below it, and m 
the Kurly niorj^jrt; a piofusc perspii«4lioii breaks nut which soaIu 
the ittticni's cl:iihps and le;ivM him in a much-exhiiuMcd con- 
dition. Day by d^y thift continues, the fuvcr And sweating; toffotluf 
CAU!»iag 3 marked diminution in the paticnt'% atmifth. 

Ain7loid Of Lard40«DUH De£eit«nitton uf ^ariuus oripuifttTt jdisa 
preCcMiC in case>i of Ijn^-^lundin^ suppuration. As to the caiH« 
of thi* cunoutt conditLon, but iittle u known; cither from the 
dcJetcriouB efrcci% of ^cpiic tomjionnda circuUtinff in the blood, 
Of from Flit loss of itonie speciri! McbsTanct? \t\ lite dischar^i 
t.g.. a\\i^V}t)e phoriphat«j^, the wuUs of llie Miiutler :Lrteries and 
the protoplasm of certain of the viacera is converted into or 
infdltuti:d with a w^ixy ^ubi^tante. from which ktdjceiii, an 
eKiremf»ly inwlublt pToteid lv>dy, may be obtained. The aime 
'amyloid' is an entirt^ luiejiomer, na this matenai ib iii no wav 
akin lo st^rcli. It it* met with ^l:) a waxy homogeneous materiAi, 
btxoiulrti; A iliiiy hiowti on the appliuitcuu iA Imcluie uf iodine, 
*nd an inky bhu* when Milphnrtc acid is *inh*p.^iieriTiy .^idded. 
With mtlhyl-\iolot Iho amyloid aubatajice becomes ruby redi 
nhdst norma] tii^tucs atc bt^iiif^J blue or tnt^^ Ttic ori;aik» 
mainly afTcctcd are tha liver, ^plreii, kidneys, and villi of lbs 
imrsltneK. and the capillaries and muBcuUr coats of th« smaJI 
terminal arterioles {Fig. 10, A.-Lnd i) arc tho pads hrstnttacbsd.thA 
change eiadualiy spreading to ihc p^irciichyniA of thtorgnn. Tbe 
iitvr l)ecome.% pvenly enhiifieil Ui a rnnnirlorflhtr drgrrr, often 
reachinij from Ihe fiiih rib lo the vtmUlit::uft or lower; it ii firm 
in conaistency hke indiarubbcr, ivunle;^-^, and waxy -looking on 
floction, Tho artciiotes jtnd cT]pilld^r^s in ihe inlcnncdiale zone 
of the Lobules ure those first iiffected, Imt tht celU lhemsadx*eft 
ftoon participate in the clian^'e. The glycogenic and bile-pro- 
ducins funciionaart naturally interfered ivith, so that the diKcative 
pr0CC4S> And especially the puwer of ^li^orlidng f^t^, i\ impcded- 
Thr kidnryi lirromp fiimil:rirly •'tilarged, Ihe change commencing in 
ibc artcrioirt Ir-Ai1in|j; to ih«glameruh (Fi^*. lo), bul Ihe capillaries 
and the liibal cpilhehum arc jU&o early affected. In this Ma«c 
the luine b ^cry abuadaot (from the lucteuscd iilttatian tluungb 





SUPPVPAUOV jt>tD ABSCESS 



cksgmeratrd ir:i]b), pale, lirnpUL -nnU L-iint^Bmtng a lew liy.nlinf- 

aift9 VMS fatly celW ; lattr ot\, whtn Uie lubiik^ are more tar^dy 

bvoJvcd, Uicrc 13 Ic^s unnt", with a higher specific t;ravity, and a 

BDsiiderablc jmourl jf ilLiuraui, Thfipicen iiicieasti in «/c,IjuI 

ftot alvrayH to to gr^it n ^i£e a'* ihe olher viscera ; tfie M ;ilp]!|*]iiari 

ar« lli« chiti i^al of lh^ intAchtc^f, Tlie capilt;irii^?( in Uie 

* </ tkt tnifsiin^ L<com« l^Td:i<:i'uus, ^i\d ullow of ;Ln mcresisod 

tdAtsou uX ihr fluid p^it> jf tIjL' lrlui>j, iosullm|{ ui dUnhLCii; 




^ 



fTiMM wtih Mullet 'fl fluU ui^ pvroAntic ACul. « J0i>} Jh Ncrmil capUlnry 

alb m Mt , /. I«ncccd ii1i>- tpuhel^^] Cf Hi f, liy;ilLnp ccu^^i [fonninif 
"CMi^l. A. iuiv cddi[ in KCtkJil. i. uiiyloi^ Atdci v ■ Ah lUitTluM i^piliuy , 
J. bMtmton of cfrtuMClJ^c E-inuc with Ic&icucytu. in. rautnl cclb (Icucu 



tbd^bftorpltOTi of fiiiuimr-i^t ib Iht'rrby mu<:\i le^^ncd, anJ »d both 
hj iodeftscd cA<tc1»^n ^thJ ilmit:iislic<J uhsorpliou of fuod the 

f\oid chAngrt m ibn viiiic«ra, far from heing a contrft^indica- 

Opcration. &r« raihor lo l>c considered a^ a m^n ihiU mdiuil 

i1 U UJ^ciidy pecc».Lry, imlc»A llic j|:c-nr;i^l couditiori of a 

itMi is nach ihnt br r^nncki sinnd chr* i^lfAin nf iL If by a 

ItcsJ opwutioo, f^., cxciEion or amputritioii, the local disease 





48 A MANUAL OF SURGERY 



can be eradicated, the amyloid changes in the viscera will FoUl 
disappear. 

TrMtmeiLt of Ohronic Abscess- — In former days the rule alwa^ 
given was to leave a chronic abscess alone as long as posalA 
and never to interfere unless forced to do so ; hectic and ii 
creased rapidity of the disease always followed such intarfereoo 
even when Abemethy's valvular incision was employed. B* 
when asepsis can be maintained, there is no reason to depa 
6-om the ordinary rule of surgery^ that pus should be evacuate 
as soon as possible after its formation, it is^ however, ma 
important to recognise the fact Chat one slip in the technique mi 
lead to a fatal issue, and therefore none should interfere wil 
these cases unless they are prepared to take the time and troub! 
needed to keep them aseptic. From the risk, too, of sepsis heiii 
admitted during the dres^ng of the case, those methods should t 
preferred which admit of the immediate total closure of tli 
wound. Many plans of treatment of chronic abscess have bee 
suggested and practised ; ne can but epitomize the more in 
portant. 

1. Simple aspiration has been known to effect a cure, but only la e^ct] 
tional drcum stances, viz., wbere the originating disease is absolutely pusv 
a^ where the patient's health and constitutioL are vigorous. It often E>i 
hrom the blocking of the aspirator needte by curdy d^briSn and there is alwa} 
a fear that much of this matertal wil! be lelt behind, forming a possible sourr 
of future re-infection. The rapid emptying of the sac, moreover, often lea: 
to hiemorrhage. and the blood thus collecting will form a favourable smI k 
the development of the spores remaining in the curdy masses, or ol the bad! 
within the pyogenic membrane 

2. Tapping iht obscta with Ihorongk imgation is another plan of trea.tmeT 
which under favourable circumstances is occasionally successful. We bav 
seen both psoas abscess and empyema cured by one thorough washing ou 
The modm opnandi is as follows: The sLin is incised in one or possiU 
Iwo separate places, and through these openings large trocars and cannule ai 
iDsertsl mto the abscess cavity, which is emptied as completely as posslbb 
It is now distended, by means of an irrigator inserted into one of the cannula 
with warm solution of carbolic lotion {i in So), or with a sublimate lotiot 
(i in 5,ooDJ, or simply with sterilised water, at a temperature of aboQt llo' F 
The al^cess is then well bne^ed with the fingers, or the patient shaJien hoc 
aide to side, and then the fluid with the curdy masses and brokcn-ilowa pyogem 
Plembrane is allowed to escape. This process is repealed again and again unti 
the escaping fluid is nearly clear, or only slightly opalescent. The caonuh 
are now \^iihdrawn. the wounds hrmly stitched up» and an antiseptic dresaii 
applied, using sufliicient pressure lo obliieiate if possible the abscess cavil) 
The patient must be kept at rest, and carefully watched to ascertaJn if (her 
is any reaccumulation^ when the same process may be repeated. 

3. Opening the abitesi and araping oiH the interior with Barker's flushin, 
gouge IS another useful plan, combining the irrigation of the previous metbo 
with the more or less complete removal of the tubercle-containing pyogeni 
membrane The instrument employed consists of a gouge or sharp sdood witi 
a long hollow handle, which communicates by a tube with a resen'oir of fliu 
placed at some height above the patient During its application Jhe constao 
rush of water or lotion through the handle clears the gouge, and removes th 
debris 11 is admirably adapted for certain caaes, but its use needs consider 
able care^ as the sharp edge can readily scrape through an abscess wall, an 



SCPPURATION AITD ABSCESS 



♦9 



I 



Ai math miaehirf ll v a <iKtvaBi«Bt ■«««»* of dviJ^j; wJili &l»as4» i>i 

be flibanjiKiuIj cIcha!. uid in 4l»mpl nuilc fci jfain Lmmnlitur lK>a]ing of iti* 

4 tmt rt Mm tf/ 411 Jitfflif^jr miff lAc 111. j/fff A'f'/iHj,' t* a mBthod Ldoo^ 
Aoctd br PrDmaor Vclpc^u In Fruicc. ^nd hu octo recfiiwd with macli 
fcnHir » wAa tarisnDi. Vatioih m^tDi« hAva botn Amployvl, but tha 
OMlorlty luve ^ onutliied Uvtine eUhrr ID (hr form of rhv lin^ turv, or lu iudo 
liviiL vfak^h IxTBfT may bv tuKjviidoi In clyEvriiir <ir<i1ivv'r}l| ho ptr cent ), 
o*ilABDhod tn Mher (3 (vr ceml The melbod of minxlucmc Lnae com- 
PDWMbbi|iU*c simple. Ihc unoum vuyiUh;, boL as « rule 01:4 mi>ti; Lh«ii a 
ncfam of todofeff» felwftM t« UMd W'hcQ iht cihcrCA) solution 3* injecleJ, 
tmmvdiftUir ^^cAitilif** ^ml iuUy di4Ean4B tha aluc*** cavity, which 
lrn«r ami tympAnitir li thcniM im ttial atnrnint n^vrr 1»" iiwwl tjir 
flKimnvtUattniE vhith thr icicrtoT of the ihorax ildih hnvLn^ tn one 
twu reconical aaa mulwl from bcin fjilurr, ^luc (o tuch JlhiciuiuEi 
■ w3^mdaM^a. too, ihiU Kricru> t^iiik >tiriptuni>i mnTdri»: fmrn Aliw>rti- 
t!b* iodofbtD Mniti-cuffH im rej>Dr[nd Irnm ihu irratmn^T. ^^hich 
erf tW bMt and 4b«E that on Iv ^Hnpird ti ir itii^it likely lo b< 
nlwD all untv Itoflc or jcilnl diKUe hu (]iupnn.r«f. And l« 
Irm i Ki Uly anplofEd ah kit uljuiKt tu one of ihr Ancivr-tlcucrilwd 

^ If ihtf hho/rt ni<iiHiy!ai liuL of a/v ^ nn>~ rrn^on in.ipplknlilc ihr ini:inal 
taHajpdc iDCtlud of ifn/^r 'nKir^n n'i ^Mv^-^f cad nJwr^yt t« a<1nnTod Thii 
It parfacily uir. » long u awpm it mLLnliUfipd tiiii ihr ),'i^^' -jbjocTioiu to 
ft Mtm thr kmgth of 0me often riiqMiitil lohrintc Abf>ui hH^lnq. fnim^l^iily Innuw 
■bi!ra. ftkbE«i|£li ■ fnr indhi»n U m^v, ilac actiJiil *bii n) ilir cEiwavtv 14 
ttn nwJttd. mikI tlu tonw«]iifn( rbk *A u»iiiuininaljnn Jurm^ unr of thr 
ft:fcttlcd 4rva^nCf (lui arc ns^uiroJ Monltii, nnd tvcn vcAfs, nre somotimcv 
.nmvd toftaia ihtt cckI. oapeeinlly when % latne. p»oui iin«cv«i \m hmng donti 




Ol J> oinahl cms od irtiFmiil clironir ih^ctv ii trmy Iv luntllile f.i ifiiif^j 
'44Hiyn miiu LDil ll 4U(h tr( fsu'ble. li i^ the mcp^t uilsdictory 

J;1ukU ShutLild iht f-<.nicrinr ^t'^U of the cuvilv be u^hflecni 
twf> iiitvciiirH, LE hhuul'I Iv ihorcmfhly iicnpfrl .tc* u lorvmov* 



^l^a ^rstaft lo 1 ounce 




qnrl itiiihffclrd, r>7, uviiti viliiTinn nf rtrt rhlond* 

\n niirmpi may thfin be mnde to ipvln heiUiTi« by ftr*t 

iTUiV Fv ^lUJTctl .icid ixirtmol lo i{r«nti]Atrr 

iKi^K I'lTu Kinijiiijc .iirt-Aj^Ehe nuKTnit ibiHLjc perb^ft 

rttrjlic acui. jjlttKinR ih« wound firtnN wiih (EKDM 

roftotorm, EiDa ilkiuinj; ir li'>t:ranul4tclroiTi The Tvirinm. 

he cijaI Rffvu^flVeofJsly In cav* vhen< abwrwes hnv« 

. _. triwirT: m4>j;lf»i, xrtd tliiiw fjix-i*! pUfif^ Sulphur b****!** Im?n 

iM^Bd of kmliifnfitr. bui hA«tii< \|iriiiil »1%'AJLtM:v, whi[»[ ir i^auufM kixi.1 

iAlaf «loajth*ii|i of U» lunoundicik: lift^uM tyviiim to iis LnuiaformaTioo into 

mad ANOlty into lulphurii:, ifid Fnors bolum in Another iLffcni 

■By b«m^o>vl ia the •^^mt it ax. and Ia iniiocvuui> ind uufnl 

fiinai &nd FlvtnU. 
WbtfQ All abvtce«s h^g Wen ctprn.'-d, .ind dn^^ nol completely 

llbcflistvsc aixl ibc cxt«rior« A^hicli is kno^vii A^.t sinus or fiiluln* 
A SlBBl is A lurron' ir.^rk lir^d wilb ^rantiUlinni;, prnct raiting 
Int^ the liE^uoSi optn At onr end ;iitd clc»:<^rl at Ihc olhor: thi^ tli«- 
cLkTKc I? |>unilcnt or cnereJy serous »ircorilmK lo whether M not 

4 



A MASUAl. OP :s(/riGJHtY 




sepftift i« preMHt. A FUtulik is^ nn abnormal communicntion bc< 
iwrm rwo raxitip-i. dt liphvrrn ;i c;iviiy iim! tht- rxtcmal Hurfcu*, 
When Kuch conditioiH resull from Ihc non-closure of a chrmic, 
ftbficcn, ihc wfill^ consist of exactly the same ^nictuic^ ms 
lliohr i>f tlic^ »nt£m.il .-kl»ci^4N. via^. ;lu rxtcnml fi1>ru-cic;itiid-iJ 
v;4iiciilar Uyri, mrr^in^' into hi-nUliy rtnupH^ ami au irtl^rri.il 
Hniri^' of pyu^'cnit iiiemln;in« conlnjning tub«rcJ«s, if lh« on(p- 
nitm^' di^KA^v \cas o{ thi^ nEiturc. If ihv btiCuloaa track b short, 
ihcie i* ii U'liiltHL-y in llic ^mnublin^ wwlJ It* bctunie tovwed 
with »^i>itTidium. Vtid utu.TCT such circum^dncM it cannot he ex* 
ptictpd ici clotJcf Lintjl tVit^ epiMiehi]i» has lit»^n renioved, ;u3d a fuw 

It TH oUun a ni^Ltter <^f ihr grr;(lPST Jifficidlj' ici >cc\(rt- ite hcaU 
Ing of A »ini)s cir l^&fiila» and iht- following ,iro< Ihr Trinin rirfun <^/ 
fA/i*' 'x<ifl iianiff ; (I) The presence of ^omr cluonic irritaui in ttic 
depths of llic: wound, »ucn d» n piece of The cloihJn^. \ catfe^ut 
ligahtrrt a pirm of Mlvrr-wlir iisrd iTt -iii o|)rTrilioii, or of hi:inir 
dio^Acd tiKmc, *-uch at n hr^tgrni^iil of dead or oHout bone; 
{2) the irritntion of cli^v^nrg^n Finding ah evil through tlic 
itl-niorniA] openme. such a* urine, fjuccs or fa*nd pvjs; {s) in- 
ftufiiricnt rlr;iiii;iK'- "f a rlrep rJivily, sfi thflt thrrr is nluMys n 
ccrt.iin nmcunt of Icnfuon in the wound: (4I WAnt of r«(t to 
the part, diic cither to voluntary niovenientSH an in the limbs, or 
to involunt^iry miiMiiUr ;u:tion in die ii]intr(!i>it<- [letgliUiuihixxl, 
AH in AcluU in ano; (5J ttibprrubr infrrtion of tho \\:t\\, or a 
tubercutiir (iepont nt the bottom oif the «mufi ; [b) oanvtitutional 
debility. 

T}it anitf-r. nf a -tinu* \s iifiert dp|ires«?il imm (hr fttnoiini of 
infiltr^ilion iiroand, but in cahvi. uhere foreign bodies are lodKed 
wilhm, or wlLcre dtsc-a^ed bone cKist*, tt i* usually vuirounded by 
prominent fung.iiinj; gTamiUlionn, 

TrSAtDI<at, — Tliff letrunjil of Iht^ <iiti-ie W The fiiM ibin^' lo 
acconipltsli m d&»ling with a smu^ot libliib. Thcr pasi^ige man 
Ik* diJAted or *ihl up lo allow of acct-^-i lo the dt^ipc'T prirl-i of the 
wound, to leinove M\y iutci^n txjd) ^htih lua^ Ixr pic^ienl. 
or to nWnvL nf the ^tU*.ia<inr^ dfainngt* of .1 fleep cavity, Th* 
mahJiig of A dfpenilcni counter opt<ning oft*n 4unice« to cur« a 
binuf, A ihoroijf;]! puriRcition of Che pjirl by puT« cvirbolic adtl 
or diluridr of ^inc niu»t jJriO lie undeilnken. and the w^UDil 
drr%(;p<] by phiggiriK with iiiitRble rnnfrrial nnil kep: nt re«i, 
whdfit the flcncml hcAJ|h of the patient is improved b\ ionics. 
OccA^ionally, the prc^vire of >i roller bAndfii;;c to immobilize tbe 
pan i« a1] that in leiiuSml, nr the applic^ilion of ^ milAhle ^plini. 
The moM complrtp ind crriain nicthrd is to by ihr tinuii open, 
And tboTtiugbly dt!stroy thf UnioK grnnuktion tir^iuc by scxnpin]C 
or cj<uteii>4iii>:. And then Ki plug the wound, aflowing it lo heal 
itovt the bitioin by i^tanulations. 

Should a futub hav't- tieroine lined with epithelimn, the cdgcft 




SUPPURATION AND ABSCESS 51 

v.'iW require pianng, and some form of plastic operation must be 
undertaken to close the opening. 

The term ^ listula ' is akso applied lo conditions other than those 
tracks remaining from the non-closure of an abscess. Three 
classes may be described : 

1. Congenital fistula, e,g.t branchial ^ umbilical urinary or f^ecal^ 
etc- 

2. Tranmatic fistula, e.g.^ aerial, pharyngeal, salivary, recto- 
vesical, tecto- vaginal, etc. 

3. FatkologictU fistula, or those secondary to abscess or disease, 
f.^., biliary, fiecal, perineal urinary, fistula in ano, etc. 

Each of these will be referred to later on under its appropriate 
heading. 



CHAPTER in, 

ULOEBATIOK. 

Ulceration has been defined as the ^molecular or parliculcile 
death of a pari/ by which is meant the disintegration of the super- 
ficial tissues, which Uquefy and disappear, as a rule, without any 
obvious slough. It differs from gangrene in that the latter terra 
is used to denote the simultaneous loss of vitality of a considei' 
able portion of tissue. The two processes are, however, often so 
closely associated that it is impossible to draw a hard-and-fast 
line of distinction between them. In short, both ulceration and 
gangrene signify tissue necrosis ; in the former the dead particles 
are not always visible fo the naked eye, whereas in Che latter 
the necrotic portions can always be seen. 

As to the Oanses of ulceration, but little need be added here to 
what has already been written as to the aetiology of inflammation 
generally {vide Chapter L). Practically, the process 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* physical, 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 likely to further the 
ulcerative process- Moreover, \khen any part becomes anesthetic, 
or is cut off from its trophic centres, the continued presence of an 
irritant may not be appreciated, and hence destructive inflamma- 
tion occurs, f.^., 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 more than 
usual to irritation ; but the chief cause of ulceration is the re- 

Elacement of the deeper layers of the skin or mucous membrane 
y the cellsof the neoplasm, fio that when the superficial epithelium 
wears off or is lost it cannot be reproduced. 
There are three main clnues of ulcers : 

(fl) SimpU infiammatory ulcere, f.^'., the spreading, healing, 
chronic, etc. 




ULCXHATtOH SJ 



(t) Maii£tutiti nktts. r^r-i rcylcrt. cpichc1iomLitoL)!i, icirrl^ouft, and 

(j) Simpk Inttunnuitcry tTIc«n. 

OlLldeftl Hl>t4>T7- -Bvrrjr iiktfi nf iliw cLivt reiLiU soonm nr Uirr 
to reoDverVt a&d lo may tw vai^ to p:ktt ih.rou^'h three atftffes, \'U., 

iO^ that of ulccrjitkir proper, ur GxlensiLjn ; ii) n atafc of Uniial' 
tiuu, DC piffMidhLni Em nealiiij^. wIiilIi iiLiy t>c Uion or loiiitt 
aicnirdinc ti^ whpih^r ihi> ulrpr Ss rtmnitig J< rj^piil nrjt sinw rounw, 
and p«rwst» iiniil ih^ turbo i« cov^rt^ wjin griLtmlAtioni^ ; and 
(n trtr «Ui:c of hrMliing yr rL-pnii- ll must K- clearly untlorMiigd 
tfuil tlw 6rw *Ugi- nlonr rcprtfvnts [hir nur nli;rfAiivi; (>Mxt» , 
whan thU «ufi«, xhr lilcirr jumper Ua^ <]ivippcaro<1. stid mcTply :i 
St^r^uil lotKcd RulMC-^noe, th« romilt of ItK* preceding ulc^ervtion. 
TrrnAinK. If every Mmpic ulfcr jiaucs through thc^c llirwi itagcv 
Ihrti «vfj xvrirty of smplt iiirrr mnit wwodwy he I'jc on^ <p/ the ihm 
fltf^#^ ADd benoe nay be dc^rit>cd ai^ a modit^cAtton of a typi<Ml 
condition rcprcMntinii; the M.igc lo which ii ticlonici^- Necessarily, 
in » ]sugt uLccr Ibc three hUfc^ m<iy t^ocJil^t. cr a healing ulcci* 

Piiuiy Cram inriijisk- iw cxirin«c cquwu rcUpse :<g;iiD to the sta|;« 
of limM destruction. 
Btafff L : TRoentjon Proper, or Sxtenfion. -The dpc-cial chamc- 
tcTLKtic of .ill llh:c:(^ ill ihi> st^^r i> i^jii di'-siruf.Iivr chaii^^c^ Att 
aill fomimnnn ^vitli ijTc-itrr or le^v rapidiiy, 

)fal»d«7e ^ppeftTUiOM- Surfait, coveted with anhy gr?t)' or 
itirtyy^Uow nutt^ti-il. partiy ^louj^h, p^itty lymph, partly tircnkinii;' 
ikiwn it^SLM? ; no (^iitmbtiiins ^ti: prrwiil : dUck^fgt. tuiisjdcritblc 
iTi Am-stinl. !hfn. i;»nioU!t, xT\d ofldi irritating iiid off'nwv*, rar<*!y 
piirul«iil: Jtwtfr^frit,', thicken L'li and intlzuncd. anil lh^ '^arroMTidinff 
tt^^Qe oficn (fxlrnuloui and mrittJ^acd , utge. sli.itply <:ut .tn<l well 
<1r*inc<l ; thf ki^^ of ihe iilfvr lends (o Jwcom<r lhi(h<mril and fixed 
t<j t^ic ithd*»t]>iiii; bttxKtuT*^- 

MkroMoytaUy, til \\%v pUcnon^c^A oi intlfimm^itioii nuy be «een 
|jfuf;To^j»i; ti> thionibuM?! jiid tiaauc nr^ciosib. ^tf Ih^it h\ .^^jpro^cli- 
infC th' liiirfwj' of thr ukei from dip htiilihy Ti«iir ;irouiid one 
«ottld pii*it throu^ j£on«« of acliv^ bvpef^mia.of ret.irded blood- 
iiw with irifiHnLtion<>f !cticooyU'<»aDaplur?nifiiof M-i-ii]« iind throm- 
U*ks, whibt ihe iUmm-s Mr 111 ^ •»la:r of njjii-ijUlinn-nccroMji. 

Fonr dTffereni formt of ulcer in thiA Arti £IAX« ha\^ l^een 
ilMvnbed: 

Tbc Sprotdinc TJlc^r is n tcrfn ^\cn to any ulcer^ttivo proceed 
ubirh i«pioj;TrsMii); without v]Llblr|M)^Ii<Ul^tlf^tIlUKhbetII|f1:tt«toft 
Tbc Bhn^Lnff U1c«r U one in which definite portititi* of dr;id 
tttvoe -we M-paMied r»5 slLtugh:^- Such a condition rosiihs either 
from the actioci of an irril.int of grcal severity, or froin the low 
viultty of iJkF tiuuifs ^tuithed^ 
The Inftaincd tnc*r i* oui; in which lht» infliiniinAiorj' signs 'Aiti 



■ 



^ A AfANUAL OF SURGERY 



y/cU marked from the commencement, or in which from the super- 
vention of fresh irritation, usually mechanical or septic, a healing 
process is replaced by a destructive one. 

The FluLgedenic Ulcer is one in which destruction occurs ver^ 
rapidly, and is usually associated with sloughing. Formerly it 
was very common as one of the varieties of wouod infection, the 
result of bad hygiene and insanitary surroundings in hospitals. 
Nowadays such a condition is never seen, having been entirely 
stamf>ed out by antiseptics. Phagedena is at present only met 
with in venereal disease, and is the result of irritating discharges 
pent up behind a long foreskin, in a dirty, careless, and usually 
debilitated individual If neglected, it may spread with great 
rapidity, and destroy a considerable portion of the penis. Fot 
full description and treatment, see Chapter XXXVIII. 

Treatment of Tint Stftgo. — This resolves itself into removing the 
cause, protecting the surface from all sources of mechanical irrita- 
tion, and purifying it from all septic contamination. The inflamed 
part must be kept at rest, and if necessary raised from a dependent 
position (i.*., the leg must not be allowed to han^ 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 Hnseed-meal poultice may lie first employed. The 
state of the bowels and constitution must be attended to, and 
probably a mild purgative will be needed. Under such a regime 
healthy repair is as a rule soon estabhshed. 

&t9^ n. : The Trannition Period comprises all the changes which 
occur from the termination of the ulcerative process proper to the 
time when healing is fully established by the wound becoming 
covered with granulations. Jn short, it may be described as the 
stage ai preparation for healings 

Naked-eye Appeonuicea. — When the destructive process has 
ceased, and the septic element has been ehminated, the surface 
of the ulcer begins to clean, and becomes, as it were, glazed 
over; sloughs and portions of dead tissues are either removed 
in the dressing or absorbed by the activity of the leuco- 
cytes and fibroblasts. The discharge l>ecomes less abundant 
and more serous in character, and the angry red blush is 
replaced by a rosy hypera^mia. The infiltration and fixity of the 
base also diminish, so that the tissues around are more supple 
and 'pliable. 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 begin to 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 : (n) the removal of the sloughs ; (i) the covering of the surface 
with a cellulo- plastic exudation ; and {c) the vascularization of 
,lhis exudation, and its conversion into granulation tissue. 



VLCBRATiOS 



55 



Appoanmi 



WhtP the rictj'jn rif ihi 



ll'lli 



^ftMti tbemicinUiii: J. lilt kuccHiytrs [ps^(?^is. 'imt ihr Jrtttnirtioii 
<^ linti« comet to nn end. The sLirfat:i* of The ulcer now becomes 
covttTVd with a by«r of roiinti tclU, mAinlv derived from the pro* 
libratiofi of the nfi^hlxjuiiiig ruimpt:tjvctissvic clcitiientN. am! 
iotrrmi^ctl hHIi 61hiu in siicli :t u'li^' lli.it lli^- rdK lii* in thr 
imcTBIicrs of ih« IiI^UhV : iMh oousiicut^^ the jilm meniLCktied 
Abfwc. 'flic vessel* m the aiuu, whtic mrrciv slans hai occurrecK 
brcomc pi^Icjit ooce mo(c> anJ ihediLulatioM ui thf^ tiei^hlNJuihciciLl 
ofihp-iiWrkih«Kn*^oT^d. Thpvnviilarijiitiortof (hi^i^upeihriiil 
film U aftsil undv^lakon, n<x;ordLng to Ihe proceu^ deacriMJ in 
cr VII, The ^oktnd ihus hccomcacovcrcd with j^nidutiun 
• aiMl with lis fomjiitirjii iht |>ioc«-««rs incJndnl in ihp »(ccr>nd 
* corrv m an end. 
i// fA/ jQ^mrr tfektwiic uUtr wkick ar/ nnfktt ffrt,idiHf! iter a<tivtiy 
ia^ m*y t^ in-^'JaJfJ in ikU irataiitonat stage, \'tx., (he mdolent or 
lau» ukei. ihe iiriiahlt, ibr v;tnto>r, rtr- Thryntip mnm rom- 
"ly Mien on iht Ifffj* of intlividu^ils whcise occupftlion involvefi 
OiftCb fltandiof^; v»ricosv vcia^ commoiily coexir^l, nnd ihc ii-ntn- 
tkm of cJw tJcin b^ dirt Jind per?<ptratJon rid^brd in from soiled 
I tJatbea and Jilthy liiitn liijjs u]lip;i?h.-s iJic lIli^^hi^f. 
^L Tb« ladoJant or CWloaa Qlcvr rxrcur!: mo^t freau^ntly on ihc 
^BfrwcT Icfiv ol vrom1^T] about the middle period of liic. The sixe 
^^■UKs imnien>ety, but Minictimci thiry are m> c\it:r\M\c as Io 
^^nvtilvr Ibc w^iolrcirrxmiferrnce (if the limli. They atp nXwi caiistd 
by buxns on any part of the body where a kr^^ woand has b(*en 
vcaenti Hcauai; pruc^eds to a certain extent, ^rtd then stops 
trom the iact thai ilie tonti action of Ibe ciLiitricial riswe ;ilrT"-iK!y 
Inicrieres with \he v\tn\ky of lh« p;in 4till tinheiiled by 
tag tfw vtfssieU, and «t) culling t^ff Ihe ^ninuintions trom 
M^rcc of i^uliiinent. The iut/itcc ib usually Muuoth and 
Kh^<mtng. ^nd of a diny yellow (oloiir. with |:]VTh;ipH » few Kidly- 
irirTD«d gianulaliooii ; Ihe *rf/,'« are often hard and sharply cut, 
And t*le\3t^ coQsictcrabiy above 1l)e svirface, nhtht (he akin 
aiDUnd m^y l>c hc«ip«>d up o\'er the cdj^c, ajid citlici covered with 
VXidcfl nmclr or riWl|rr-MrcL T>ip sk\n nf chi* limb U frcr^iit-ntly 
dMply pigfneQted from chronic c^ngofition, th^ pigment -it ion aiart- 
ia^ m tlie ficparale pnpitlir ai- miici\\sc, y^h'ich gr^dunUy covdr-.sc:c. 
The diiihmrgi i.** pondmt or ^roiis, und nuiy be so HbiiiniHor .mil 
irritating a» tocauup ecrem-i of the parts around. Jind thns fjive 
nK U% Ma lonn of ifi/tnalous uAvr, Th« ^^r cs adherent to ihd 
undcflyitic ti»stu.-». fascia;. i;tc.; And Ehis constitute:^ one of the 
main diflWulltc^ in bealuii;, iir. conttacliim i^f the T^orc is tluis 
pmmted. If the ule^i exlend*^ r^» the perio^iTPirm. :l^ happens 
n<it unfrv^Pcntly when j>tac«d over Ihe shin, chronic pt^rioslitiSi 
tM tttm osteitis, jcsuUn and a Mtbporiostcal noclc is formed, tot- 
iT^Mvi'tinK PVicily (u llic M/e and Htlualiun of the tdccr, foruiing 
1 mushroom -lihapM node, and &vet^ pouibly go^n^ on to necrosis. 




A MANUAL OF SURGERY 



Tht tt]rniptom» of tliis c^ondition (ns cktAiIed in Chftptcr XV'IIL] 
nil] dttuiitpdiiy \)k ^kcr, 

Tho so'c;lIIi^1 Irritable U1c«r i>^ tiKunlly mci with in fhi< na^- 
Thare is noiUiiLt; ^ct) pt^oiiliiir :iboiit Ul except ita jhMtion, 
usually in tile }cK, often over the Ankle, ard Ihc pAia fipocom- 
p&nyiilK >t. Tlir? siirfncc of >l hcfilici^ or clironir ulcer cjui 
usually br' rmichrd withotii th^ palirni c^nmplaimnii - hut in thit 
variety the ptiin is t^xccwivc, tTspccially at tii^fht. It wa5 pcuntcd 
out by llie Lite Mr. Hilloii that, if a prolic l> mo lightly over the 
snrfnrc nf Mich a wire, tinr iir tmne n|hiU will be indii^ti^ ii» the 
chief KCbtKof EtiE? puBti, the rv^E lM?inf{ ititfrn«iliv«. In All prob- 
ability, ncrv« libmcnts atv there exposed, as the pain boit a very 
n^arked liuinm^ at ^litKning thatai:tVE> 

The VulcocaUlaar rvi-iiTs in ilie lei' of a pMtir-ni who ifl MilTeriiis 
from ;i^^t:;v:i1«<I v;khco>>e vtiini. The vkm b«<^(>niea pauiv«ly 
confipesitcd, and its nulritiori is co|1^cqul*ntly impuirrd: any iniury 
i>r ulirA^idii. ^liiL'h VkOtild it^ilily HtMl eii a suuiid lliiiti, i!> UlceJy 
undvr *in:h cu<'«niMfltire*i to give riw lo a rhronir <jfir(», AK^Lti), 
It may Ixi pr«<«d«d bv ec/emn r«£uJling ^oin th^ irritation of dirt 
or the frkliLjn ofh^rJ trrjUH^tt, whilst i>ccn9ioDnJly it nMy ici^ult 
fitini the yicldiujH' uf the tlihiucd Ma vhkh foiin^ the i»t\y cuvri- 
In^ of A nnif^h-di later! vein, an ACcidenT Trading to i^v(*rc hnrnM- 
tha^> Thp chnr-tcloff^ of a \aticoMi ulcer vi^ry conndernbly, but 
in the mdin th<^y correspond 1c those of the second stoue. 

The Tnatment of ul;'rt>« in ihis M:iC4- difTer^ ncconnng to ibe 
conditionN pri>M<iii, If it \y mi^relv a patistiiK phasff in Che proBMs 
of nj] ulcer tending rnpicLIy to repnir. all That >^ needed is, to continue 
the Mine counc of iri^Hfclinciil hs w;in adopted *it an rarhcf peviod 
of the rase, vi*.» r^st am! ptoiexlinn frmn iiriiatinn. It may he , 
advisable Co thield the siiifacu from contact with dteuings by I 
the mlcrvcntion o\ a SHmitll por1»o4i oi punficd ■ protective ' — •>-, " 
oiled tiWk toated witli dextrin- m> that the repLaraU^e mAienal 
may noi be damoj^^id during rhr^ir r«mova]- 

The Chronic ULoM' nu«dn much c;ire in iKt^ trratment, and (ouw 
CAMS require operative interlcrerce, Hc^^t ir a mote or Icfift 
rle\uled posjlioEi is abv^Iiitet) c^MTUtial in oidei to rdieve th* 
<*>nge^ed condiliiin of thf- hnih : whiUt if the «ur£;ic« t* foul, a 
charcoal poultice may 1^ beneficial, or it may be dut&led over wich 
iodoform, and boraeic poultices appliL-d. Tlii» may l>c preceded 
in wime rasus by Eonthin}^ <hr f»uffjifr of (he 'i^ire with nhrate 
of silver, or with a snliition of chloride of sine (40 ^riuiu to 
t ounce). 

Preimrf has Iwen found of considerable wrvicc in the aftr^- 
trcMmenE of llie>e ulcers ; an ordiniiiy tMiidajL^c, tr^ichiriK from ihe 
tcTes to the kner?. will iiiiif\i:e in some cases, n &miAhle oreaeitn^ of 
boric acid ointrni^nt. with pcihaps some resin ointment addea to 
make it more atiJoulatin^, beinR applied liene-tth it, Martit't 
indioiubUer bamit^r it marc ner^iccitble when the vrisvi ars nn>ch 





oayb 



I 
I 



mlarfcnl : and wlwm thrtr is nni mur!] a.rt\nri. Bayuf^'t phn iif 
, 'ri*,, fiiciippia^ the Ucnb inti uktr with acilicsi\e platti^r. 
be advtnblc. The itmpping mu.-rt t« Uid on vcn- cvcniy, 
cfaanoed cvciT f^rEy ciKhl lumtv If Ihtic i> muth dihchnrK^. 
TTiiut Iv rul in lti« p1:t.vrcr to allou' uf ilv f^xtT, u'h]T!it nnu- 
woot maM turrotnitl Ihi; limb io pre\'4^t its l>tcGminf;; (tmiI. 
Of bic yean ft new method oi <\ta,Unf; with chronic utct-n ha* 
trcD Mj^ffpiieJ by P^ufcvM^i Umiii. of Haiuliury* ^"^ ?»uiiic extrf* 
ksr rt^i-i tare followed. 1l consi^u in the u^ of »n :«(lh«sjv« 
piut^r, made up aa follows: Gtflutinv, ^ parts; oxide of xiiic, 
5 piirts: boric add. i p*rt ; civccrinc, tf piiits ; water. 6 pnrU. 
To this A \tu\e i*:\itUytj\ <m sulpliui iriuv bu ^ddril. Tli« liirih i»i 
fifW thoroughly wftvh^d wiih ^oap and WAi«r, and purified with 
c^rbotic lolion (i in soj. Il tF< then ^v^Appcd round with ft Iftyvr 
of ftotncptif i^Aun:, And (he poster, heated »o us to make it Ivoutd, 
AfipUed owf An xilrcr, r^'Aihint; wrll ftl)inr ftnd Ik-Iow it. Wlwre 
lhsr#ia much vanooKiiyof ihov^ini^, tho pattc should extend from 
the atilile lo the kncr^ the tinot bnnjf nl'^o included in some CJ^VUS. 
Anaihcf Liycr <*i ^u/r v^ pUccd over ihr pn^tr* and the whole 
■nQwml to dT>'. U thftfr is much disrhflEK*" iri^m thr nkeT. it 
tboold no< Iwr cox'crcd ; hut where it i» hut iliftht in amount, the 
pwtc mfty be c*-imrd nifht over it, and thf; whole ftpplicatioa led 
m pCMution fnr ^ wec)^ i>i two. 

Whi-r thp td|jr« are very indnratcd and thickt-nrd. and aW 
actum is at a KUndBlill, byme k suARcstxon inAV he E^illuwed. vix., 
the whole Mfface, a5 ^-cll as the Mirrnunding skici. Ir^ l>listcrcd. 
tndthima nuitaWe dterain^i ajiiilipd. A inure %iitisf;u:EoTy melluHt. 
I^t re<|utrin^ an jnj~ithetic. \* to thoroii|;h1y srr:tpe the vurfaf:e 
u^th ft ^arp ffTOOGt ftnd then lo mh in a stroni^ *Joliition uf 
chlonde of imc. Thin may be accompanied by some meani!! of 
fi^«njj thr iilcei to iillotv of its ctmtrArtion, such ^s Nusshaum's 
pbn oi vnciune the tkrn surrounding t^i« uk^r at ji iii«ianc4- of 
I, t» or 5 incnc^aixl thu» ei.in*tidcrrahlo »pac< for conlitiction ib 

Sbod- ShovJd it W .uDiereiit to a thiCKentd tibin, the lia»c 
|)uld lt» diviiled, ftn<l ilu' nidifiiint m^u' Ikuh- rfiiLOv»-i1> hut 
<tf COurw> 1h« fiiirfacv rnu^t h^r thoionghly purified Iwfor^ doing 
riuii. A» fitron ft» hrnUhy jKli-.n is cvtAblishcd, *hin crftfting 
mav be ttmlenakm. if iit^cc^Mfy. 

Wh«^#' ^-irimw win* riciM, trPiHmeni U of Hitlr avail iinleM 
ihMP ate cfliciomly dealt with either by operation or by soint 
Mrtmbic nipport. IJrna'ii pASte often an5\vern thi^ piirpi>sc mont 
admJE^My. 

The Irrttabla 0tc«r mny l>e trcaTed hy i]i>i;cijveiin^* rhr pamlnl 
cpo<s, and in^isuif; tlie ii»aue» jutt abo%'« iht-m with a knifp, 
•J a^ to divide the exposed nerves. Scraping nnder an anftAhf^iic 
t\, bowevrr, pieferahle. 

The Eesamtoitf tTkcr mu^ be de:ilt with dinrtremly frnm iIia 
others, or the ecz«mft will be a|;grjiv*At«r<l- Soothing ApplicAtinnii 



A ^ASOAL Oy SVRGMHY 



nrc neod^idt lUcH as lead lotion, aod vrhen once ifaf ncutc (tftj^ 

to A pint of lolio plumbi), or n «olu(iou of icMhyoJ (i in 4 of 
t^Hter), may 1^ b«Ti«ficJftlly employed* A mixEurc of bontoat^ of 
£t]ic vtnd boi'lc ftcid ointmerslft )» a very useful JLpplJCJttioni Uiuu's 
pastr Willi ichthjol mfly alsi> Iw applied, 

8U;« in ! Repair hflviuK now Wn UtUy ^^ahligh^d, and an 
iilccr proper no lofi^rr cxir^tit*^, wc have merely to deal wilh « 
licflUhy E^iftiiLilAtiiic wound, ^ml lo descnbc iioi a hc^ilthy ulccfi 
frir Mirh n niinlition r.-imint rxisi, hiiT a healing wmmd. iW 
result of iikernilionH or, tta wt may cmU it to nvoid confiinOTU a 
' healing ulcer/ 

A H^Uag nictT i^ char^t:teri7«d Uy [he fnlkmin); concfitic^n^: 
Snrf^f^ smoc«h and evffn, shelvinK ((radiially from th* *Jein. »nd 
covered wilh he;iltby itranuUtioQfi : tliete present x florid red 
appearanct, nrc pninlcos, and bleed, but not rcodilyi 00 beini: 
touched. The dtakatge \\xx\f.s iiccuidmit I" the plin tjf tiealinent 
adopted : if lli«< surf:4c« 14 kept free from liW trrituntv. niher wpttc 
01 nnti&«pCic, tlif* Uii^churee it merely ;»?roas ; but should th« 
^'cund l>ccome seplk. or be dressed with irrilatinjf antiMptic^. 
mdiiui}' pu^ Will be fi^LrtK-d. 'the *>%\ym\\\\iX%\\^ skin is M>ri, 
tl^xibl^. And fre"> from ij-iflamTTiatory corii^tfstion ; the htku ic 
ftimJhrly U^<* from hTiity: wliiist the mitTt:tn\ proseni ^ ho«L)(i£ 
cd^, which has hrxn desicilred as iiiiunfe^lm^ tiirew i:olourcd 
£onf<A; u'ilhin is u rrv^ .^i«-.^ eunHJ^ctiEi^ of the ^ranuhilion liwnw, 
covered by a siDfle layer of epithelial celU winch cannot be sn^n 
except in a K£^)od Ui;hl ; n«xt comes i\ thin dusky putpic or t>txt< 
line. wIjciu the ifraiiulations are covered by a fcM^ Uyer» of 
epiihrliiim. and th<* Hrrularion is hemming rrtarded nwin^; lo 
cicatricial development ; whdst oiilgide ig a vkiU srone due to Ilw 
hpftpini^ up of Hoddcn cuticle upon the hciLhhy or healed paxt- 

'Hic method of repair in such a wound rcuuviKlf^ in the chaog? 
of the deep Uyc!rs of the Rrannlaiion tifisiie imn fibm-cicatridal 
tiFCue^ the contmctioa of thit cicntrii^L^I tiaisue. and the covpring 
of the surface with cutLcle. Vox full dMcriptinn ace Crhaptcf VII, 

Oi:ciisionally if pmollicnt ,ijj|ilir;iiions ;4n* ij*icd [iwifredy am! tou 
|on|;, the gmrtulation^ becomi.' palc> protulierant and (i?rleniatou«. 
:ind the- hcidinp process is temponrily checked. A depressed 
^oncrfil condition of the patimt, or a VTirico^c condition of the 
vnns may ;dvi arcounl fur Ehi>h. :tnd the term n ^^Ak tdttj is 
npplied t^it, whiUt th« prominent ^ibby i;rJLnuLttioDft are popu- 
larly knuwn a-i ^fvtui fifsk . 

Tlic Tnatment uf « healinu ulcer is liniple in theexUcme. All 
that \^ lu-rck-'i i> lo keep the Muface free from irric^tion. anti 
Nature will rapidly bring rtlH»ui a euro- The hmb, if such it t>*i 
must be kept h1 tc^u atn] if the Ici; is the x^ut of the trotiblc, \X 
mu«t not be alKtwcd to h^u^ down. The wound 1% dressed with 
nny Mmple unirritalin^ Anii^rpric, and perhjpf^ horir ndri is ilk 





UtCRRATtOfi 



food 



of 



pf ihe 



m 




Av any ; a pircc ol protrchvr, Ihr tr^^\cl srfr ol lue»orc> may 

»ilb ttdvaningr nr jiJ;irj^l nvi*r ihn woun:!, of oinimfnt ^ptftid on 

lim or fcauce u>p]Mn. If the f^^nulniurnf^ bccnnif 1<V' prommcni, 

~'ic^ ihav be lightly touched vhith TiiCC'tEc of tilvrr, And a morr 

'mubituig lotion 4p|>liinL 

l^TRe ulctTs rr<imr^ tmnc ;iiAisTHi]c<: in orrter Trt obtain p\\k^- 
ilhiotis hc^Uin^. othcr«ite i lime will come when the contraction 
^^ tbc cicatnti*! liwuc will interfere with the nutrition i>f ibc 
^^toiouUtions, aiul farncrforzli Uir? Iie.ilin^^ puKm » At ;u] rati. 
^Vahmifc proi>r«<lir^« luve been adopteO to hnsten matteis, amonff*^ 
^^■em fnoDvol tiie plastic opcrcitionu detailed in Chapter XXXiX., 
^^id alw> the different mctliodi of skin-K^afting, 

ftkln-CT^ftiDf. Of Ihe traris|>hiiilr]li[>n tif mort^ or \t^i of lht> 
tJiickne^v vi iIl« ^ui from a healthy to :i lienlin^; pnri. was SntrO- 
(luccd by Ri^vurdin in iMi)> iuid hn^ nincv bi:rn mucl; t-hiliontti^l. 
follitwini: ificChud) iue cinptuyi^d : 

Trtnt^pl-inuri^n of ^maW porilonti of ilie ciidf'l? nnri cistii^, 

diD'« 'X-t^ojii plan. A small jvKtior of the cutaneous 

if pajicbcd u^ with or vrtthokit rorc<;pstt nn6 removed by a 

r of ^hnrp turned ?vciMor». In lbii:kirfr!^ it ^huultl irrclude ihe 

irle atk\ a prirrinffi of ihf niris Ui*ra. «i thjit a '^''"P ''^'" '^''^ "^ 

will lilo^ly ro^e from :he cjcroude^:! Mirf.ici?, Ihe firaft is 

placed cut i^ doTuiAArdi^ on (be ^lHacc of the ^I'AoubtionK 

^ ibc wcAJnil, 40(1 lovefvd v.'i\\\ |irLJt4.iclivr, piirilir^il Iil U^ir 

*eid. Many of theiu' may br applifl-rf ,4] th*» twme lime, i»nd Ihe 

ikbolc wound c^rebiily drc'--w;ii and pn>t(?riccL If Ihi^re la mueh 

livdifirice, tbc i^r.ift^ will i)Ol ' t^ke' ; but if I he woitnd h piire« 

jnd merely diviuiii^in}^ srnim. ihrre should Iw no difficulty in 

leilinH tbem t« Rtow. Utually they disnppear for ;i day or two, 

fnoj the cuticle becommt; ^loitencd and disinlc^;ritcd : but soon 

^H Jte epalbrlium of the ^ull-i ^pre.'idv ^cid Eiiake^ iiNelf ^ iuble ;is a 

^Hlatnci centte of re|Kdr. llie iri'^l^^t oarrr \s needed hi hnndliriff 

^Hbr Kraft. otbvrwi«« it readily perUheSv 

^V 1^ TnuiK)UiiC4tion cf LirRe portiona of cuticle nn sMR^csted 
t \rj TtatTTKh* This racthtjd coo^i^tti in lemovinjC \nt^ alii.j)3 of 
odtdc SUmI oitUv^ra with a ra^rr. ;ind irnp1:tnlinj; rhiem on the 
lurlice of the wound previoa&ly denutJed of all ^rzinululions. Th^ 
Bkcnted fmrfacc ib umally first »:nipod, nod the rL-si-dtuit; hDCinor- 
lfai|;e ^aynl tvy pip^&uie ^ith a ^pun^e. n liiyei L>f piulL'ttivt; 
b*ii^,howevw,tntfrpofted, soihat when t iie sponge iv tioh'ieqiiffntly 
•COkOVcU lh«r bkedtn^ shall not rccLir. T)i<r Mriph of onticlu htv 
then cut. care l>eii)fi tftlccri 10 niHhe them a^ ihiji .is po^Mhk; 
ihew ihouW Ix? alloar^ ;o feniain ho-tkir^i; in thr exuded blood 
mtw rvguired for likc. When it h thon^ht that ciiifii-ieri maceri^il 
hn beco thus o!>laEned. the sponj^c and protective are rennoved, 
■nd ihe i^tafts ifcnlly iianfierred, bcinc Apphed in such a way 
tful lli«y inrrlnp rarh fithrt, and also the m;irRins of the defect, 
ere la alnayf^ a coosiclcrable t«nclcncy for Ihe ed^eb of ihir graflft 



A UASUAL OF SURGERY 



to lum 111. aii<l tills must Ivi prevented, They dfc then oov*?r«4 
uitli pfo:(;i.lUc oi lhi«i *4lvcf'pcipc(> -irid (he whole Jic&srcJ aiili- 
>irpti(Tally- Thi^rc it uMully no m:rd to look ai Ihc wound for 
Aom^ dj^yn. The outer nidcft of the thij^li or appcr arm ar« lb* 
l>cM pUccA from which to t\kc. the ^<ift^. Lxaclly the Ninte 
mrlhoil may Iw iidopicd in dt?;iLin^ ;viLh fjv.s\i lAoiimU whrrr Ibo 
nkir covering is (kfidenTn ;md thus *ub*eqnenl contraction iray be 
li3 n Urffe extent prevented. 

3. The whole thkknesa of the *kiii may be uwd in Kome 
jn^t^nccN. Thuti. the ijre|nitiiii ti»me rttnuiveil ici drtumtisinn i» 
most v;ilu:iMe? for thiti piirpci^, 1x<inf{ loft and llrrxible. All 
redundant And f:Uty ti^Lie miibl be reniovud« and f>Aiy tho $km 
applied. The i^'mnulatioiiA should ^Iwiynbe pi cxiou^y scraped 
awjty. ami (lie ^'(nft stitched down lo the ck^irirml t:*isxie below 
writb tine caigtit. It may u)«io be ;app1iKl to ibv raw ^urficu of ah 
opL*nilioii wound. For Iho deinils lo be ol^B(^r\-cd in ihts pr^H 
ceedju^r bw i]\e Knieral filler of plaMiL >ui^eiy laid down m 
Chnpifr XXXIX- 

f H The Kkin of nnim^U, such as fro^s and younfE rat«, hat l>o#n 
cn^ploycd with su<x%Hfi in m^tiio cases; but it is \\m m casy^ and 
oiudi moie ?i«i(isfAC(ory, lo mjike iis« of hunuri ^km for ihia 
piiqxin;. 

5. .\ni>:her plnn thnt ticis heert f^u^^sted consicTd in * luwaif ' 
ihe surf^ix of llie jfr^nnlation* with thn epilhcliAl d6bm tcmovtd 
tiy w^igoriKM w rA]iing of a healthy pociiiui oi \Utr ^kia. 



(h] InfootiTft niean. 

The dilTeitriil foiiiib of iiifc^Ltive iikei^ iii^l u,nh tn ?iui|*jt^l 
practice will lir drsrriluHl tinder ihi? appropnaie he^diTig^ in dif- 
lercnl pftrt^ of ihe hook. It will auhice hore to niUDlion them : 

Soft diADcr* (Chaptei XXXVllL^.^Thia niay be t'lk^n 4» a 
tyi*^? of .til iiifcTCtive- iilcci*. clcaily )«hi>wiiii>! ihebtaf^fFi^ of mf«c|ion. 
irfuU^tion, uliremtion, and repair. 

mo«n doo to SjpbiliB (Chapter XXXVLU,) : 
{a) 'V\it. jiriviiarA' sore. 

(ij Serond-iTy idocn^^ nukinly of nniroii* m^^mhranfii;. 
(r) Interinediatp. rupi^l. ot ectbym.itcuii forc». 
i^) Tertiary \.t\i\-.- fMrn the dif^intcf^Ation of e«minBtji, 
crtliet ?tL.i]jf. I ii. :,il ntc] miihJpk, or deep ami Niii|£lC' 
In inhfrile*! syi>liilrv :iny tjr all of the aliovc varietie* may be 
S«^o, ^xct^pt the prirrury imrv. 
UlQOni due to Tufa«Tel« : 

tai Tilt lu(>oii] uker. due to a cutuneauH tuberculosa 

\?- '^4). or 
{#J Th« tubercular uJcer, Arising u& a rule imm ih« bur^iMf 
of a subcutaneous or ^iibniucoua lubcrcUlar abscc^ 
(p. jaj). 





ULCEitAnos 



61 



{t) V^fioutt other tiibcrcuJar vikurativi" L-^im^ nf the <km 
Btv dcKiiiJcd l)y (Jcrmntobgbl?. lki.Ili the title 
' ftciufuludpima/ whilM H»i/ir]'s <]i>wCMS«^ (ur FiyrhenaA 
irvluritluiTi} L« 3lLiO punilily tubrrrcuUr m cngiii, 






if) BbllKiumt Ulcirra. 

aic clut, as h;»ii afrirAdy bo^ii p*"<im*'d mjt, nnl lo any 

lory proocCTi, l>iit to the actu-il r<'iihiL"':nio^nt of the Mn 

tlw^ IfTWB'th, w iha: b*-; of »Libsuiii:L- iiccr-ssiinly endues. It 

lion will Iw; app?iide<l iMcr [Cbap(er VI.) : 
<#> Kodcoi ulcer, « chroaic CAnccr 5tnniii£ in ihL' scLwccoua 
d» or b^ir follide:!. Aitd acc^mipaiiicil vntb vc;ry little over* 

(^) Ep(lb«lionnu1ouK ulc«r> uritnn;; from oanccT of the skin or 
nocouA tncmbranca. 

aSctri|K>u4 uktii, rv^uhiiij^' fu>m UchiUuclion of llie »k.ln over 
Thon>^ itiniotir, 
^) Ftin^'aiiRg olc«r. wh«re a n»opL'LStk ^rowtli protrudes Cram 
Ifae akin. U m^y be <.dUNcd by ji soft ciiceptifilond cancci, or 4 
suconu, twhiUi a cyMiv^clerom^ rnammf cixes n'stf to a similar 
kppnr^nc^. It con^itutes ih« condition K)fm«rly kticwn aft a 

Out* or two ul<:«ib icfiTUtic (o bo iiic[itiuiiL-(l, tbtj chaiuctui^lic 
ijvp^i of wh'ch iir^ <In^, nm tn ;»ny spi°ri-il morllfirarion nf 
te iilc«*nlive pruc««A, but 10 sf>m& ^«n«iral or locil condittoii 
i>-V Tc-*vr-i its n.irkfr upon the *ok. 

Perforftiinc Ulca of tita Foot ih h term ^Lpplind to ail ArTcctioii 
mth 11) in cartaia opniral ii^^rvoiis dit^fr-uu^^, vucli .i^ raiw^ 
Ik, KyrinjEomy*liAt Apln'^ bifu1.ii etc. in which Ihc sensilive- 
DcM of tlic soics of llic foct i> diminUhcrf. w ih.il the patient 
,13EIckH appm-i-ile any ii»iight ii^^umn ilirerlrd Um;iid^ them; 
it jim<% zo a untilar WiV in i]itc;i«c£T Kudi as dinbetts, syphilis, 
im, etc., which lead to pcriphcr^iL tiGuritis; and (j) nii-ky 
follow traumatk lesions of the ncfve»; (4) it t» txcasiciiinily 
to purp pl;int;»r ksirins, .ipaii hum ^itiy iit?rvuui itiJlueace. t^,. 
sappuratiiif; imrt or com, or even a cbioiiiL- tipiEhetioma. Tlie 
ImU m the gtcat Coc i» Ihc pcut moTit ftoqucntly ulToctfjcJ, biit 
May %po< to whicb uodm: presaure is diiccled lUiLy bccuiiic in- 
voCved, Aivl not inft^tiently ^Fvifrul sui;Ti sr>r?s iik;iy Ih' srrn l:ii 
tlie fiftnw foot. A corn or caLlo^ity tir^t foiins, nnd imd?r ihiK n 
bma, in wbkli fiuppUTiitmn t;iifc» pUcc, the pM?^ icndtnK tt:^ 
mnJ noc otiJy to tlie buctn-c, but .il?^ deeply, so .i-s la iiivoKr 
booBS ond-jOUiis. A typind peTfwuMTiK nWrr prrw»nt?i thi- ;ip- 
of « sifiufi pAMing douvo to tbc dcc|>er portK of the 



^ 




6i A MANUAL OF SURGERY 

foot, the orifice of which is surrounded by heaped-up and thickened 
cuticle. There is usually but little discharge and often no pain. 
Left to itself^ considerable destruction of the bones and joints 
of the foot may be caused, necessitating amputation ; but if taken 
in hand early, a cure can be established by carefully paring away 
the thickened mass of cuticle, purifyin|> the sinus, and protecting 
the parts from pressure, at the same time that measures are 
directed towards the cure of any nerve lesion present. 

A Scorbutic or BMmorrlu^c Ulcer is one characterized by a 
tendency to the discharge of blood from the surface : the granula- 
tions are always of a dusky purplish appearance, and are promi- 
nent and almost fungntinf^. 



CHAPTER IV. 

GAKQEENE, 

Bv 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, 
lutrosis is said to have occurred, and the necrosed mass is called 
^ Mqmsirum ; whilst the term gangreni \& mor^ especially applied 
lo a necrotic process affecting simultaneously the hard and soft 
tissues of a limb. 

0«ii«r«I History of & Case of Qftngiwi*. 

Bign* of Doath. — Death of a limited portion of the body can be 
recognised prior to the supervention of evident post- mortem changes 
wiihin it by five characteristic signs: 

I. Loss of pulsation in the vessels. 

^. Loss of temperature^ since no new warm blood is brought to it. 

3. Loss of sensation in the dead part, although much pain may 
be exp>enenced whilst death is occurring^ and such may be referred 
:o the dead part through irritation of the nerves above. 

4. Loss of function of the gangrenous mass, which, if it is a 
limb, lies Raccid, motionless, and helpless. 

5. Change of colour, the character of which depends on Ihd 
amount of blood in the part at the lime of death ; if the limb is 
fuJl of blood, it becomes purple and mottled ; if auiemic. a waxy 
or cream colour results. 

These five sij^ns may be in measure present when the vitality 
of a limb is merely seriously depressed, as by ligature of the main 
vessel or by its embolic obstruction ; but if they continue for any 
Icnijih of time, death is practically certain to ensue, and they will 
then be rendered more obvious hy the phenomena about to he 
described, 

Cluuiges occurring in the Doad Tiasnos. — The character of these 
changes depends mainly on the condition of affairs at the time 
of death, and whether or not putrefaction occurs. The follow- 
ing conditions are described : 



fi4 Ji MANUAL OF SURGERY 

1- Dry Gangrene (= death + nmmmificatiofi). — Such can onh 
occur when the tissue involved is, previous to its death, more d 
less drained of its fluids, so that it readily shrivels up and loM 
its moisture. The usual cause is chronic arterial obstruction, a 
brought about by atheroma or calcification of the terminal arleriei 
to which usually a sudden or gradual complete occlusion of tb 
main trunk is superadded. The dead part becomes hard, dt] 
and wrinkledf and is of a dark-brown or black colour from tb 
diffusion of the disintegrated haemoglobin (Fig. ii). The mon 
fleshy parts may, however, retain a certain amount of moisture 
Septic troubles rarely involve the dry dead tissue itself, but tbi 
surrounding hving tissues are often considerably aflected. 

2^ Hoist Qangrene ari^s when a part of the body full of fluic 
dies, and is especially associated with any obstruction on the siik 
of the veins, or with acute arterial thrombosis in a previoudj 
sound limb, ^.^., in traumatic g;angrene due to pressure upon, a 




Fig. ij— Senilu Dhv G^>jukenk, affecting both FtET. 

rupture of, the main trunk. The loss of the vis a Urgo derive 
from the heart's impulse causes a negative pressure in the capil 
laries. which become filled by regurgitation from the veini 
Obviously, such a condition is admirably suited for the develop 
ment of putrefactive organisms, which always exist in numbers o 
the skin, and unless the most vigorous efforts are made to rend« 
it aseptic before or immediately after death, moist gangrene i 
certain to be associated with putrefaction. Unhappily, this pre 
caution is but seldom adopted, or even available, and hence i 
the majority of cases putrefaction occurs; it must be clearl 
understood, however, that it is no essential part of the process. 

Aseptic Hoiat Oangreue is characterized by the dead tissue 
becoming more or less discoloured, either purple or any shad 
from black to yellow, green or white. It remains of much th 
same size and consistency as at the time of death so long as it i 
kept from contamination, and is then simply and quietly cast OJ 





OAStlBSSR 



the mirmuDdlni- tissues vKttouC B.ny obvious hiknuDBtory 

S«ptlc or pQtrtd Mold Oftiifrviit [Fiff- r^) i« rec^st^ly atto* 
lUd with A rnpid hrir:,ikinj;-'ijp and disintegration of tb« ma38« 
■hich liocotDC^ blacti, K<«^-i^ ^^^ yellow, 'Hic c:Litid« ia ruB^ 
ihe cull* vera hjr blcb^ romainrng iclinkinj^- *erum» or evw 
ibblctt ol ga«, and tbc«c arc readily pressed aloDg undtf lb* 
for some dintancc. The tiMuea of the hml> U^ Sirft 
"•bd bcermbte, vul on gntHpin); il cmphyfcttuluufa u&cltliitf 1% 
readily noted. 

TIm Lfttor HutoTT d a. ^»n|*nmoti» ta«w depeods entiroly on 
Uw^a crticity ct not, oad op the wzc of tbe deacf tiuuc. 

^li tiKf nccfolii: jircii is mtiaIL iti sli% And asi-i>tic> I: may, 

ta%'Uar9ble circumstances, be friitir^lv abtarUd in e%stct]y the 

way as A cdtRul lif^turc is dealt witii- &i.kch n-\siy be often 

ftftcT Hlou^bin^ cf sinull pcrtiODS of amputation flaps ; if 

put is kept dry nm\ aseptic, k Es gradually removed from 




below, aad when the process i» completed, a i^m.-JI dark scab will 
fall or tv^ jnrked off, and h cic^iiriv fuuml 1>ene:ith ir. Tn an 
oacllj iJmiiar w»y di-:kd bone muy b<r itisurlW, if the scqueKtruin 
n BoC too largo or too dc^n^i arid if it in in clc^ac proxiinity lo 
faealthj v^sculiir tisMJc. Tlius, ;i child i^^iie lo the hospital with a 
portion of tho outer ubL0 of thi^ skuLI^ ns^ Inrge as (he palm of a 
maa*f bond, quite ban and d«^, as the result of a aloughing 
cvilalitiis; it waa troat<^ antiMjpiLCbUy, and wc icrudually »avr 
pamilaCMJOfa spnoginK up thruu^L llir lionc lo all aif«<:liuu», aiid 
QoaUy tbe whole vt^s ;LT>BOrb«d, with the pxcoption of merely si 
■BoB dake, ibc uxo of one's little finger nAil» which ^paratcd^ 
The dea^l povtioci U first invaded by leucocytes from the lymphatic 
i|MCea Of vesfdii of Ihr imntnliatcly iiintii^iknuN living titi^uc-s 
ttd ItUtltrated by them and ihn ArciimpanyinK blood pb^m;!- By 
apeooeaeof amo dijccsitioti this inhltmtcd portion di--i,tppcftr^, and 
li replaCJOd S> panellation tis!tuc. I'hx^ process of removal and 
lapliOflinatlT Tk ranliniM^d until ihe uhoir of ibt: drjiU tishURdi^' 
and ths resulting mass of granulation tissue becomes 

5 



tf 



A MANUAL OF SUHGEitY 



coQverted into a dcttrix. and cg>«reij with cuticle id the usual 
wny. 

(b) If the rnAe9, thouf;h fteaptic, ii: of fitich 3l size, or con^its of 
Vach li&5iic5. AS to prevent its totAl nh!iorptii>n» or if tlic vitaJ 
activity of the paticni i-^ lowrnctl. a modificnlinn of the Mine pro- 
cess result* in partutl ahsorptiftn tif the dcr-nl materijil, tj'fiilit tkt u^ 
matfuifi' tt rajt ojf aad itparaUd by a HmpU proiea of anm\HH irf-'^mfio*. 
Thcdcnd pari jmiiicclbtcly comicij[)U»lt>IhcIivrai,' is rcniOX'Cd and 

repUcedJiy fimnnliiirjii ti^Mnr. ;iiHithisdi;iiiK'^'^'""^"^'J'^^'"^^^^'^*"*S 
into the mass urtil tlit Layer of jji.inialiiTions u-hkh \\\s pfrneiraifd 
tiirthcit ii at such a dit.ttmfc (rom itc nvtriliv© ba^ia ^£ lo Iw 
unable to derive from it rtuflici^nt pabulum, owini^ lo the contrac- 
tion of tIk? ciraTriL'ml ti'iMi? \ihic'1i is fcriiiin^ tiehlnd ; and then h 
«impLv uJcLVAtivv proc«4^ frt^itn deftfctivv niiirition caus» a Itn^ of 
cleavage to form l*twoL"n the livinj^ nnd d*ud, b_y ni«ana of which 
the latter is seiTdiaitd ffom tlie iKxly- Tlie sii:c of the portion 
oast ofT from tW Ivwiy U tliU'^ distinctly It-^ iJian ih« afnt of 
ofiffinjil necrosisn Whilst this i& occxirrin^, th#T* \s no local 
inflammjitory rejiction, And no rc^ultin^ coMMtliitional di^turhcincc. 
It U> slow ijj pio^ii^bS, but tbcLc die none of the nbJ(» attacl^iiifi to 
the mnrr nipid srptir pmrrfding. Of roiiPie, thr *1pn*et and 
harder the tifi«iic», the ton^r ihey take in »pnrating. 

{c\ If the KAri|:rcnoas poHion i* acptic, its itpwa,tkm is acconi' 
p1isli('d hya diitiii''M)f iitJ^atHinattir^ aft taking plait in. aiiJiU tiu itp€mi 
oft tht mrrrtuiviiHff livtttj^ limtff. Th*: extent of th*- gangrene it 
primnrilv ifi.3i> ajc'\ hy n iitu cf tifmariatwn, due to the chanteo in 
colour '" LLiiiiu lu ibe dead part, the living lissuc^rcuJnJneibeir 
tionnal hue, Ihtx the irritation of rhc rhemiral proiluc-fs Ermrd 
in the necrosed mas^ causes in a few days inilainrn^iEion in ibe 
surrcunding Etructurc^, rc^ultin^ in hypenrmio and sub!ie<iucnt 
exudation of plasma and Icococytcs; the tisMie of the part div 
appeats, ;iiid is repEaccd l*y n edl infiltration, whirh in itim fircitn 
dour into pus, whilst a layer of ^mnulalion tissue turm* at the 
limit of thtf hvin;; portion, and thus the JiHdJ Hat cf itf^rathm is 
produced. CliniL-jJIy, one [ioticr> in the e.irlicM ^U^c a l>ri|;ht 
red line of hyperffrriiii r*t the extremity of (lit livinjf li«<tue, 
and this gradually spreads and d4<«pens until almui (be ei({hth ur 
Icntb day, when, if the cuticle in intact, the living and dead parts 
are «cpArftted by a iiarruw white or yellow hne. whiih is poved. 
on prirking rhn epidf^ntiifi, to he dn* to (he pitwnce of a layer of 
puft ; n£ the pui^ e^eapcf^, a (^hallow groove ia seen, running heim^ecn 
a granuJating ?iurfnce on the side of lite lining Ilj^quc and the 
gangrenous rua^s- This proresft, gradnftllv esttendin^ Ihraugli 
the whole Ihirbnesi^ of thf limb, i^ nttendeo by lh« local d^aof 
inflammation^ vi/,, local pain and fever, the amoitnt of uhkU 
dcpciKb on the amount of palrid inalefiaJ ^T^H^ibcd. The luflam- 
inatory piocess. moreover. \y not always limited to the Mn^ of 
aeparation], but m^y spread upwardii along th« Jyinphaticfi. or in 





CAHGRBSE 



6l 



the bccUl and muEcuIar pIan«K, untiln pcih^pf^ ilie «p'hot« liniU 
nuy bc<omc involved in an rxtcnavc Mippiirniivc pcoccss 

CoastltntiODfll Sjnsptonu of aaL^«D«, 

These may be described under two distinct hendintc^ : 
{a} lliOM: ifcnctal condilioDit which predispose lo ihe txctirrcncu 
of lf.atii£tcDe. Thrx^ use mainly vt a ilebiliTitLiitg chj.rarl(?r, nfTecl- 
^^ either the compoiition of the blood or the \'iEaiity of the limbs. 
bus> the patient may be !.-ufl<;nnK i^*>^ ^eticral asthcnin, i^ioh as 
fnill» Erom prtccdi^e £^ver?i ; or liis circuUlian may Inck vigour 
iba from wt^utmi^f llic licaji imi.sdr-^or Injui xims valvular 
ag^n, hs& artvritfs nvAy be fto diMUed, or rt^ndeivd ka 
tbercinaloua or colcuroous duini^v, that, ilthou^b a 
'iuifply of biwdniay rcatb llit e.xtrcrnitic^ fcn .^ll^nlinary 
Lfi ituiH.*,4M(t ^ ijf 1ih*i y^l any ur>usii.il (Jf!iri;Lnd upon UircbcLilation 
iTinot he TO*-!. Mariy <rvidence« of sijcb mahuitnliar u^anlly 
uiifot ihcmscKvs bclorc the on^ct of jjiin^rcnc. G t'ntiiJ disciL'ics^ 
stji.h ai oid1>i:lcs dud jLUpuiiLiiiurm, mny alho l« prc^cnii vrliilHt (hi? 
rjir^i?tiii<br\al rvM(^nr.p*i of fl vidoiis life may }v seen. 

(i) Tbo«« coDditionn dopVDding on the presence and coEin^ction 
»Tth the body of the dead lissue. Various (otms vi septic or 
^HaaajOC poiftomiDif rcMih finm litis usually causiit^ fevrr, MSlhenic 

Pin type and variable in amounl. Pain, moreover, la frrqiicmily a 
very prominent ientuTc in wjmc forms of gnngrunc, flud even if tho 
piiicuL 14 |>ro-ie<,lcd by the surgeon's cArc frotii the dan^rs of 
tqi^s, yc4 hff U oimdimr-.^ liablr. la lirr-nmr rxh^n^lfd from ihU 
caosc. 

Troatment of Oangrcno. 

This naturally dJvidca itself mttj the lutiil and ^ncral. \Vc 
^ltlll nut diM USX t^f r^u^^tiuEi of Local iiealTiiPEtl beii?. leiLVin^ it 
lo bm di'^tt ^lilh und^r the appropriate htfadin^'b lieri-afl^i. Ati 
to(l«MniJ troalmrni> but little need^ to bt? bulJ biyond thut thi} 
MfQO^th of ibc pAtioat inubt be ntainlrtlucd by plenty of ca»ly 
oviinilabJc food, sulTictcni nlfnulani, Aiid lunit-s. Pain and 
t>*i»iHill<rg mu(t be combaitrd by the^dniiniciralion of a exitl- 
aUo Kcnount of opium or fnorphta, if the kidneys arc hi^thy. 
U4b«to» ai>d iiJhunuikuii^t iiccU dielulic dod tlierupcLitic measures 
ift ordfT lO Until, if pcwrable, ihir nrrrlion of siigai and albumin , 

Tarletlfls of Qangrene. 

Hjivinir tbut Irartd in oniHnt ihr gpner;il history of a ca«[* of 

the si^s of death in the part, the various po«-murtein 

iDi^ which may oc^ur in it. the mcan:a whereby Nature ridn 

body of %iich an enHtimbianar, and the saiiou^ diiugoi^, loiril 

I gvnttTal, lh<^ patient mns— we now turn to the diffcreni forms 

titc dtscftM n-hkh are met with* and propose Eo discuas them 

The Jbllowint; clasis^calion U one i^hicfaf though 



A MASdAL OF St/tfGEifY 



ftdmiUeUly iiciptifect.dex^^in.i :ii«as»rt*f;nmptngi?tlic?r allied typesi 

of tb«n1ir^lion. :in(l will £erve a«u us«fu)onv furpractical purposM. 

L Idiopathic QfmgTOne, or thnt predisposed to by preceduaff 

va^cuUi ^1 [^f^iLFr^l coiidLtidiis, m where a trauma, if preacDl at 
hII, I* of very sliglii significance couipiLred with ibU ptP-rxisiia^ 

{a) Gangrene from embolus. 
(6) UfLyiaiud's discd-w:. 
(fj Gflngrnnr rtue lo ergot, 
(o) Diahfitif. gnnjjrene. 

It. TrauiQAtlc Qftngreno, vvhkh may be due todiL~ect or iodirect 
injiity, ami xuht-re [he d:imn^c done to the vessels or tissurs by 
the trnumn is the immediale cJiuse of the lo&ft of \-itiLlity. Two 
vn.rictie,i of t!ii3 may be net with, viz, : 

(a) The biditcct. whi?rf; the Ic^on involvesthc vra^eUcf the 
limb perhaps some distance alwve the spot wher« ibe 
KODiiiene occurs. 
(h) The oirect* where the ^angronouf^ proce3!i i» limiled to 
the part injured. 
HI, gp«clflcoTlT]r«etlv«QuigT«iM, which fLtisesfromtheaciK-ity 
■uid iiidutEK-f^ ot iiiK'io or^aniMii^. 

(o) AluIi' i[iflixiiLrnziloi> t^t: ^prcjulin^ tr^uitiatic ^angreoe. 
lb) \SV'iiiuI pliajiedeiiii mid lio^iul ^rigren^ 
Y) Ntfcioiis uf lioiie (most ca«C!>J. 
la) Nonj;L aud cancrum oris. 

IV. Gfujfiece from Tliermal Oanget^fTo^i-biie And biimv 

K^oh of thubd %afiij(Leb iiiut;l iiuw cl^ini separate and individual 
altCDtioQ. 

!- Idlopathlr-, Oaasraae. 

(a) Embolic Ouignae, (l^or ^--nt'tLit deraiU ji«^ to rml>oli, M« 
Chftptor X] VVhfiii tht uvunaitury of it bmhhecomes blocked by 
A ^nplceiiiboKts the condition of ufTAiTs It exactly simiUr to that 
which ohlAins Afliit li^nttitr — gv,> the vitality of lh>? pitrt i« 
dLTninished uiitil Kucb .'l time ait the collateral circulation it 
established. UndoT ordinAry circLimstdncci'.i then, it should not 
l^ivc rise logfloercuc ; but If cither ihc ifcncral or local vitality b 
much ritdnrcd, tlic nlwtmction of the mam trunk may l>e jtut ^til- 
ficient to determine the death of more or le«s cf the hmb- Thflr« 
arc two chief conditions under which (^on^rene h likely to follow 
an cmttuluH : (i.) Where the einbolu-t con^istv of a fibrinous vene- 
ration det;it'htd from one rif the cardiac valveit in a cHsa of eooo- 
corditis followmj- rheumatic or other fe\-«ta. Tho ffawnl 
nutrilloiT han been dcpn^neJ by the procodioi; fiovoTt the noftrt'c 
action is wt^k, aud the (..iLLuutiuii i>Lj»»ib1y bnpejud by the 
valvular li^ston, ^ that ih<; block of a lenuinal main trunk, even 




OAi^aSNB 



*9 



(ik-) ll alsoToflovrt wh«n a d^t^hed aihi^roniAtnn^ pUtc blocks the 
main vcsad ol a Jtnih previously lenJt-TNl anirmic l>y arterial dc- 
g e tt cra tioa, an ncctJiTf'rc4:<xc^MonAl1y mri wilh Jn rliWty pajplc. 
Tlw«ar1y Synptoms ;*rp ftlikr in hnrh mndtiinns. Sharp p«in 
is ^VEDcnilly piodnccd by tbc todRmrnt of the embolus, both at the 
poifll of impaction nnd iJm) down the limb Along the course o£ the 
vrwL Embnli ^rr roost rommcmly ntfrstral nt the j)uml» of 
iliv',«o« of (he m^n trunki (Fig. ij, A^, or wh^rtf the cilibre !s 
•tKldcnly dimminhcd by the ori^prt ni x lur^c branch, 1h« emboltia 






ifica viddlinic over tbc bifurcAtiom, .ind rhun, ni it mcrca»es m 

r t^' tbc wubw*()tiFfit ilfrpciHrl thprei^n of Alinn, rrecdmlly closing 

h bnroche* (FiR. 13. B). In the Icjwi-r limb ii occurs sit (he 
Ansoa of the femoral or popliteal ; iu the upper, m the origin of 





Ft^ ^— DiAaitAM* 09 CwDotcs M]>i:tLivo titk HircKc^Tiow or 

4K ANTCAV 

.b A th» invbolat k tAvn, and cho cDmeT^nnnivrvl of a t1ir<«nbi]« on it, but noi 
f«l obsiracifaaff 1^ i-nwl . in H both bran£he« ol Ihe iruak an blocked by 
(te pDvnh of the cloi 

tbcHipetior profunda, or where the brachml divideSp Pulsation 
ta ihr \eT<i*rls Wow Ihi* bWk rr^^iev, sen^.itTon antl tPTTiperalme 
jJiiniiiich, and the p;irt fccU hoavy a,tid i)^^]««e. If the i^s^s sire 
hcftllh^. AS iti the ht^t proup of case?, rc^'urijilfttton ihrciich ^c 
moA IS the uMial rcsulr. the tcnmiMl puiciun of the limb hccom- 
it^ coogoded and cnlenuiniu, :iiiA An.ilCy frilling inro a condilior 
o/raoist gaAfn^n«- If, howcv-cr, the terminal :iTtcriGs are calcified 
cr «|beTOBi*tou&, tto thai the limb ia in a rendition cf chronic 
■JKtnuii. this is ekiC so likely to occur, ^ind diy g^ingr^ne folbwfi. 
The pfooesssdniperipherally, and -iprcadiigradnsllyiipwariU until 
a rettion i» nMchcd where there it lurficient circulation to maintain 
the liEe of the pirl. Sucb uMully occurs in the neighbourhood of 
^ mat, since (lieio la always n tnau^ fiep nn-nslomosis bete ihan in 
jlntefvrkubir ponion* of !he limb ; thus, in the leg tlie pan- 
is uAUaJJy aff*rfcted either immediately ubove the ankle or 




70 d MANUAL OP SURGSRY 

below th« \mft. Thfr sttbiu^qnent tiTstcpry d^pentlft iipnn «1ii 

or not the de^d li««ue i« SL]lr>vrc^l to L>ec^m« septic, Ati<l in do wiy 

TroAtment, — The <i]l-impottjuil rcfjitiNtc In dtmlin^ wilb a 
nf this ratiire h to pret-cnt the ndvnnl of sepwn, *inct it may" 
tritisform wlul would olhen\'isc be ^ condition aisoaated with 
hut Utile danger iolo one of Ihc R'^vcst momcrt. As !*oon a» 
iHissililr pifter llie ohslnic:(ifni liii* Mktn pUcc, and miy ^ib^olule 
^^ns of dciltli ;ir? nunifesl, ^rupulou^ ran* muHf be takvn lo 
purify thv part. The naiJe shouEd be c\iU and the wJiole bmb 
tborou^hly but ijcnlly stmUbtd with carbolic lotion (i in ao). 
ftp(?L-ial aUciilKJti Uebg diictlcj lu the iiUcrvaU lictwecu the loc* 
And t1i« folds of akin tinker and alongside of the n^ik> It dicald 
then he wrapped in a lay^r or two of nictist and purified i^aiim, 
bwcitlicd round with ^licyllf, ioiloform, or sicrlli/rd wool. Ard 
li^hilv, tlioogh fimily, baniU^pdH TVie limb is Uv^i ^lichlly 
rniB«a, k> aft lo prevent venous re^urglution without intorfcniaig 
with the nrtcrinl supply, nr>d by this mcar£ gangrene may be pre- 
veiktcd. Ifp Lowcvcr, llicsc picr-nutlons arc not *ucccf«fni, and 
the pad dies, the same mra*:ures as lo the maintrn^jrce of 
nsopsis must be continued until a natural line of lU^par^tiort fonw. 
In old people wjlh dry gangrene the sAinc rules are fallowed is 
ii)i ihe >ritile typr : but in the moist form, occunint; in younf 
p«opLe, ihc n;uural prtictss of »patation may ht* haMcnrd by 
Mverini; the dead from Ihe living* find sawing through Ihc liortc, 
or poasihl> nmpulalion through ihc llwni; Iimhuc:' a little nlxi^v 
may be mnsidered advi'^ble, a more shapely Mxinip Ix-ing lhii« 
obtained. Where 4cpsis has occurred it is AdviMble to ampuralfi 
thfouRh hcalthj' tissue as soon ana definite limit hnr been reached 
by the necrotic process. If« however, there ha> been much 
%ptp:idin^ ?H-ptic inflaiitm^luin, one may Ite driven much higher tip 
the limb than would bt otherwise n«ce*sary, whilkt vvry ftcute 
Mptic symploma may detcrmire utnputntion bclore any line of 
aeparatiou nai formed. 

(fryBikynanil'v DlBaue, or Spontaneoni dymrnvtHeal O&nsraw, K 
a condition usually m&X with m young women bt^twoen the URCf 
of fifteen and (hiriy, who are of an anaemic, chlorotic, or iiervous 
l^mpfriaiiieul. It is due lo viiso-motoi ^fjasm, dcpendeiit titlur on 
'iomc d'^op iinrerognt**d lesion of the sfnnal cord, or in 4om6 teases 
lo A peripheral nei.irili»H II occurs in conditions u( nervous m^ 
haustior, and has been known to be !»laited by Fright. Its onset 
iiboftrn suddrn, and il may last for a viiri,<ble lime, from dayfLin 
mnntht. If panKTr-nr tupf^r^^enos, the latter U the limit more 
tjftun reached, but ii by no moans necossArily follows thfll ii%SMC 
necrosis occur* in every tiiw* Three stages aic visually de- 
scribed ; (u) local syncope or ansrmiB, aH^ang w thr. dirrri result 
^f arteri^il spa^m, and charactcrixed byj;iallnr and painfulness of 
the part ; (ti,| local asphyxia or congestion, in whicli the afl^cxl 




GASGREtiiS 



n 





blue arid cyHnotteit fmm vencm« reKun^itntinit ; and 
■.) finally ih^ part di^, cfii^n bvcominj; dry and bbck- The 
Ihgtrft and lo«e nt<e moat bkeiy to l>ccomc m\'olvod, the proccw 
tUrtnig l>y iht Mdc uf Ihc oiiil i but lynimctriciil spots oii the 

more or l«A in thai order o( fn^fjuency. Hev^^j (lo*§ not 
iptkny the process, but p^roxy^mni hu^moqloblnuri^i hn^ hc<-n J 
^ed. And i& supposed tu bir due to a va^u-motot dii^turbanco ' 
of ihp kidnryv Arkylo^ii^ of ihe *im,t|ler joinu, and lrH';tli:'rd 
pi4tchri;of ^in^-rsth^MSi^Lf auociAK'd vv'iih pAinol a ntfumlgic typr, art? 
U«D BOtnciintcr* presort, resiJltiiij; from the peripheral neuritis. 
The ONUlition s^mc^lwt rc^cnibk* the lii[cf stages of a tJulbLxin 
^teoin Uft ml and ocnffpsifd appe:(nirre. ku is di^tinf^aiEhrrl from 
Hfil by iU more duftky colaut, the pettier pain. Che ab^nce ot 
^Blckini;, ^uul the: f^ct thai ihc process is not limited t^ cxpo.scd or 
HtcrmiiLA! piirii. or lo cold wtitber, 

Thr Troatm^nt inu*i be in the iirst case piie\x'ntive. The con- 
jtittUicn ^ould bv built up t>y iron, qoiDtnc, and il D««d be by , 
iaUiQt5« wliibt locally fnctioti with MlmidAtlng cmbrocfttionSi 1 
dutjdie»« uiid ptuitKrtiiin ftriiri colli juul injiify» nnxal bol 
'toyrd^ Wbeit actual g:i[i^*T«n«r i« pre^m. the dead tIftsiiaJ 
lOliDoid bo kopi A^ptic, when sooner or later it will bo absorbed OT 
laepAiatcd- 

Ir) OftBfnne ftoon Brcol >^ n i^ii^ phennmenon, but h has bcun 
knotrn to occur when dist.i^vd fVi? hut bi-en uufd in the munnfac- 

I hire o( I'Tcad. Tht* cHcd w to piodnco chronic ;injimia of the 
eUiniJttic^ fjuiEt LoctU Action of iim srnallei (einiiLiiil ^ileiiolcs, but 
b AddittOD peripheral neuritis and unse^lhe^ia may supervere. 
(Yotttbly 1li« gJingrcne i^ m:vinly Ju« to Eh^ latter condition, the 
nticELl Dcin^un^^vAreof injuries whidvbcinf consiantly repeated, J 
«k1 itt au ill-iioijTL>hrii lirrli lu tleath tif llie p^K, The result-! 
a^ gaagtctis may %^rj' in extent from the lo»r)f one ortwo6ng;ers 
DT tocA to the fo^nlire of the ^oal^r portion of otie or moit hmbfi. 
' (d) DMwtlc O«a|r«a0 is in p^rt due to Ihe alnmorm.-il condition 
itic lilotxl prcMiUt in diat>ctcs< thereby leilucm^^ the power of 
M re^^ wa]U and tifitaieft lo tcsUt infl^mm.itory eiiiuiges: but 
in pATt tbc result of a EHiIcro^irg cndartcriti.iH and peripheral 
t«. It i.i not commouly met with in the subjects of mAli^'' 
. . . diabete%, on*, as a mle, in people IkIow fatty vtKiis of ajje, 
remlU tuually from tome di^ht traumatic or inlecGive inji^ry, 
oommonly commence! on the under mde or at the extfomity 
lof one of tbe tocn ji»a bleb. Muicjunded by a dusky puiplc arcolft. 
Wh^n the tiMi IS opened or tniivts, the ceiiTial poninn of the 
uncfeilyiiig li^ue is found to be necTCtSc« And from this focus the 
!iprc2kd«. taking on a moi»t or ft dry type accorclinK to the 
il of v'UM.'ul&r di^cMSe- 
Ir the TrMt]E«Bt ar* Attempt shotild I* mad? to rr^diicc Lhe 
rxcretkon of bugar by adniiniat^ring cod^ia luid regubting th« 





7* 



A MANUAL OF SURGERY 



diet, but too much time must not be lost in this proceeding. A 
careful investigalion of the condition of the vessels is called for. 
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 mvn 
trunks are affected some way up, then either the separation d 
the necrosed mass must be left to Nature, the surgeon merdr 
assisting by the division of bones, or, if the patient's general state 
is tolerably good, a high amputation may be undertaken. Under 
the latter circumstances, however, there is some risk of the super- 
vention of the diabetic coma. 

[e] BeidLe Qangrene is a condition which, as the name implies, 
occurs almost entirely in elderly people, and is the result of im- 
perfect 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- 

Oaiuei- — These are to be found mainly in the condition of the 
drculatory organs, {a) Catcificatitm or rigidity of the smaller arteries 
of the Itmb or part is the most important factor. The chauge 
commences in the muscular fibres of the tunica media, in which 
a deposit of lime salts occurs, so that the vessels become pjpe'lite 
and inelastic, and incapable of accommodating themselves to the 
requisite variations in the blood-supply. Hence a fixed mininial 
amount of blood passes into the limb, which is thus thrown 
into a chronic state of anemia and malnutrition. The tunica 
inlima, moreover, is often roughened so as to predispose to 
thrombosis with or without injury. The larger trunks may 
also be in a condition of atheroma, (bj A u/eak heart is gener- 
ally present, leading to low pulse tension, and increased diffi- 
culty in propelling the blood through the narrowed vessels, 
{cj The vetwus return may also be inttrfered with by the existence 
Of varicose veins, or an emphysematous condition of the lungs; 
whilst (d) the condition of ike blood may be impoverished by albu- 
minuria. When such predisposing factors are present, any* 
thing that results in [e) thrombosis either in the main trunks or in ifu 
peripheral arterioles or capiUaries is likely to determine the onset of 
gangrene. Tlirombosis of the main vessels may be due to some 
injury to the limb which is often overlooked, or more frequently 
arises idiopathically from a deposit of fibrin on the already 
roughened walls. If the obstruction originates in the smaller 
trunks or capillaries, it is almost always brought about by some 
slight injury, such as striking Che 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 vaiy 
accordingly. 

SymptoDU. — Preliminary evidences of malnutrition of the limb 
'will probably have been noticed for some time in the form ofcrirbp 



CASCRENE 



n 



tiidwmu m th« muficl«St which i:ii>idly L>t*t:t>nic tati^rd und tired, 
«)wt sntsfltiona of pins »Dd ntiealcs fir numbness are al^io com* 

tincd of- Thr- circalaiion in llie rilibli may Iw ^ sliylit w^ lo 
Kflrcely pvrcepriN«, an(J the wl^ole tirtib fcwU cold and he^vy. 
Tbe dtin ifi noquontly more or Ic&t cont;«fitvd, and extremely prorti 
to low lormA of ulceration or eczema. W'lieii ilio gaagrenc com- 
cnenm as a rrJ^uU of wimc pt-riphcral legion, nn ww* of painful 
(cdncfis U uswilly fir«e notx#d, p<if hapn running on to ulceration, 
aad in the ccwtrc of this p»tch a ^lou^n Is formal, wVich becomes 
Ai^4Dd bktck. The pioccs* gMdurilly siJicadh Uutu thi* fotus 
wib more or lens itifl.Tmmarifin. «i th.il it is somc-rimts known as 
^ll^Hnnatory Mnile R;infcri?nc/ If^ however, it is idiopathic in 
^H^Pand espodally if the rcsuli of throniiNDsi^ of Iho main 
^^Kra, dr.ilh txnui^ nilhoul ihr sitpervoniioTi of local inHarn- 
Qiatory phenomena. Ihc tors mnrHy ^hriveUing up and dyin^. 
vtiilst there u marked pain alone the limb r non inflammfttory 
MtiBe gangrene'). The inner sidfi oi the gre.it toe is perb^ipi the 
covubonr^t M|u.»tloti f[>r llifl tionimpnmnf^nt cif ihr nnsc-Uief, and 
(hence It sprrad^ from one lot- to another, and aI«o nlon^ lh« 
ififltep and up the ankU' tofhr kf;, Hain is^imo:^ marked feature, 
vhibe the extent of the gangrene is dependent partly on the 
tmount of L'enrral and Uku) vttailiEy, and T>.irTly on the iis^plicity 
or txH of iHe Furrouiidin^ piirta. A& thf-< diAeaiie spreads, the 
petieai tends to become exhausted by the lonj;<onlinued pain 
ind w^itii cjf sleep: «ni! «eptic fe^ci, bcdMiiev. ov the intervene 
xkm of snmp pulmonary complication, may alio hjist^n a fata] 

HThc Tre^QWOt adopted untU within the last fow yc«Td wns 
^po^erned b> tlie jl'^ixstiun that Einy utteinpl tu leiiiove lUededd 
(iuuir^ Ivy amprit-iting in nejghbounng living parts wan ijoomed 
eo Uihjrc, on account of a sliniluf process btartin;; in the h^pa ; if 
merely cutting a com suifices to originate llic lUAUdy, nuKh more 
^■ooU so sever*? an injury is an amputftiion. Tlie p^vX^ were 
AaawA *rith iodrtform. or some filmiUr antiM^ptic, ard wrapped in 
cctt«fk<wool to koqi Ihcm i^-flrm; the surijcon then waited for n 
Hoe of KMr^tion* and even then did tjot amputate, but merely 
awdrted Nattirrr Jiy dividing tendons nr l-innrs. At the ^ame time. 
tlw f«nen] health wat maintained hy thn jndkiotiKndmimRtration 
of milable nouri^ment, ttimulantr- And tonics, whilst pair wnn 
allnialcd by the ii»c of opiuni in ^^uch lIdkcs as the condition of 
ibe kidneys wltowed. In spite of every care, however, the old 
and enCe^bted eonctitution of the patients often proved unequal 
to Ike task of riddini: the body oi the dead ma^ so that death 
inxn eihauMiim or ,blcw[l.poiKming was Ihe Tule tiitlicr than the 
eieeption, aiu] even if the puii^nt did recover, the prolonged and 
enfnreed it*y in bed diminislK^d hin vital powers con^derably. 
Il lus now, however, been dearly dcmoDstrated that ^rJy 
perfornted midei 4:arefu1 antisepnv, ujsd W/ away from 



i 



74 ^ MANUAL OF SURGEFY 

tkt dead mass at a point where the surgeon considers the blood- 
supply sufficient to nourish the Haps, and yet not so neat tbs. 
trunk as to seriously threaten life throxigh shock, holds out tin, 
best prospectsof relief. In order to determine the most £avourabli" ; 
site for the amputation, the pulsation in Che main artery should bv i 
fek for, and if feasible no operation performed at a spot wbeit' 
it seems to be occluded. The condition of the limb will largdT 
influence the surgeon's decision ; if thin, attenuated, and shriveUed, 
with but little subcutaneous fat» it will be wise to amputate high; 
but if the limb is fairly well nourished and with plenty of adipose 
tissue, Che operation may be performed at a lower spot withoat 
danger- The colour of the skin, indicating the freedom or not d 
the cutaneous circulation, should be also observed. Id operatingt 
as little damage as possible should be inflicted on the paitl, 
the flaps being nearly equal in length and not too flimsy, t 
circular amputation, or some slight modification of it, being pef- 
haps the best. In many cases where the mischief is limited to 
the foot, it will probably \^e found necessary to amputate throngh 
the lower third of the thigh^ or at any rate in the neighbourhood 
of the knee-joint. 

11- Tmnmatic Qangre&o. 

By traumatic gangrene is meant the loss of vitality of some 
part of the body as the result of an injury, whether applied to 
the main bloodvessels {indirect traumatic gangrene), or directly 
to the tissues (direct traumatic gangrene), 

(a) Indirect Traumatic QangreDe may arise from a considerable 
variety of lesions, and the resulting course and clinical history ia 
similarly \'ariable. 

(i.) Ligaiurr of the main artery should not produce gangrene 
in a healthy limb; but where it has fallen into a state of 
chronic malnutrition and anaemia from preceding arterial diseasCi 
death of a certain portion may result, the case running a simihu 
course to one of gangrene due to embolus. It is usually of tbt 
dry tyP^T one or two toes shrivelling up ; but if it reaches tht 
more fleshy portions, it may remain moist. 

Where the gangrene is limited in extent, Trofttment consists ii 
waiting for a de^nite line of separation to form, an antiseptv 
dressing being applied and the general health built up, and thei 
in assisting the natural processes at this spot by dividing tendon 
and bones. Where, however, a considerable area of the limb lose 
its vitality, and especially if the dead tissue is moist and septic 
an early high amputation is called for. 

(ii.) Arterial tkromboiis frmn injury will, similarly, only caus 
gangrene under special Circumstances, the course and treatmei 
being similar to that for the senile type. 

(ill.) Obstruction to hoik main artery and vein is an almost certai 



GAKGftBSB 



75 



precuraor ol f;;ani;fr&n«. A few cv^es are, howcvori on record m 
whkh l>o<h vessel* have hccit lii^ittired, or even pi>flJon?i of tlienj 
retnovcd t\iihout Iraclin^f tuRflnstere^ns tn draling with canf^emiis 
4ppoAa1s tn th« axilla, or in th« extirpation nf ;kiieunfiins ; hui in 
bolh these initaoccG there has I>een pre^-iniisly pteseni flUcH ar 
obMraction to the circulation* as nni&l h^vc nccc^sriarnl llic 
<ycp l ntf up of coliaiera] an^tUonuitit: Ijranchp*. In n norni;il limb 
tm occlusion of both alTorent and cfTcrcnl Ininki^ in woll-ni^h sure 
10 detenniiie tiiiuc necrosis. i1 may thcreJcirc; \^ c-m&cd hy the 
induaioa of botb vc3NcI> in n li^liirc, or Uy the itrangMlalion of 
oigMifi, *fhber wftlitn the boiiy. as m a slran^lattd hemii» or 
oai4id0 of it* iiS when a h^Ltturi? li lied round the ha^e of the ptams, 
or a bAAda^ applied too tiglitly round n fractured limb- h mny 
a)M> occur uodei Utr }aCEci ciii:uni!^t:inL-es I'uim the liinli bec^timiniiC 
^miollpn from ettr^va^ition of bTooJ or inlliiramatory exudation* 
^■flrr tiie l^tAJiduf^e has been put on with no undue Eension. 
^B A V£i]r uiTiiUr ic&uIe itiuy lie crcduced by the excesaive 
^Hypcrtrniia and exudation following the sudden relij^f of a tightlv' 
^^mistnctvd pan, which has thus beeo dvprivied of bv^h tLiteri'al 
blood lor B0R1O time; the vessel wall» are thtrrcb^ 30 diiina£[cd 
that thry aic unable to lesisl ihtr bluod-pteuuie. ami lieiice 
the phrnompna of indamrnEition ar* mai>ifesied to such a degree 
that tha circulation i& btou^^ht to ixn abaolute BtandF;tilJ o^ing 
Co the mnount and pressure of the exudation. Tills occurrence 
a «oin«timr^ ni<-i lArth ith*.': frii'il-bitfS, and also in h loop of 
bowel, u-hich ha*; br>cn stiHTig^iJai^-d. afier removing llie obsiniC' 
tro to iht circdAlLOQ. 

A Hmilar train of n^mptomx may result from rupture of th« 
nuiu suifiy, fttrd i^cnnpre^don of the vein by the eytTjivflSrttf^l 
blood, ao occurrence pvrhaps most Irec^uently t^een ixiit^r frff flutes 
and Jittcc^wBi : it 13 always of the mi^iit type. 

A& lu TrollDMit. the p;Kt^ ^rr kqil M'arni .ind icnderQi] a^plic 
itfitil such St time si* gjin^rene is cU-finttdy e*iabMshtd, and then 
Mnptitalirca Ihroui^h the $jte of obstruction* cr }U3E abov« it, roust 
be uadertakcu. II niAy be po^ible lr> sAve a luub when |,'&u^cac 
i* thresletitng from fracture or ilisliv.ilion by CDlltnj^ doun at 
000, titrtiing out any clots whicli may have formed* and securing 
tbt divided or lacerated vessels. whiUt at the same time thcmuiiR 
of ot»UiictJou lU Ihc^bape of llie di^pUceO Ikjiic n dealt vritb by 
fiomv tuirahl*' ^uTjriViil mpM^uri**!. 

{tf Pmct Travs&tlc OaD^rent, or that resulting from the imme- 
dw« cfiitct of injury lo the paits, is similarly duo to a variety of 

(i.) S^ntf fruthfi or himi'Ti titv n common c-iusp r^f thi* type of 
jEBflgraiM ; thiw a limb mny hreome mangled between the u'he^lft 
ai nukchioery, or by hca^ y wdi;hts fMbng on it, or by the pa9«ai;o 
of vehicles mer it. Noi only are the parth cru^ied, ?iev6rely 
cootuMd, Of #wn * pulped/ but the bloodve^^sels muy lie Tnm, 




76 A MANUAL OF SURGERY 

and the resulting extravasation assists in determiniag the condi- 
tion. The gangrene is of the moist type, and is more likely to 
supervene in patients whose circulation is defective, or wbow 
vitality is diminished. Thus, a crush of the foot in an eldcdy 
patient is often liable to lead to it, whereas in a young and heaJtbf 
adult it might be prevented. 

Trefttmant. — If the part is hopelessly damaged, there is not the 
slightest use in retaining it in connection with the bodyj whilst 
the patient may run considei-abk risk from the onset of sepas; 
and therefore immediate amputation should be undertaken. Thi 

auestion of shock and its influence in determining operation ii 
iscussed elsewhere (p. 206). Where 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 easily capable of producing gan- 
grene, such as that which arises from injudicious splint pressuiB 
or in the form of bedsores. Splint pressure is a cause that should 
easily be eliminated if sufficient care is taken in adjusting and 
padding the sphnts prior to applying them, and hence only occurs 
as an accidental circumstance or from carelessness. Where there 
is a well-marked tendency to displacement 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 precautioB 
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 appears white, anaemic, 
and insensitive. A case of this type was noticed by one of us 
some years back, where the pressure needed to retain a foot in 
place after a subastragaloid displacement was sufficient to lead to 
gangrene, in spite of the patient not having complained of any 
great discomfort. 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 met with in patients who are kept for any length 
of time in the recumbent posture, or in any one particmai 
position. The parts most exposed to pressure first become rd 
and congested, and finally ulceration or actual gangrene super- 
venes. As a general rule, bedsores are not very extensive gi 
deep, but occasionally when the patient is debilitated, and espe 
cially if a condition of lowered sensation is present due to impair 
ment of the nerve-supply, as in paraplegia, the process maj 
extend widely and deeply, destroying fasciae, laj-ing open muscula; 
sheaths, and even leading to necrosis or caries of bones. Tlj< 
spinal canal itself has been opened in this way, and death fron 



CAHGRgSS 



If 



^^4^ic M*ftiAgitift h^ r«£uUed. To provent the cocurt^ncc of 
Mcti >orV9, tbc moM s<:iu;)uli:iii« j^ECcntiOQ shuiiUI be |-ivcn t^ Uie 
|Hftb «x^i?*^ tij prr^Mjjr. The nniM- hjusI sfc lIuL iht' draw- 
ih««t or bc<l'lineii is plarpd Jtmoolhiy and itiihoul cr^asefl, and 
thftt no conUrniiutiojt by urint or li-ces i& allowed ; if ilio 
pvtic&t i& pcr^piiiiii; freely, ttic flicct ^linuM be frcqucatly 
cfaftngeii. so :*h lo prrrvcnl dccwirjfKisiiion of ihe Hwrat, T\\e 
ckia cf lb« back RboLiJd be daily cxantined, washed with fiom« 
uatmtftttTfi? ftoapt nnd rublx'^fl wilh a &oolhiiigt Etren>;^hrnin£, 
4i)t! hAldeni&K applicinioEi. such a\ spirit of wine, niRihyliitcd 
^im, o* prrh;i|ft, Iwin^r *ilill. :i tnixiiitt nf hr^ndy and white of 
cftR> It i)i <bco duvled over with a mild antlMplic ]>Dwder, 
t4ich uh boiracic acid^ If the skin becomes red, it should be 
PU£U<mJ wilb colkjcIUai, %x\d ptolcclcd from prcrauTC hy niean» of 
1 circtUar hollaMr wiiler-pillnw. P;tr:Lplrgic (];itienls or old people? 
tfaoukl at oTKc t« pb<:«d on a i^-.Ltei'bed, wbkb r»u£t b« suffi 
aentlyi but col exc« »i vol y. distended. \i tboro 121 too tittle wator, 
ibc wdgbt uf the budy dj;i{>1aotf*i U tu one uUe. and no good 
roulu: whiM if xht^iv i^ 100 rr)i)c:h. tli« bed becomes hard and 
resstaat* aad fad& in thi» object for which it was «mployed- 
When.&B ooen »orc f6rnis> It must be k<;pt aseptic, and drcs^d 
diher wirb boric acid ointment* or ir ih<r morv fihigKiT^b i:ase« 
«Hb f<m and boric acid oiniTn^nK mixed. Fristr^ haUam j« 
»lso uM^l in this condition. 

(iii') Th« 4ct>0D of t^mwjf ot fdiufu^ cAfm^co/A is often fallowed 
by m. tcKttlired tranmatic gftngrene, the degree of which A'ill viiry 
with th« Asiount and characi«r of the irntant present, and tho 
duratioD of iU action- All thai is needed, as a rnic, 15 b^ hccp 
ibe iiut> aaet^, and ^Uow iLcn^ to be ab«orb^ or sepaiatcd b> 
tntiiml procesM:*. 

^B 1 1 1. SpeclAj: or Infective Qaaercne. 

^H All !!)• forms of ^anpenc inclmlrd in thi^ ^^ff^i^^p "^e charge- 

^|^ri£cd by their ori>ciii in the development of iik]cro-orK^nitim&. 

^Krbicli t? ibe vimJcnce of their product! determine the death of 

^vlhff afTrrtr^ lisMitr^. 

(j) A^t# Spraadinff or SpraadioE TraUDUtlc Gajigr«nd (the 
fWty^M* fOUdfOTant ijf MaiE^nneuvcr).— Thi^ di^i^^c is od« o£ 
tlie most lapidly fatal and various met with in aurgery. 

O^gaN^ — <}-) Tbe irJtvidwd atl^etced is :is a nile pT«di§posed to 
stpCic infUitirnatory conditiona^ a£ a refiuli of vicious or carelfi£fi 
iiviQ£, « firofn simplo malnutrition. Those who \x^ in the hnbit 
of cotisumiag Ur|^ amounts of alcohol, even if not actual 
dnmicardc, nicb as brewrt«' drayirif^n, who uyi^ roniinnAlIy t<}>ikcd 
wilfa dftnlc, are especially bablo 10 thi« Jiffeciion. Some forms of 
vintt, f^icb are parliculaflv active, may lead to n developnvont 
of tb^ dbmM- even in ^ bcAllhy {jcisoCi 



7S A MANUAL OF SURGERY 



(ii.) The Usiint from which it ori^ates is usually a severe oo^ 
such as a compound fracture or dislocation, especially if the kA 

parts are mucb contused, or if dirt is ground into them. It^ 
originates from small and insignificant pricks, scratches, or aba- 
sions, if thereby a virulent organism gains access to the tigswi. 
In this way post-mortem porters, nurses, or pathological demon- 
strators may become infected, and the gravest coDsequcncea 
ensue. 

(iii.) As to I he organism present, that most commonly met withii 
the haciihts of malignant wdema, Jirst isolated by Koch (the BanUn 
septicus of some authors). It is a rod-shaped microbe, somewtut 
longer and more slender than that of anthrax. It is anaerobic, 
and in its growth Uqueftes gelatine, and produces au unpleasant 
penetrating odour. On injection into the subcutaneous tissues of 
a mouse, the animal dies in eight to fifteen hours, locally i 
spreading cedema is produced, the connective- tissue spaces bnof 
filled with fluid containing bacilli, and perhaps some gas-bubUe& 
Bacilli are also found in the exudations which occur in the sercm 
cavities, in the connective tissues of important organs, and in the 
blood for some time after death. Similar results are also said to 
occur from the activity of the Bacillas aerogents capsulatus. There 
is some little doubt as to the exact modus aptrandi of the organisms, 
but it is probable that they originally develop in the damaged or 
dead tissues of the wound, and that the toxines thereby produced 
are ai^sorbed along the lymphatics of the limb, giving rise to 
inflammation wherever they spread, and thereby producing a 
suitable soil in which the microbes can further develop. 

The Symptoma are those of a hyperacute cellulitis, accompanied 
by those of general septicaemia. The wound early lakes on an 
unhealthy action, the surface becoming covered with slou^is, 
and a thin serous or sero- sanguineous discharge being exuded. 
The inflammatory process rapidly spreads along the connective- 
tissue planes of the limb, which becomes swollen, painful, and 
brawny. At f^rst it is of a dusky purplish colour, but soon 
evidences of actual gangrene supervene, and the necrotic tissues 
become crepitant and emphysematous, partly from ^mple putffr 
faction, partly from the gaseous developments associated with the 
growth of the specific organism. At the same time evidences of 
profound toxic disturbance manifest themselves, the patient per* 
haps having a high temperature and being delirious; but not 
uncommonly this may be entirely absent, the temperature beii^ 
subnormal and coma present- The outlook is exceedingly grave, 
death usually ensuing in from five to seven days after the 
onset. 

The only Treatment which holds out much 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 



GANGREXE 



H 




icfirction may have prnRrrMpd ^a lapidly ihaf dr^th fallows from 
KpiicmTiia even after the htnh Liii been rcrnovcd. In n few cases 
where tbc piatient is seen CArly. it niny hr pn^uble to sAve both 
and litnb liy (rtrly inmitiK ibtt jflVrtml ii%Mirs. and immrrsing 
in a coDlmuovu; warm, antiieplic: baih- At the siime time 
general hc>-ihli munt tic ^itti^ndi^d to by p^^^^fi plenty of fluid 
nslmicDt. tui^ethri with di(Tu?ttb!e stltnuUnU. mch ay cthcv 
and ammrmiit, ;ird p<n\jbly full dnvK jif i>piiirn. 

{ft) Hocplul Ofta«r«n« «&d Wound Pli&£Qd«iia are coniXiiiom 
affectioi; ^^ounds v\liich v,iiti: ^i^'cn oltcn i:nout:b m the prr^-unti- 
septic ria. but ^c hcju' prj,tlicjity unknown. l]i:uih\ nut otily la 
umwfKis, but to tlw incre^^^d rare dirert^d »f^ ventibtinn nnd 
bOi|Mtal hygi«ri)€i Thev i:onsUted iii a rnpidJy sprc'^Ldtnj^' uJceca- 
tion ot i;uirif:r^nc, ^bicli ;Ltt^c1icd opcratiim s^ouiids n few duya 
aftei tbrii iittlkttou, Mird ^s a i ide led tu lapid dt^tilb. Il \s 
fertnnati'ly iiTin^rf-«ary nowndayft lo dcw^ribp nrdippriisfi Fhoiri. 

(c\ KktmIh cf Bom 14 pntctiutJIy alwnyn ditc to tho dcvclop- 
Dcot of Ofc^niuiis. am] m^y be cither actilc of chronic* In the 
foTTiKi. the infUmnwiory fi.Htrli-in is sn *cvcrr that thr: vt^isds 
Ncome stnmgled wiihm ihc bony alveoli; in ihc latter, k iii 
Itri^y du« to an obliicrAtivc endartcrititi, which acegmpanicr* the 
vartou* spcci6c proccsLfci. Thi^ subject is fully discussed in 
^Owptrt Win. 

{d} OatsfTUtn Orli and Nonut— Cancrasi orii i* an infective 
stuTiLaCdii, aHcctint: youn^ children hvinj: in squalid 
in uver-|]opuUled d.i-*lritt> i>f large dtics. The 
Ale afwayk in a low *tarff of henlThn arid fft^ivtently can* 
wJaacing from one of the exanthemata, particularly measlcis. 
THe process irtarta in an abr.xsion of the rnucour. mtinbranc^ which, 
faring Inbctvd often bum a (Ii»^ist^d 01 dirty tiKJilu br?(.-^iznKS in- 
ftimtll and gin^enoui. A fovil at^hy-^ray pnliact^uus ^loii^h 
loraft on tlie t&side of one ol the theek:;. aiid ^um this the mo&t 
aflen^ve iliacharjjx: i^ poured forth intcj tlic mouth and s^vallowod. 
ibr hreaib tii ron^'r^ui.-[icv Ivi-ornii]^ i[]tL'[isely f'rtul. The ^an- 
giwqa procBAs gradu^tty spread^i both superncially and deeply ; 
tM chftMC bcGomos bwollcn. bhinv, and lenso^ and, should tho 
noQQia exited throuf^h ith whole sub&taiicc. a black alough 
torm^ tm lis oiitrr awt:-ci, And i;raduMly mcreaM;s in si/e. In 
th« wofKl CAUTJE, ibc adjacent honoR of l^o f^co may be .-ilTected 
and dtCf and Ihc tonfcuci pilitic, and avcn the fnucc», mfty be also 

igntrral pticnotn>?naarethnKP of a severrsBprfmia. since not 
t Ibe toxic proiucii swallowed, Inii they are alifo absorbed by 
iphalic^. and may be inhaled, in the fatter C£v:i« ^ivini- riae 
sDptic poemoudi^i. Morec^cr, Ehe piitieot nn]^ a cLin^iderAblc 
liftkof drvtJc^ng pyt-m'ui, from iniplicatiun of lb<.' fidal or other 
vcatt in the Decrouc process, whilst infective n^px icirmU m;iy al« 
tDpervene. Rt^orft and higli fo-er often occur early in the ca!«. 






hut ricftih is visuftlly preceded by symptoms of coLlApse And coma 
with a MLbiioniiAl IcrikperaUiic. 

The TrflfttDMTit must he pti>nipt and cnergi«>r if tb«! rhild'ft Wk 
ifi To be utv«d. The p^tifrnt should he at oooc ftn;i?stbctixc<), aaiA 
oil the pultACcous slmjgh scrnpc^l fmm Ehc intcnor oi the maaih 
by mttiiniL of ^l Volkmaim s gpoon. until healthy bleeding in%uc a 
ivdchefl. The denuded surface is then freely rubbed cntr with 
pure carbolic or strong mtric add- If the Xntn'stoi the face An 
involved, they must lie removed, as also any (jflVudiujij todtb. 
Aflcrwaids the diild should l>e lAell fed up. and piefeiahly (ax a 
time with ftuid^i th« mouth \-i 10 be frequently washed our with 
antiseptic lotions, such as n solution of ftamta^ (i in 10}, boro- 
Ig'K'cci'idc (i in 2o\, ot prrmaugtfiuatc of potctsh, or witli a C^^^ 
of chWiite of [xnash (lagraiun Ui 1 ounce). A mixtur^voMitJiiitin^ 
chlonite of potash, dilute hydrrjchloric .icid, and infuMom of cin- 
chona, mav be ndmim&teroo for n f<TW dnys, aud then iron and 
qujiiinc. III Ibt moat severe c:asc:> the 5iAmc Ircalmcnl should be 
adopii*d, rv^'n if the whole thickness of the chprlf hAf> hrm £t|- 
Ctoached on ; toss of substance must he iTkad« good by fiubec- 
auent plastic work. Nece^^'krily, the cicatrization follovinjt thi£ 
Ofstruclivc process rc?^u]ls in a good dc^l of pcnuAncnt impair- 
ment to the movemenls of ibi? j;iw. 

Noma is the name ^iven to a, dmilar proceu occurring about 
the t'cnit:tl ot^nuft of children, especially the vulval of youoK ^rb. 

Tilt Treatment to l>e <idoplcd is Idcntic^tTly the Mme* except 
that here it may ttc possible to immerse the patient in An anii- 
septic bnth, thtrehy diluting the toxic products, and poesably 
preventing tbe necessity of having rocom^se to mote »crious suipcal 
procedures. 

(/J Oarbuscle uid Boil.^A Oikrbiincle is iin infective i^un^rette of 
the sulKTUtaneou^ tissues, due to a. Iccul iiwiision wtlh pyofi;«mc 
miccoljcs, the couunoriesi being ihc S/aphylircciati P^gtm-t cuimu. 
It occurs in intliwduttls run down by iiny i^tifietal dehilltatki^ 
condition, such as- albummuriu or di.(h^l«5, and in whom tb« 
l,-<Mnucidal pov/cfrs of the tisauca are much depreciated I it la 
alx^ met with ocLa^iuucilIy 3s a ^cquc^la v( iiLulc fevers. Th« 
exciting cause may he somp blow or squiM*7P, rpsnlting in cxttAva> 
Eation of blood, or some local dLmimjtion of vitality; into thifi 
ftrca cocci are implanted either by auto-mfcction, or more usuaUy 
ihrou^h the «weat-gUm^s or Itatr follides. or through somie slight 
^nprrfidfiJ abmaon. 

Sl^iu. — A carhtmcle commences n£ ft hard painful infiitratkm 
of the subcutaneous tissues, the ^in o^cr which bccomci ret] and 
^tmmJtv The sweltmg ^i^dually increases in size in all diicctionav 
icn a dij.meter of sit or more inches is reached. Ai it ex* 
dpbenlly, thu central parts, which x^-cre formerly brawny, 
loft and l?oggy> and tne o\'erlyin^ ^kin shows cvideckcea 
Dg to tbe pressure within. Ve>idcs burnt on the soi^LCt 





GditanENK 



and fuudly posltik?i : the^ in turn tmEsI. ani3 allow- a tarily cxU 
to tli« ashj^'Cray slougtiv and purnlrni di^hruge licrtimtiUird 
b«low, FiWh opr'ntnics i;rndu:Ll3y Icnn, k-udti^g to jh cht>nfnTtii 
OoculilioQ uf tlkc cutis. Out; |jrubAl]|>' lo iIiq pos^^c of tbc pii« 
■loDfi: th^ Vtnvs of IcMst re^)iAi;&nce, viz.. ttw |)vrforHtimis of iht? 
Ciitifi at iIm sixes of th« »bac«<oxis glands and hair (oltklo-s- Some 
of IImcd ip«rluftts cniariK' and run into on« anothi^r, producing a 
crtitral ifTC^Iar ctalcitfLJiiii u^t^niii|^'> xi Ibc botttjtii ul which vs% 
thr t«*crotir li«ixp. A* tht* vioh'i\ctoi th* iiil1:(mm;i(inn wilKidr*, 
tKc «loUi£hi graduall)' »vpArjit«, leaving jl ctwtn granulating wound. 
Cafbimd<« moi^ fTci{ucntly occur on ihc back, chc rj^pc of th« 
DmJi, thr iihixilitors Jiitil nalcs whvrvf ihc ;^iiality of tV<r iImuc* a, 
orv^r very active ; whc«i ihry fnrm on mcru ^AU^ulAr partii, *uch 
2ft the £acc aikfl lip«. the con8cqu<-ncce may bo <^voti more icHous, 
0«rjn|! to the onfct of nn infective thrcmbo»i« of the Inri^c \'ctn3 
vbtch arc itctc present. Ttir) arr ummI)/ HTitflr, and utay l>e 
aceofflpftnied l>y a painful cnlargemv^nt of the* nearest lympliaiir 

Tbere is uMiaJly <oo»derable cc:inntilulional dbturltftnco of an 

BvcnK type, altbouxti the tritii>rratnri- i^ m>l iipcessiit ily much 
fd. Somrlini«f tbe jirav^ii ^ymptotn^i of Wood-ptii^iimiiig 
'p-v.< rnia or ^qitica-mijil may supvrvuiif, 

Dudpioab — t, Ftvw Bpili.— i'afiifftegKetl^, n boil i^ an infccti%^ 
^taigmie of a «nal] [mrtion of the ^Icin. A rarlmiule af^e<lf^ ihr 
M>ctltaft«oi& titim» primarily, and the tkm finiy wcondarihr 
Ciw*K4iift boiis arc multiple, comtal in shape, marc localized, afld 
mPi.'i^ ^'»{ vmalion lua occurred the pruesiA is tcriiiiiuAlcd by the 
ri if th^ ptis and ^JougTi through a s^gtr opentac. 

C-.iu.i' i' ^, on the otli^r hand, ura usually smf-l«, much larger, 
t«tlrr. and the sloughing process may coniinxK^ pcffiptwfmlly^ 
vlit]^ Ihr central pin isil^scharginj^ its slou^h^ throuKh aerenl 
oprmaov 3, FrMR G>iwfntfl[L--Ctiuneous ^mmaia ai« utmiy 
vmllipio, occutrini; in |VAti^nlf^ \4'ilh a disliret and ottvci rrcvtt 
•ipMlilrc hi*lt>r^. TIk'v Air not very pahiful, and do ikj( t*ndlO 
aciain any #;reiit si/i'- Thry tixially j»lr.r-i.ii»- biily, IcawjC ^- 
eular »ofr<. i>r if nnuliiple, Mrmi with Bcriii^finou* o^ttlint 
il uwally bat hitle dcfmile blc^tjiFhinc. '1 he devppr gUBisnau 
alto l«ft» painful, hwt \*in one openii^it, and leave chcavaIc^ 
in Ih* \mii^% of which mc yi'JhiuiUi J^ni^h^ !ikt- y^vt ««ih 
Tba dtftCbiTRe U usually'not diKtinctly puralirnt. Uu i 
biiwdriaincd e^m. 

The Pngnoib of carbuncle m«jtily flcpcnd» upon th« 
nf Tfv inlprn^l oiK:trV' If thtr iKitienL in a ciaihniie<I«rf 
ditlvle* or allnimmuna, ll»er*? ts alwayv ronsicWfalAe n^ ^i 
taikicv fr<*^ exhaustion- The ^awniUriiy o4 ll»«p«rt» 

II ltk<^ Ihr fATif. vet ilw implwJUiOB 
IN i^> cLirk^lk pyanii^. 

L mu»l nlwa>'ft lie of a tonic. 






4 



A MAtfUAL OFSURCESy 




Goo[3 ffxrjd. iror, iiuinioc, and akohol according to judrmcnti 
muil be ajlriiiuislcred- uliihi iipptupiiate niciliune (t.g.. Lutiei&oi 
Opium) ikiid liirtU:ition of diet ai« nvc«ssary in dUbv^k pat*vnr«, 
LocftlJy, many ilitTc-rviit formbof troatni«nl liavc been siJCfi«<cd. 
The niostl thoroui^li aiiit uiiftfactory \» to lay the c^buncTc freely 
ap«i under an anft'StTie(k» and scntpe with & sharp spoon or cut 
away »ll almi^h« until heulthy ti»^uo is rMchsd, nnrl thrit 10 
thoroujflily dUinfccl the caviij- with pure ^r)>oLic ncid. The 
bollun tluib fcJLiucd Jn fftulTed ^itli ^ntiKiptic drcf«ineSi sw:h as 
gBii/r snnk*vl ir ,in inrinfnnii (*mid'iifin (in ppf cr.nt,), aiwT ihc cmsr 
will ihi^E) pmhahJy proceed rnpidly to conviilcAceocc. Anolh«r 
less radical pnsceedtnj^, especinlly snilcd to old people. i» to 
m^Wc » free crud'tl iucts'mii, und filltm' the )^louii;hi« tii ^pAj^iic. 
Awi*tinH matters h^ ;tn:j*jepiic poultices. The old plan ot de- 
«troymf{ the cutis with potas<« fiiiui ■« exlremdy paimul, and hav 
nothing' to recommend it. 

In tlir airly stages, it h;i^ lieen propuwd Eci Inject the fturround* 
1i!tsue« with pure carlx^lic ucid in tlii^ hop«of destroying iho 
inii»mA, and thus preventing: i;uppuraIion- In a certoiu nufflb«r 

ca^ea this oliject will Iw smcce-Hfully accmnplished. l>Tjt where 
Ihe otf^Jiiisni* iiic ul all vituletil, It >vill ^jiubalily fail. 

ABoU cir FnriinoJ* i^ a bCill mortr limiif^d form of gangrtne than 
a carbuncki m that only a small portiuii of i\an and submtanonuft 
ti»LLe. u-iually touml a h.iii Mlitlt. is deployed, ExpciiintrutaJly, 
a plentiful crop of lr(>il*t can \'t produci^d Uy niM^m^ <t cuUiuc 
of -^tauhylouKCu^ into the bkin, und ditiic^lly it is suppowd that 
a ^iiniW infection throuf^h tlic hair folhcle> i» the most corm&on 
oiiiiiit; iif tliU LuiiditionH Thi? sciLuxidaEy Ivuilb aiounJ a prlnutry 
on? flTT- u'lthmiT dmibl due Cc^ the friction of the drr-twingii rovcrfd 
with piiannd nucrobuft upon Ihe he.tlthy luttig^iment. 

People with a ccidtsc akir ami u Cendef»cy to comedones, or 
obfiirucllmi of cli*- sclmcirouh follitlcs. art ^pecinlly liable lo the 
occurrence of ImjiTs, A ^angrrnnns irrtflmmflliod ensues after 
infection^ re^uJltn^ m ihc d(;jitli of Ihe hnir Mlide, or of tbe 
sweat or schficcou:^ gland irLVolvcd> and of the surrounding coa- 
nenivt tissuen ;iiid the sltiugh thuii formwi is casl off by a proctna 
of suppiii-ilion. A matured or ripe boil» therefore, coniisisof a 
central slough or core, n zone of puu nround it, and exFeraal to 
this gramdation tissue mert^ins ii^tc healthy skin and conuectire 
tbsue. Althmi^h infrctiun froni wiilumt i!« Ihv local vxcitinff 
cause, there ia frcquL-ntly present some dcprc^won of Ihe vitti 
powvrit; such may lead to crops of boilrt recuiiins again ikli4 
a^aiiiH 

fllfiU' — A 1>ui] cummenceis a^ a smhll red irrifatde pimplo. from 
Ahxh J4 h;iir mav often lie fl«t*n to piotiude, which increaar^ 
^adually in ^itc, occominj; more and more painful. nnCil tt fonits 
a cunicnl tunuiui, deep led in luIuui Jind exi^tJtsite]) tcndei. A 
small whitish ^poi jipp^-ir^ ir ih« c^icrp. and aronnd this sO'C^pd 





'tiANGFBHS 



core ytllow mxs. caa be fieen. Finally it bursts, discharginp ihe 
and :iut>w<iuefitly ihc coic or slou^'h comca away. I'lw 
luceai 15 ibcn al im cdJ, and the i*ountl lapully IiqUh by (^'Uitm- 
irsn. Ocri^ioiiiifly ih* iiitbrnmalion eirtend^ n little mure 

fK into the ^thcnunt^iuti li^^ue^, conttttithn^ a * carbimcular 
The ni.'iL'hbotirint: Ivrnphalic i^ljuida buccjinc •lymputhctic- 
r rnlHr^eil Aiid piinfu), mix rarely 4i.ippurAie. A sitccrs^on of 
K nuiy appvfit on* aflrr anriih^r ir ihe f^Aine indivldvial for 
c<ckfi or iTKinihs. Occct^nruilly tlicy subside without tuppuraticm, 
vini; the puis ihkkcQcd And infiltratedt d condition known as 
Uimi hoil.' 

tmoit — Locally, many boils may be? tcfl to hurt! fiatufiilly, 
pOAsihIy the pincp:!s may Iw chiiukc^i by surrovmdinR 
rn with .t piece of oidin.irY adhc^vf: pU>lcj , v,Ah a liole over 
aj3**x of tile tiWpllinK- Asa TTile, hnwr-v^-r, om^ h;is-lenkmaHf*r* 
■pplyint; pouJticc?, and tncLiui;; when mnlurt', Ctmstif unonally, 
tk:! arc usually cjUlcd for« exceiiC in plcthoHc iiidi\ icJLta]:i» m 
whom a ?bpaic diet ^ind atintitieJicc uom Mimitkni^ tjiny lie iccuin- 
mendnl' A cliAn|;«? of air 1o a brarin^ %r.idde pLioe ti olt^n ^idvtH- 
ablr. especially wlien tli« condition perdid£(, cropt of boiU appearing 
L time ts> time. Sulphide oJ calcium (j) to ( ^raini combined 
pill% with tiutiiine aiiij irun nuy «Iwj In? admuu^lcjcd. bul the 
TDer dnig U prol^bTy not of much inlu^. 






IV. (hLacroDO from XhemiAl Cftuaoa. 

I- FnM(-bite, — 'n*is f<irdition i^ ml vi^ry frcT|iK-Mily sri.'[i jd 
ni* cotiniry, but U by nn mrami nrronimon in irtjions vhii}-re ihn 
Iter U njor*r t*vftrc- h otcurt in Ihtjuc ivho :^rc txpostd to the 
atid ihc 5>mplom^ iirc iniWcd mure rcvulily if a hii-li wind 
iwin^, ilw* he;tt (J fbr bn<!y hfin^ then*by mofp qtiic-bly ilis* 
it m^y ohKiaate in one of two wajs : 
f«) ypu^m tju dttfct fWtik cf toid lui the tiisuts^ vrliieh become 
lUiikrft* hard, and of a dull, waxy appearance. No ^mtx is Ai< 
f, e^pcrimccil in the frer^^iiif; process. *i ih;it onlooker*; are 
likely to recocnisc the condition than the individual himscif> 
Tbc eMrerni1ie« oi tbc licdy. whcTc Ihe circulaliom is a little 
^ii^ish. aiui expotcil put?^ are chicily liable to be attacked, and 
tbii« Uw nov. e:in(, fing^n. and Foe4 are nio^t often iiwolved. It 
aIk) mure tikeJy to ucciir in lli« youn^ and in old people, whoii^o 
Ldj pi>Aer» are not very ijrcat, t^raduaUy the pnil ilirivolTv n^>, 
tiJack. and ia kiIici alisoibud oi ^p.iiated l>y a ptix/evh of 
Eion with or without sappuration. Th»» most marked t'eulure 
'FQC bom tfo^l-bite \\< iho tnore eMcnsivc implic-atlon of 
ipct^cuJ ptirt^ on account of iheit ^tdAtc-r i^xp^^^urt'* 
Ftem thf \»^u^unit im.Samrtititvm thai aris^-s in party which, 
thotisb inweo. nf*^ not irnmodiati^lv killetl. The ihawin^^ of Much. 
ruUunea is ttCCom|MLOicd with tnc »cv«reM pain, And the pro- 

6^a 





J MASVAl. or SURGERY 



\OAffbd ■n«ni'< MUM cuch a bui^Tini; of th« vilalfty oi th« V9s#«l 
wulls thai tilft-ffr«dairi»icn of the circulaliun a only Ico l^cly lo 
Iw folluvreJIty iin ncuir iiilUmtiLalioii* x%)iklj triuiiiMlr:^ lO tirriiHU 
from strjingukllon of the vusv^ls. U il f^srapet ii^liijil fVilli. iSt 
part r«iiKuns r«(UL'oiij{L;»uJ, ond painful for »oin« time, jiui «iipct 
hcIa] ulccTi iiiAV cvcLi foi rii : cvcmIuaII)'. Iiowevcr, ic iccovcrw. 

Tltfttmaat — Tbc fro/cn iMiCsniutil tie lhiiw«d very ^j^ultuily. 
And ih« hlood admirccd mio ih« ti(iKii«ft ^iTTy idowly if m^atrima- 
tcry fptnicnsio in to be avoided* 'J'hcy should be ^;ctitly rubbed 
wiUi uiovr or ccld Wdicft 4nd |jrijidvj-iii> waniicd by bcin^: bcid id 
the hamh ni ihr rnsnijuibtcir, ami rhr ptilicn: *bnuld lie pUL-nl iu 
n cool room, the tcriperntuTc of which u rnivecl tmt ilowly. Ak 
TcactioD conicK on. a »niikl] Amount nf Vkntm dnok nuy b? 
ciiiitidUily >^ivcii. Kxcc^Mvr p»\n oc cuiiKc^llw u%lcitia may lie 
HmilptI by clex^lim nf the jKiri. If ;ii:tiiAl gingrene urx'utb^ line 
dead liuuc mu&l lie rcnci«red ;md kc?pt ateptic, and th« case carv< 
fulty Wiilclicd until a definite line of Kp^mtion b»-H foTn;c>d. 

'1. Burnt Mid flculdv^ - Tbcw? niay \rc cDii^dcied as a specul 
YiaHely Li] uuiind, not [iece*>K:iri1y endiT^g in gnrgr^'n^. hmii^^ht 
about l>y tile acIiL>ii o] heat ; Lnini», tutii^ by Ibe dow proxinuty 
to, or direct contact nith. flame or bented sobd bodi«A; subis, by 
ibe action uf U^Llin^ ualcrf . siijieTliralH M^niii), or oib«r hot fluiiu 
or »jaM*«. the dilfeienco in the vtrect^ l>«in^ coiiipArAblv to the dU- 
tinction Ivetween rf>ajitinK :»nd boiling. N;itufiilly duids, *uch a« 
oilj whitb btiil al a hi^hei icmpefaiviic tijiiu i*aUT- piuduce 
iorn-'iiMnyly s-.'Vtif results. 

1'he E9act» ul burns uiid bcaidtEvairy with ihe 3Dmc« of h«jiti it« 
intniHity.ard tbc dumlioti of it^applicatlon. Six diftcrrni dec^ec6 
of burn virit JeHLiilied by I)u])iiylitri. arid hJii i:Us>ilk4LLOi> niay 
fiiill ti^ THain^ with ftflv.int^tfte. The Jtrtf lirgrff (^jt^VJt^ mprrfy 
in ft t«corch or stipcrliciai conjf&ailion oi th* *l*in, without desumc^ 
tioo of iiH«LK. The pAri nidy, lio^^vcr, rcmftir red. painful, niid 
prone lo iilceraiioii for n cimt, Shoidd the thatch lie olten 
rapcAtod. ft«t by periple i^nofilAiilly WAnilla^ ihetr lej^K liefoie the 
hrt, the i;liin f«com«$i chronicAjly pitfii^ented and mduralcd 
{erytknua nh ie»ft. In [he ir<tfnd dti'tn tU^ cLiticle is raised from 
llirnili!^, ^ni1 ^ blHi or bliMei resiibv When tbU bunhls. and llie 
cuticle is remt>\eii, ihecutis vera, fed and painful, is ex-pos*d below. 
Jr Ibe ihtrj dezr/t ilic culielc \> ttcMtoycd, as is altio pait ot the 
tijli-i vera, but iheti|Aof the inier|>apillary proces»ei. incJuilinj; tbe 
exqniMlely senMllve nerve EermitUili;. nie laid liareand !vfl iiilad ; 
ounsequvnlly this is a most (Kiinixil fwrm of bUHin Tbp devp«r 
Structures of (he iikiD \^r... tlic sweat and !iebAceou» Klaodti and 
liau' f(jllicirs^ceini«in utituu^heLl. ^> that, ahhougb LDO SUr^M^e 
<1urifi|; ih*- lu-alltiy proceis tiecomei covprrd wiib graAulation^ 
the uUei^uiiient is very rMpuNy re^ilactHJ, &mce there are fio inany 
epithcbal elements fri>m whidi il iiiay i;row. The culicic ift able 
lofontt noi from the cd^e only, as muaLiXCui vbeiex'CT llicifthok 







GANGilByS 



as 



6t 



' ih^ <'t>tiinc<ni4 en\'elQpr 15 (i«»!roycd. hul also from inrumcr- 
htc foci M^ltntnl u^Tr tlitf u-uliuiI Mirf^t^. The iv^uWtitti km 
rcetv visible, *nd onJ^rK^jes 110 contr:ic:ir»fi : ii i« i<unpr^ 
cIohIipc from contiimin*; .\\\ (he vl«mcni9 of iho true wein. 
At: fMrrih digiit Oic whole !]>icknc*a uf the iniccDTiicnt 1* 
iSe«tK>ynI. as \\r\\ ms pan of thr snlH^uTflnrou^i iKsm-s. fn llu- 
Ifih, fhr muw[*'ii aT* alu>«nrroarhi?<cI upon, whiUl in Che riilA the 
i^holc limb ir- chnrrod .'Lnil (Uf^arcftni^^-d- In the InM IhrciC formi: 
InhIjp^ can only occur l»y friiiovrti of »<lr>tif)»s aoH tht fnrm-^iion 
n^ 4 cK3Uri\, whlrh by ilt cnnir.it'lion may Irsd 10 suhsrciupnt 
ilpfonnit)'. 

J'Ik LocaI ffistMT of A hum mny be dcscrib^fl in ihree staiT^^ 
cwrc^iKiDditig to ibc; three &l^f<:s llinnii^h whit h an uTccr or A 
fars^inl urouDil pnws: (i) Thr ii4:4Krof flr^riLctiim nr Imrring, 
varvHis deforces of which ha\« been just riHudud (i> ; (3) the 
of infUmm.ition luid ^Imi^hing, whereby the dead liwo* is 
>fd. aitd tlir WTHind ti^tEvrriFit intn n 1i<rAlt1iy i^uiiuldliiJi' 
; (j) the 4ra^« of repair, which ff>iTows the tour^ d*»«icnhea 
her^ {p, 194). TItere are do spi^cidl cli:Lruclenstii:fi of these 
pci>ce*&iC79 which «il! for p,irtitii!ar not^^. 

Tbc OeMtsl or CoaatltuUoiiJil GnodiLloaii wbidi correspond tL> 
tbew itirer a:ig«4 r^juire i\ little fulltr nolice. 

hV-^ »n immediate rt-Mili <jf ihc hLirnini;^ and de^ttuclion of 
ti'.^iip. Ibe pjUical lie* fcjr n llnie (L''cjit^> <>r '^^ accardinc to 
~r(^tns(aDC«) in a itale nf ntoek. ft i*t iirrponaitt to rrrcn^isc 
the iniMisiiy of thi^ depeni]*. roi so much or\ thi? d*pth of the 
I AS on hd extent, so tnnt toul chArrini^ of a Itmb will prob- 
aUj r^use EcM depces^iun of the %y^teEii than an e^tcn^^ive »upcr- 
fir^Ul tf- wrh, pfcp^ally if tht* latter lnvolx'e*ithP3hf1nmm. Fhiring 
rhf< internal viscera, especially those connected unlh the 





i-,.:^. ^, .^icm, bocomr intctiMily congealed* 

2. \\*1tilM ihr s^'parAiK^n 'if thi? sitjughs U lirinK efTcclc^l, a 
perind nf lafluamaitOtT fever followR, Hue RJlhrT to iiei>tic ron- 
t-uTitnation of Ihi* ^longh^, or to the abtmrption of the products 
of the charred tisMKrs* It is usually of nn aMhcnic type. And the 
patient xs hkrly in \w. wntn oti: iinlr« he is r-AxcUxWy Urtikcd after. 
Any nt»d e^-cfyfoim nf intemftl complication may irise tTorir^ thi» 
■daifc, whi^b U-%unlly Instft from fiaurto fourteen day?;. Cofii-esiion 
of the br,un or hmc^ is not unnimmotily seen, birt the |,'a^t^O' 
cnleUinjI rmei U th-i(, prrhaps, moit generally ;irul viioiisly 
effecteij, Tbe muoou* mcmhruneof the stomach und inTPstim-** 
becocne^i cnffor(fe*J n-ith hlood, loading; to exhausting vomiting 
add dUrrhira, and pouibly uicemtton. or c^-en pcnlo»~dis» m^y 
«ipervvne, 

Ihirinj^ ihr iati^r d.^ir-i c?f th»!- •M\\:,'.', the ciuiou*; seqiiehi 

LDown as PerferatlBi Ulcer of the DuodoDOm 1^ linblc to occut, 

ugh it aa admittedly riul at all Lummon. The presence uf nn 

-Li;i in (he duodeouoi \% sugge^ed by pnin in the rpiiciistrijin 



i 



86 A MANUAL OF SURGERY 

after food, perhaps some vomiting, which may be blood- stained* 
and possibly the passage of a motion containing a good deal m 
altered blood ; but occasionally the tirst sign of such mischid ifi 
the sudden collapse of the patient, followed by rapid death, with 
or without peritonitis, owinc to perforation or excessive htemot- 
rhage. The bleeding usually arises from erosion of the superior 
pancreali CO -duodenal artery, if perforation involves the anterior 
wall, general peritonitis is certain to follow ; but when the posteriir 
wa!l is affected, a retro-peritoneal abscess may ensue, as ain 
occurs in gastric ulcer {Chapter XXX.). The JEtiolagy of thk 
condition is extremely obscure. The ulcers usually occur id 
the first or second part of the duodenum, and never below tb> 
entrance of the common bile-duct, although they may be found 
opposite its exit. In appearance they present a clean jy-punch«l- 
out loss of substance with little or no surrounding inffammatioo, 
and their distinct limitation suggests that tbey are due to tbs 
auto- digestion of a distinct arterial area» the vitality of whidi 
has been diminished by a preceding thrombosis of the vesseL 
This may arise from the lodgment of a capillary embolas, 
although why such should be located in this particular region 
is difficult to see. Another theory supposes that some irrit^v* 
substance derived from septic or other changes in the burnt 
tissues is excreted by the liver, and that this is capable of 
inducing thrombosis in the tissues in close contiguity to the 
entrance of the bile-duct, or at any rate of producing ulceratioiL 
In proof of this idea. Dr. Hunter'sexperiments might be quoled.in 
which he succeeded in producing ulcers of the duodenum in animals 
by injecting toluymenediamin. as also the fact that this complica- 
tion has become much less common since the introduction of anti- 
septics. Thai the condition is not necessarily fatal is shown by 
cicatrices having been found in this locality after death, when 
due to other causes, 

3. When healthy repair is occurring locally, and the parts are 
kept aseptic, no abnormal constitutional condition should Xft pre- 
sent, although there may be a certain amount of asthenic ^ 
anaemia. Where, however, the parts are septic and suppurating 
freely, this tendency w ill be much more marked, and the patient 
may even die of exliaustion, combined with hectic fever and 
amyloid changes in the viscera. 

Causes of Death from Bums. — If an individual is burnt to death, 
the fatal event is usually occasioned by asphyxia from the smolw 
and noxious fumes of the fire; shock and syncope from frighl 
may perhaps be adjuvants, especially if the heart is weak or dia 
eased. Within the first few days death results from shock 01 
collapse ; in the second stage, from sepsis, internal complications 
ulceration of the duodenum, etc. ; in the third stage, from exhaus 
tion or intercurrent maladies. The prognosis in children is alway 
more unfa\ourable than in adults. 



GAXCJi£»l£ 




TnatMotat, — h t< impD>i«iM(^ to do more here th^in ttkrtch out 
MffMf of Ihe more impijrt.ini principles and plans thAt have beea 

lu tile Hjpcrficia] scorcher without vcucAtion, iill tlul in c-illcd 
toe .Kfi 4 rule* i^ IImt pro! ruction of Ilip AFTpf^tpd p.-irtiipithpr hy (hisltng 
xhttu o%t7 with flour ()r p^ntin^ ihetn wtEh ci^llodion. Wher« 
bavc formud. the cuticle nlioulcl be n^nslicd ontiacpticuily 
tlacn pucctUTfH). w> as to allow tTic cuut^iiup^i -^cftiiMi tti citcape. 
(hen t hi* nT^.\ should hf* <)u«[rd wirh br>ric slHiI pDiA'J^r, ard 
with i^ilk^ylK: ivc>oL Carron oil {i.f., a mi\ lure of equal 
ptrt» M tinsccd-oil And Icinc-walcr} i> Abu much iLficd, ^^ipplicd on 
lint , it t^, hovrc\cr, nut a.ii dnlisvplic^. jilliuiti;;!: Ej> adding tt ^tmdl 
:fMrticni of 4?ur-aiyptii4 oil [i lo loi (his c^n hr niitri^riRd- 
crly some Fr^ncli iiutbcitUic:^ hav* commended the u«f of 
uric ACtti Of! ft dressing id ca^cA of tiurus where tlic rtitiit \«m 
not brt;rt mnn^ty destroyed ; thy vtsicl*-* are pimrliirftd, <LnJ 
3 pMCc of linr> «oaktd in u saiuraccd Rolution of picnc 
, 19 opfilicd to the hurnt ^orfAcc, and over thi«. in lura, a pad 
vUicylic or »JciiltScd wool is fitiidy UiDdftgcd. Thus a dry 
OK iji inniluml, whirh may In* Irft I'fi Hf« fnr ."ujine lUys, 
vttea 11 \% rr:kpplicd- Wo h^vo usod ihk proceeding' in i^v^ral 
ctosft. and hare been cxcccdinj^ly plcJi»cd viiih the rc:tu31?, 

IVberc tlic hum indndcs df^ctpcr stnjclurc^. Lhc ctoihiin muBl l>C 
renHWed inih a^ \hx\c dr^^^ng 2.i> pot«iblr, in-ill^ <^"L away if 
accMAry: the dirtiai;cd (iKtL]o£ ere then ^-cll hachr^d with sume 
lOlisGptic, such tkf carbolic loliifn >n 40)- and covervd up t<.^ 
rqadly -in poujhlr with linl ^ntkrd in cufz^lyptu^ oil ui v,n±k 
cvbolk oil. )d nooie case^, where the skin and «arfMce flrr 
WMtfdinfily dirty, it b well lo anfcsthutiju; tho patient, and then 
Wait away pail3 ti'hicb must obviously s-lou^h ajid thorovichly 
Lurily Ihr witunJ, which is thm cov-i^it-d willi prulet li v^i Hiui 
dWMd vnth cyanide c^itxe, or ^omt' i^ucl^ rTiutt-riaL 

At the 9ani« time, the gcocral coodilion oi tht patient muflt Tioi 
'bf t^rerlookeJ ; be i% puKubly in a slate uf considerable rnhock, 
tMlthotefiMeshoiihl he put tolled and ccnered with wALEiihljij^keln 
ar ru^, whJfil p«rhap« a iiEik' warm stimtiUtiiig Buid is ad- 
noAAtcrcd, In the c^aac of children with very cxtL-n^ivc: bums, it 
ii soinc^iiuc^t uwful 1u pal tlirni into A hut Uill), to which ^ome 
fuTAl^ptn^ nil, if ohuin^ihl^) hii^ liern added ; the clolhcv^ M<e tlicn 
ovfid or cut ftwav, aekI Ih* pnliunt allowed 10 rem-iin fur *.onie 
linw, tir nnlil lh« mixV \u\f* sithwdcd. in ihn warm waler, which 
nuy, if unc^siiry, Iw rcplrnishnl. Thr wounds arc then drr«cd, 
utd ttir litllr- p^lTPEii r**mov*^d lo brd. \l may be desiTable to 
ineAl I)w tmniciMQat at pv^ry dresfiLng. 

t When 1 limb ba.\ been hopt^lrwly charred or buml to the botic, 
ifr uvle?(s tci fpt^iti it. ;.iid immrdiair ampuljilion Uifk^ugh tbc 
iKAtval hi^llhy ti««tie« should be undertaken. 

When the next stage, viz., that of ioflamniation and sl^u^lung. 



88 A MANUAL OF SURGERY 



has been reached, the only requisite is to keep the parts asaseptJ^ 
a.s possible, assisting the natural processes of repair by varr** 
moist applications, and snipping away sloughs as they loosom* 
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 cicatnsation is reached, the granulating 
wounds are treated on general principles. The ^aDulationst^en 
tend to become prominent, and stimulating applications, such a» 
touching them with lunar caustic, may be called for. 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. Sores involving the whole circumference d 
the limb are especially difficult to deal with ; in one such case 
we were only able to bring about a cure by removing an inch or 
two from the humerus, and thus shortening the lirnb, accwdioj 
to the plan recommended by Professor Annandale- 



CHAPTER V, 
SEFfllfl AND XNTEOTION. 

Sepna- 

■1 BipUc Proceu is one due to the activity of organisms which 
Iflvf only the power of developing in dead tissues or fluids, or in 
Passive material such as blood-clot, pus, or serum. They may 
occasionally gain an entrance into the general circulation, but are 
^oickly disposed of, and do no harm. They are termed non- 
pathogenic or saprophytic microbes, and the processes resulting 
from their activity are akin either to putrefaction or fermentation. 
There are many bacteria in existence which can produce such 
results, and amongst them may be mentioned the Proteus vulgaris, 
Mkrocouui prodigiosus, various forms of iarcinay Bacillus subtiiis, B. 
•ddiiaciui, and, under certain circumstances, the B. colt communis. 
The action of these organisms is to reduce the more complex to 
simple compounds, thus bringing about their disintegration. At 
the same time, irritating or poisonous chemical products are 
fonned, known as ptomaines, upon the action of which the 
symptoms of septic poisoning, whether local or general, are 
depeiident. 

LocU Septic Froceswi are those produced in a wound or its 
wnEiediate neighbourhood, or in a suitabie cavity, by putrefactive 
clianges arising in some substance within it. The ptomaines 
Ibus formed give rise to Jocal inflammation, perhaps running on 
to suf^ration, whilst their absorption along the lymphatics may 
cause a wide extension of the mischief. Amongst such conditions 
^ loJlowiog may be noted : 

Wmmd Influmution, arising either from septic contamination 
^ to a dirty state of the skin, instruments or hands of the 
^eon. or from a faulty dressing. In such cases the infective 
isogenic organisms are usually present, as welJ as those which 
P^rise to sepsis- It must be clearly understood that in clinical 
*wk the term * sepsis * is often made use of, without any strict 
P*tIiaJogical significance, to indicate that the process of healing 
^ oot fcJIowing a normal course, owing to the presence of micro- 
^'pnisnifi. Many so-called septic wounds are in reality infected 



90 A MANUAL OF SURGERY 

with some one pathogenic organism, whilst in almost every i 
stance ordinary pyogenic (i,^., infective) organisms are present, 
well as those characteristic of sepsis. A dry wound is much 1 
likely to become septic than one in which there is much exudat 
of blood or serum, so that absolute haemostasis and good drain 
are two most important preventive measures. When sepsis oca 
the lips of the wound become puffy, red, and swollen, au 
there is much tension, the pain becomes very severe and throbbi 
Healing comes to an end, and unless all tension is quickly reliei 
not only will there be high fever, but the, inflammatory misd 
may also extend in all directions, leading to diffuse suppurati 
All stitches should \ie immediately removed, the wound ^ 
washed out with some antiseptic, and stuffed with gauze soa 
in an emulsion of iodoform and glycerine. Occasionally it i 
be advisable to temporarily apply an antiseptic fomentation, 
the same time, the bowels are well opened, and the general ha 
of the patient carefully attended to. 

The FerBisteDce of BuppnT&tion ^m a Cliroiiic Absceu is i 
due to sepsis. If it is efficiently excluded, the discharge com 
of nothing hut serum after the cavity has been once complei 
emptied ; should sepsis he admitted, suppuration follows, aco 
panied by hectic fever. 

The putrefaction associated with Uolfft Qangreiia is also sq 
in origin, and from such a source, as also from dirty ulo 
neglected abrasions, and wounds, etc., various forms of difl 
or localized Lympluuigitifi may occur, with or without glandi 
enlargement. 

The offensive odour associated with neglected syphilitic : 
cancerous ulcerations is again the result of sepsis, and no essen 
part of the causative affection. In either case, if the ulcera 
surface is dealt with antiseplically, there is but little dischai 
and no smell ; but let putrefaction once occur, and the ! 
becomes intolerably offensive, whilst the local disease tend* 
spread more rapidly. Thus, in syphilitic affections of boi 
necrosis is almost unkno'.\n apart from this complication. 

Serous cavities nmy similarly Ix'come the seats of acute se 
inflammations from punctured wounds, accompanied with efTui 
— *',j^., septic arthritis, septic peritiinitis, etc. 

The deoersL] Septic Processes, due to the absorption of ptom^ 
may be described under three headings, viz. : 

1. HectJG Fever (p. 4.5}, in which a minimal dose is absorl 
spread over a long period of time. 

2. Septic Traumatic Fever, due to the absorption of a so 
what larger amount of the poison after an operation or inj 
which is followed by septic inflammation- A bum or compc 
fracture which is not rendered aseptic is always accompaniet 
fever, ranging from 102^ to [04" F., for some days, until the wc 
is securely sealed off^ by the development of granulation tis 



SMFSIS ASiP iSFUCTIOM 



V 



^ nivi once this tins occurrtd. the Cover usufttly di»pp«ar^ as 
the ifaaaiK« of lymphatic:: pre^cnli Absorption, unlcAft septic 
isleml is roUioed uodcr prcivvurr^ 

^ AcBto fttftmnls, ct fieptlo Intoilcatlon, duo ici th« nhsorprion 
tii'ATj^ dofie oi ptonuLiDcv. Thia condition ^-n* for lonK cofi- 
foadcO with Uvic lofcctivc Mpticfcmin, nnd even rniw, ihough 
dorhr <J^^i^ui^l>F(I p4tlK>bKiL:al!y, the diMi[ic:li<m brt\^dc:ii the 
liouinldlly iH EU^I jjtKiiyf pvi\ib]«^, crxct^pt by 4^M,uitiiij{ the result ^ 
SapamiA u «£&«nliully a tux^tmijt or condittdn due to cbotiucal 
famtng', the blood is ooi infective — 1',£„ if a. imall quantity is 
OKuUtcd into ;iiiul]jf.-i iiiditidual. tlic iliKc^ise is jeuI le^icxlutedp 
n, to pui 11 in Hno(h*^r ntiy, the 4)inptom& are dutirily prcpor- 
bantc (o the dow. Any condition iii which thci'tj ifi n Ufj^'o mats 
dpMxctymn (issue Of Huitl fruni wliicll dbi^uiptiun idi: occur iiiAy 
Wlo stpn^mia— «^<, a portion uf dtrcuriLposini^ plac«'iilH In Uw 
F«sp-al uteruii, lh# ctifitcnee of wptic pus under pwtRiirff in 
Uffcntocealcaviiy, njoidt, or clxci^herc; or a m;i?i8or puIiofytnfE 
md-cl-fl. 'sxy. iu tttp pleuiMl cavity &flu d pcutliHliiii; wound. 

IV ftrmptonu usually mnimf.nfp, rwn nr thr**!* dnys afirt ihp 

owe Jus come thIo opefati*^n, rtiih a tovprp hgor, follx>wcd by a 

■Wbuscd higb lenipcF'ttiife, ullboiii^h somctiniGf^ it is subnormal 

k intbe more lacrron^ r^r^es. Tliiirc \s Ic^^s of ;ippiu iter, a dry lonijiie. 

Hi i|Bkk poise ripirlly iiecominR wciili, wverc he^dathe, ind 

^■■xntful dctinum of Romc intaDsity. Tlie patient ir iit hr^t 

HfBMipatcd. but ^omitinc ^nd diATrho^k mny cnvue from ^AMro- 

' nncsCiful imi;itinti. EriliiiwHl by fnt^l ^xhiiuslion iind r<ilUp*e : or 

lit pfttkot iitiy become comntosc and imcotisdous for some time 

Wice death, accordioic '<* whether the ptomniincs net chicily uptm 

Ik 4lime!iitAry ^yvtcm or upon the cerebr,-il ceatres. There 1% 

AMrilv fiotne d>spnrea from pulmrfujiry cr?rKt^^Mivn» find ;dlnh 

BODru, Shuuld, h*jw*\i!r. the putrefying mass l>e removed tol^T- 

AfclrOKHy, the fc^'er will oanac as by iti^i^c, the tongue cleans, 

tti^ kpprbte lelums, tile hcudadie vauishe^p and in twenty four 

wtiu^ the |Mlit-nt feelit Ji different individual' 

Pau- Bottom AppMraacBftn — UticmnpoKitiuii ls c^irlv. rigor 

feeble, A&d cftda^^'rir lividity well marked, especially alone 

Snrs of the ?iutHrilicial veiii^ and pusLenuily. The blood 

ORlfiiljiiev imp^rfwruy. and H durU and l&ny in rolour ; if allowed 

locuad, Iho scrufn <vhich svparai^s from (he corpu&clss is much 

niiked &oni ihc brcHkiiij^'up of chc red b]ood-ccLl» which occurs 

ht all M'piic and infr<:tj\r I'ASi^, Thin rnndiiidn rxplmn^i tbe 

tftourxt cj cad*v<erii^ li^'idttv, and aim the po'il'inonem Maininfj 

~Flbe mJocirdium and tunic-'t intm\i of the Ur^nr ve%f^eb, whicli 

;»4iclt « nurkc:<j feature in ihe^c CA?io:Fii iind Vkhich wa^ formerly 

'h^ to twjili from x riiffiiv. aneritit. Mom of tht^ stmus 

itwft contain a certain amount of blood- ti^incd secviin. und 

ajmosl all the teroun mcmbri»nc;j jrc well ni:irJi*.'J pL^lcchiir, 

under the perlcardinnt and pleura. The iuni;b arc 



ga A MANUAL OF SURGERY 

deeply congested, especially at the back, and very oederaat 
the liver, spleen and kidneys are enlarged, pulpy, soft and 
gested, but particularly the spleen. The epithelium of most 
the secreting glands, if examined microscopically, gives evi 
of cloudy swelling. 

The Treatpinent of acute saprtemia must be almost enti 
directed to the local cause. If it arises from a wound, such as 
compound fracture, the latter must be freely laid open, washed 
with antiseptics, and drained ; if from a cavity containing putn| 
blood, serum, or pus, the fluid must be immediately evacuated, ttj 
cavily well flushed out, and efficient drainage provided; possitt 
continuous irrigation may be ad\'isab]e. If a sloughing woundl 
the cause of ihe mischief, the sloughs must be cut or scra|iei 
away under an anaesthetic, and the surface disinfected wilj 
chloride of ^inc or pure carbolic acid. A putrid gangrenous linl 
demands amputation - 

General treatment is merely symptomatic. Possibly a gooi 
purge may be advisable in the early stages, but in the later i 
supporting and stimulating plan of treatment musi be adopted 
Recently it has been proposed to deal with the acute toxseraiad 
peritonitis and similar conditions by the repeated injection inlD 
the veins of large quantities of normal saline solution, and 1 
number of excellent results have been obtained by this racarn 
the injections being followed by diuresis and diarrhcea, whid 
presumably assist in the elimination of the virus. (See also to 
Septicemia, p. to6.) 

JnfectioQ. 

An infective process is one due to the activity of micrti- 
organisms which can develop in li^Hng tissues — the true patho- 
genic bacteria or parasites. Such find an entrance into the bodj 
in many ways, as through the healthy skin, or by the rauoms 
membranes of the alimentary canal, respiratory tract, or genito- 
urinary appar^itus, or throu^'h wounds and abrasions ; and vtf) 
often the manifestations of disease differ widely with the chaD«i 
of entrance- These may also be divided into two main groups 
the Local and the GeneraU 

Local Infective Ptocobws are those caused at the spot of inocula 
tion by the growth and development of the microbes. After s 
period of mcubation— which varies with different organisms, afl 
durmg which we may imagine (hat they are struggling with th 
germicidal action of the tissues, and establishing their foothold i 
the body^lhe or^'amsms begin to grow and multiply, and by ih 
deleterious products of their activity cause irritation of the tissiM 
and various forms of inflammation. 

These inflammatory foci may remain limited, or may tend' 
spread w^th more or less rapi.Uty by continuity of tissue or alor 
lymph channels ; or the organisms may be widely dissemina^ 



SEPSIS AND INFECTION 



93 



through the body by tbe bloodvessels m the shape of emboli. A 

ceruln amount of constitutional disturbance may accompany 
ttoe nianifestations due to the absorption of the toxines produced 
bcally, whilst in some diseases the general toxic symptoms (or 
toxemia) associated with some shght local mischief may be 
utremely severe, as in tetanus and diphtheria- Hence local 
infective processes may be classified in two divisions : (a) those in 
which (here is no general toxeemiaf such as a soft chancre, a 
tubercular abscess, or an ordinary attack of gonorrhoea ; and 
^) those in which the toxa^mic condition is well marked, as in 
ffysipeUs, tetanus, diphtheria, etc., the character of the symptoms 
TUTing necessarily with the different toxines. 

Many of the organisms which are the causes of local infection 
Saj also develop generally in the system, and produce grave con> 
ttitulioDal affections- 

Qntanl InfectiTS ProccBaeH are those in which the organisms 
dtvelop and multiply in the blood -stream, so that inoculation of 
isound person with the blood would almost certainly transmit the 
(faease. \[any of the bacteria producing local infection may also 
give rise to these general diseases, and, indeed, in surgery we 
rarely see the latter without some local cause being present to 
expEain its origin. Septicemia, pyaemia, acute tuberculosis, the 
ttcood stage of syphilis, anthrac^mia, and probably the exan- 
themata, are illustrations of general infection. 

We now propose to pass in review the chief forms of infective 
disease met with in surgical practice. Acute suppuration has 
alrejidy been dealt with (Chapter II.) i it remains to discuss the 
v-arious forms of cellulitis, erysipelas, septicaemia, pyaemia, tetanus, 
hydrophobia, and anthrax, and subsequently to deal with those 
grouped tc^ether under the term * infective granulomata." 

CeUulltU. 

Cellulitis (or, as it used to be termed, d\ffu%r phUgmon) is a 
disease which, although exhibiting many diverse manifestations, 
is characterized by the great general feature, viz., the existence 
of a 5[Meading inflammation of the subcutaneousor cellular tissues, 
doc to tbe activity of micro-organisms, and running on to suppu- 
^oQ, sloughingt or even general gangrene. 

-\s to O&uAAtloii, the one essential, a?- we have just stated, is the 
Jflfection of the cellular tissues with some organism capable of 
multiplying locally, and of developing toxic compounds, which 
HQonly act at the site of inoculation, but also extend along the 
lyrnphatics, and by their absorption into the general circulation, 
Jive rise to severe toxemic phenomena. The entrance of the 
organisms may result from an operation wound which has lieen 
allowed to go septic, or from an accidental breach of surface 
■bJch has not been rendered aseptic, or even from tlie slightest 



94 A MANUAL OF SURGERY 



form of graze, prick, or scratch. Deep septic wounds which 
not properly drained are amongst the most favourable for til 
development of this condition, especially if the general heaJthi 
the individual is bad, or the hygienic surroundings are of an L 
sanitary nature. !n the deeper regions of the body, where Tnodl 
loose cellular tissue is present, inflammatory phenomena reacfiM 
supervene from the absorption of septic material from neigbboiffi 
ing contaminated structures, e.g.j pelvic cellulitis arising fromi 
septic uterus. 

Cellulitis may arise from a considerable variety of rHuro-ergawm, 
The less severe types are probably due to the Staphyioctcm 
pyogenes aureus or alius, whilst the more severe are caused ht 
the Streptococcus pyogenes, which, as will be stated hereafter, ■ 
probably identical with the organism of erysipelas. !n nuBf 
cases various types oi non- pathogenic or septic organisms m^ 
accompany the above. The most acute forms of the diseasi 
running on to &prea<ling gangrene are probably always the xesA 
of infection with the Bacillus of malignani adetna (p. 78). 

Glinic&l HUtory- — The symptoms manifested in any particulir 
case must necessarily differ somewhat according to the site of 
inoculation and The virulence of the causative microbes^ and henCB 
anything from a merely localized suppuration to the acutest foro 
of spreading gangrene may result. Taking a case of moderate 
severity, due to a prick or abrasion which has become infectei. 
one finds that there is often a period of quiescence for a day of 
two, during which the virus is incubating and the original siterf 
inoculation shows but .slight signs of infiammation, beyond beiiig 
a little tender. The patient, though feeling somewhat seedy,is 
able to continue his work, but finally is obliged to give up, owing 
partly to the increased pain, partly to his general condition, 
rever will almost always be present to a greater or less degree, 
and in the more severe types one or more rigors may occur. 
Occasionally, however, the temperature may be subnormaL 
owing to the depressing effects of the toxic substances absorbed 
On examining the affected part, it is found to be hot, tender, and 
infiltrated ; if superficial, it looks red and angry, and may fed 
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, however, il 
is left, or is merely poulticed, the process rapidly spreads, and 
may involve more or less the whole hmb, which becomes peatlj 
swollen, very a-dematous, red, and brawny, intense pam anc 
sleeplessness, accompanied perhaps with delirium, form the mos 
prominent symptoms, and this, accompanied by the toxic fev« 
rapidly eNhausts the patient's strength. Finally, suppuratioi 
occurs beneath the skin, whilst the cellular tissue sloughs, per 
haps the whole of the subcutaneous areolar tissue being thereb 



SBPSrS AtiD l>lFECnO>i 



9S 



ottstrojrcdt Ahbouj^h the skiiT only ]t:Wcs w:iy in placet. Hcncr it 

Ueip^fi part of llie limb,ADd thu chief ftjcxia of mi^ciiicf 14 loitnd .'lE 
a (liMJincc froc!i ihr otiifiiijil sUc of mucuUuoi^i the inlcrvcr^mi; 
portKin \m\i^ h\A liJClir afeit.'J : sufh iiit c>ri:tiiieT»ci' is jirotrably 
diM ift lympJiAii^ :il«Arpiicn. 0*:c3*^irir.illy rh? Iroiihlf ^prcjidft 
aIobk l**c deeper .%rc*>ljir pUnc^s inv<iivinir rmiscuUr bclltes, which 
fOJky be infilir^tcd ivtlh pi;s, or rarty AClualij slmteli. This 
nccuirrncp U siwciallj likrly in omif tvhr^h thfl rlisr-isp :« rlup In 
irpCiE irtt];imrtution of n deep penetrating wound, such ak folki^v« 
« li^i)^)ot in)ury, or %hcn Vttc pnlii-nt i» very dcbilit.^ted, sl.^ ^ti 
aculc »pr&iilittg )^;uigrenc. In a\\ these; niare si:ve;c f»Im^ the 
patient runs a cucisid(-rAt>le riftk of dcvicloping general *ief|nic2?mU. 
or c^-«n pyzmii- 

Tnatmeat -Wi:h the exception of those r&re ca^i; due to the 
liKillii^ of nuli^nAiii itileinii, L-dlu1i;i> ravilis frcim the activity uf 
OCI^MCti^iTT^, nhicTi ar« r^^di^y devT roved, and ovf^r which th« 
unilici<UJ prvpcfti^ tA the body have contidcrablo conEroJ- 
Hence cjrcliil Attirntiou to th^: dicta of antiseptic sur^ry ciiu 
pirvmt ith oiLU([eiLce [u :i veiy lai^e p.vlc^nU Abra^iuns and 
lAuil puitciurod u'oundt should ;ilw,iyf^ ht? c^irefiilly protected* 
mad ail pctwtratim; injune^ di^infr^ctt:d. c^pecifilJy if the piiliont 
aui3 any ri^k Lif u^fcctroii oAiiig tu bi-*i uccupiititiu or :^unuuii(lLiig?ti 
Should ind^mrruTory ph^^numirna Mi[>ifr\-f?ne. thr Jipphcatkin of 
laiiMpCic fomeiiiaiioD«, fAichas \\\t horacic poidlice, may pr^v^nt 
tbcii cxtemaott. whil»t the boucU ^^hould be freely acted upiDii nnrl 
tlxr i^eitetal bt'^dtb atk'tided IOh Paihu^ tbia, aikd if (ht'ic '\^ aiiy 
riency for thr int^amn\Atlon to spread. inci*iions should be mfidc 
tho brawny tU«ue&, so a8 10 eiv« exit to th« fl«rou« nnd 
tiojc di»chAr£r«: the wounds thus mode are dusted voTh 
:m and *Jiiir<^i with gauxe, ovc* whirh ilic ummI dressings 
inpllnd ; ami it it oftcri wib*- tf> jnmrpor.il** a piece of mAckin- 
ID tbe ouKf fotds of the dn?£smj;, ^o as to keep th^ part^ 
«nd cAooura£e a free di».charec, UndcL' sticJi a regime 
liiif; naay lir pntirrly prrvr-nird, nr, at any fiitt', hrnitcd. At 
imc time tbe paticnt'c; ht^ihh and strength must be miiin- 
Ijuncd by the admutetration ^.^i r.uitabJe food and stimulants, 
vhal*t fiuinine U very uwful internally. 

Afltiiitrpfit*x.xM:i!ic H(-riim ha> also been fnnpliiyed an a curative 
AmiU und tbe results hitbcrtu <tbtaiD«d have boen «ncour:i{^Dg. 
Tne Jaf»e variei from 5 to 10 ex, two or thre« times a d*y- 
iDf^her c-vtelltul i)Uii uf trcatuicnt j^ it> imracrso the wounds, 
ier frtrrly inrUrn;; thi- infrltc^ted |Mn. in a cncitnuuxis wtinn 
Lth, Ivy this irwAOS dittoing fli^ toxineg 10 such nn i^xtcnt -^s 
rcriiki them innocuous. VVarjii lAdtcr dcK.-^ perfectly well, 
[booKh il riuy Ik Itoded bflforc ti?e vhilb advan1>H£«^ Ami- 
w pruciicAlly iisclew in checkinj^ th^ dUoAsr when once 




96 A MANUAL OF SURGERY 



Started ; the surgeon has to depend mainly on the relief 
tension, the removal of toxic discharges, and the antiseptic pm 
of the tissues. 

Special Varieties of OelloUtis. 

CfllliilitiB of till AJEillA is an exceediagLv serious disease, not uafreq 
resulting from an infected wound of ihc fiogersn such as occurs in the 
mortem room, and hence is uot uncommon in medical practitioners, 
DT nuraeq. Ii may a^^o be caused by CKtension from a primary 
lymphadenitis. The tissues of the armpit become hard and brawny, the 
i& severe, and the disease is liable io spread lowarda the chest waits i 
or between the pectoral muscles, it may alao travel upwards, and lay 
the shoulder joint from sloughing of the capsule, and so give rise to u 
arthritis The most extensive incisions are called for in oitier to pirvau 
risk of such complications, but respect must be paid to the important ve 
and nerves contained in the cavily. 

gnbtbammarf C«llnlitit usually occurs as a result of the eilenaion of liJliai 
malion from the deeper pans of tbe breast, or perhaps from the cartili^B K 
bones of the chest wall. The areolar tissue beneath the breast become* inft: 
traled and brawny, and the gland itself is somewhat swollen and toAf. 
Shoulil suppuration occur, ihe mamma appears to float on a fluid bast (Si*, 
Submammary Abscess ] Free incisions must be made into the infected W 
alon^ the lower portion of the circumference of the organ. 

Callttlitia of thfl Soalp usually results from a wound which has tru^xrted ihl 
occi pi to- frontalis aponeurosis, and opened up the subjacent layer of loaH' 
areolar tissue Suppuration extends m all directions to the limits of ittK^ 
ment of this structure, and hence abscesses are likely to point in the ftfldMrf 
just above the eyebrows, or o^er the ayEoma, or along the superior cunwJ liM 
of the occipital bone , whilst, in addition to the severe local and ganenl db- 
turhance, the patient runs a risk of necrosis of the skuti and of various iDU* 
cranial complications. Kor further details, see Chapter XXI. 

CBllalitia of the Orbit is not an uncommon sequela of penetrating woonds ii 
this region, owinj; to the difficulty of rendering them aseptic and of dniaii| 
them The x^holc of the orbital tissues are inliUrated and swollen, the lidi 
become crdemaious. and the eveball i^ ihrurit forwards bv the tensioa ii 
the parcel behind There is a considerable likelihood of the inflammj^ 
sprtadm^backuArdsio the meninges, owin^ to the fact that the dura mater li 
coniinuou!^ with [he orbital periosteum throujih the foramina by which A* 
nerves and vessels enter. Necrt">sis of the orbital walls may also occur, whikt 
the eye itself may suffer either from an infective panophthalmitis due to 
lymphatic infection, or from optic neuritis secondary to retro-ocular inAunna- 
tion and pressure, or at a Eater dale from optic ner\'e atrophy secondu^'m 
cicatricial contraction around the nerve [f the cellular tissue of the oriiit 
sloujihs, the subst-iiiieiit moiements of the globe may be much hampered, or 
indeed lost, whilst the lids may Iw? drawn back to such an extent as to pit»'aol 
their complete closure, rifiilfniif -—No penetrating wound of the orbit ou^ 
t<i Ix- closed if there is :i.nv question of ^piic infection . indeed, it is often w» 
(o slightly increase ili size, sf> as to enable the deeper parts to be cleaucd 
Drainage must alv^avs be providtd for. and in manv cases this is best aCGcm^ 
plished by slufhna it with Kauze. [f cellulitis follows, the oripnal woBOd 
must \ie well opened up. and possiblv fresh incisions may be called fordthei 
through the lids or through the fornix tonj unci iva> Antiseptic fomentatitou 
or poultices are then applied If panophthalmitis super\«Qes, the best plan t 
lu incise the eveball crucially, anfl clear out its contents, rather than to entirely 
remove the elol'c. 

8Dbm&xillti7 CflUulitii, or, as it is sometimes termed, Ludwi^'s An^nd 
from the name of the surgeon who first prominenflv called attention to it, isu 
infective inflammation of the cellalar tissue beneath the deep cer^'tcal fasci 



SSPSIS A^D ISPSCTJOU 



9t 



«%Uh OeCBfB In •IdMt^ and wtailr individualk ur in iAMmi. vdchoitt. *■ A 
nte, ftnjr ftppuvnt imn. alihnugh mmi pnJuLhly ti ^i^milt firm «Dii(t hixnl 
ooodldca. 11 4bo oodficiiMb' r«uli9 iVum intiattiinailan cuendlnc brryoruJ 
il^ (AMnle o$ latUnteA cIrpOi. onJ ria^ orulnjiiic in d^XAite oi llm middle ear. 
ihe wnichtrf tmvrilinn dm*ftw<jJ> jJ"iik ibg jinjuirit muncfr. Il E^cinrnvDoa 
•V A bvm^BVV wduratinn in tbt cdbEDAKillihrr TEp;xiti. nhich i^ londnr, puinCul, 
aH!l bat . ifctffv !• * <rflAin »«inimt ot fv^cr, qnd ihiH int-rvafet /iif J juiif uiih 
Itat OQvni ol the jirra InHamHl ie iprrk ro vprv-ul rn th? Imnt of ihe nwk 
vid hbK of ibe cnairai; vrhi^t iiuv ihrfrbv 1v uiHitc! ro pritiftiile frum the 
MmuUi D«aCvnn» kftufil^Bit urim? eirhci fimn |)teenuiv ljii ituv^L-Unt vDWctn 
■dA >Ti>i, bcvcDiMiuion oi ih« inHAfniawiiflo ta ihc (I^illii caotrnir crditna 
Mri oiwi^niwni ^l^ipEitt^. o* fr<iTa tbfl njpvmintioTV of [lyirmui o^vLtij; it) v«ioui 
ItoOfltMvlt Tile prmH ncually rrdi m ^Loughitiff ol ihr c^Iular iiuue and 
foppBraUofi ihepuvhamikif^C in dlMlrr^iionAtf a ^twimiilix'InrlkionikihmiiMh 

GOMIbk tb* B W a M omMilulfoiul and mpimiorv cli^mrbuiu. <A<hJM ili ttitv 
kMVMW iJk* nwH Bkky icnuid tlailoniLry and induntod ioi kii>uu:iiitnLbl« timc- 

Tb* Ttt^Smmt nusi be prompt ano «nB>s«ltc ; h frw mcUioii II duuIv 
Maif Ihfl aMfgri Irr* irit» Ihr m«.UE u| ihv bmwnv fibii)*. <w alang any 
i>* of iaJMj wh**w p'J\ *i iHrpairninjr 1*1 fnrm \ piiililinirtwl abncvi ni*y ti 
qptBod frna ihv nioath . but ii ki tvlcet. if ficiBlblD, to dn w fmm IwI'jia, ?(i 
«■ tiQ ctclndc «cpu» Trior t-> 9u|rpuruji^n. fcjuicalUiuu:! uiav Lc uvd . wbJil 
inaiM. ttjjnulitfiii^quiaiW. und pleiTlyuf ^uod food areDcectad C0B*tiluti'>na]ly 

FlMft €*IlBlllil ana*! fmrn vitpnaUin of ifiduniaation from lliv pdvic 
■■USA t" ih^ Irto^ rr<[liiiiT ri««iiH frn^hi-aihinv ih^m ti miy br mi«< na 
1ya|Aadc abwiption from >cpiSc miitrliil conUUnfd In the U(?rui, of it may 
a Anpic or lepik: niAamnuiioJX Iruin (bi? uv«fy- r^Mupioii lubc, i-r 

lB|C)da lo the bU<!Jr-E ctr rei^tum iitnv hLhi liic^^r iJli cl^f ItiruUc U 
yriib all ihu loc^ liiil n^nimJ M^n^ nf eIchtp tnJtivmmAiJiPEi, nmf 
IndaBfl, virb prrtionitlt bf<iQe vM Ji-ncvd by aif<D.K. nrm, poiatTit t'^'fiUini; 
labc MtMt ii^jFitdm nr /^ rr.run, Jind '>1r^ri bv un L(ii]iirnii?d niA4« of infUm. 
aafT '■ma^iift, dal> jiq fii>rcuHii»ii riving al'rtf rb* |rub;r arrh AhheFtor^ 
■ar ntm in chk rflnahcriL, buntinc cillW irtlvrnulty ur intu bumc uJ ibr 
ur paanibly in boih d^rr<:iioa*, picduuns \rii-y ioiracLablc foiini of 
<)t breal fiuula^, v^hllv vEinom ototruniion arnJ pyitmifk orr very 1l1(c1v 



Ma^ Iwnllnl Ell ilfiril with t/arh rmtirK iitTiT in ib* rxrly ^in>- 
■Ofiv. whoi Twi llrmtflttou rifdipii. unall tliinniit ni)lum. jVtid htn 
lo the b>poga^nurn. crjEijo^nod pctb^w with Koi luitLacpi.^ 
f«l^ial or racial dL;i«icbek, inuuld be kduplcd , ar buer. when pu> h*i r^rmcJ 
M Aaabtosaw* dshI io bt oEvnod. Xo alioolute dindion* can be Enid dvssn 
M BMl j^fy OAOtii^e^ri- nii^ aa a gtnml tu1«, an incvunn n maih* jiici 
tkmm iviUMn^ nj^axenl atLd elm? lo Tbv publr aptnp Ih« abtlriitimal mufcls 
m ilHrldro (a > autftc^cDt uienl i<^ rnnble thr sar^ecn lo 4cirk downwinU 
ths UacvnniAJi* tucLt aiH.1 die i-u iLuiwum OtukHiiruA!l)r il will 
in pub lbs penloamm vtJf asidr «> aa to nttch tbc brmvl 



pDi u Inqvaody iii«i vrlib. A* aooa at thv ■ubpvriton«(Ll 
t^oed. ini^ kmit Kti^urrt rv 'h^nnitii. anil<inly bhini mitniinctirt or 

id iha Acj tfl^ iummait : ilu; uvily uf liic ulmcan HluriilJ Iji^ well wAMhrd 
^w aaid Fl&cianiJT drainrd . 
lairiiBi I flbatmrtlon may b* nol vith (u a minoia v-iiL«1a ^m ihe 
of ckatrieai lomtog flUbiai|untlv lo the nllulilia, and hydro' 
mayarUa In tteaame *mf from preuuiv on ihc ur«ier 



ErjnpeJas U a specific iofccliuu^dmviMjducirithc dc\T-lQpjmi:nt 
'fha SJnf l O L -mau gyii/infjfn (Fi^IiIcimiu) i» L lie smelter l>mph.^ik» 

7 



A MASVAL OFSVmiBRY 



ortliesdcinaiulsDTK'tUniit-cJus ti^uitti (atiid oci:4iaona]ly aIso of iba 
ruucouv msiVbrane^). s<.i rhn^l ic may be defined a<tjispre»<ling, inflic- 
ti\^. and contiiio^ut. inHnnLnuUon of xhv bkui and mticouft niMn^ 
biiuir^, the i-L>nMiliiLiui]<il ^lyiuptom^ bt^iii^ due to ihe AbAOtptM 
uf toxirtes iltvfliipcd loyally- 

Th«re Iia^ liecr cuiisJilffjiMtf diwu»sloii ;w Eo nlipTlittr ihcrrr i» 
any di^crciR'c; Ifr^t^^'rcii the «r)>.ipt:Li& mlcrohvftiuj the ordinMy 
Strtptvi^onui pyvfjrnr^, txi-uiiiii^ m sprr^dlng Uippumtion. The 
rnirrosropirfll rharrtrifrs arr- indisTin^iUhflUIr, and tbr irrnr«-Eb in 
\'ariou^ r«iigcni>i U V4^r\ Mmil^ir. Irocii^alion experiments, more- 
«\'cr, i^rtftiiily ?^ccm to indicittc ihfil they nrfr cloncly allied spodet, 
iUAil tilt' iii-ijvJiit) of Uk Icnoluti^'* tonsiLlcr ihcrn lo l>c idcnticaU 
tlip diftVrinK *'tfi*ri4 df^prndinR mi*rely nn the mftbod of irvoiiib- 
lion and the virulence of i\u\ pnrtinihr t>fK;ini-nTi : in aii^cord- 
aitce uilh thi?. idm bolb rr^acE in marked biNhion to th«^ injection 
of iUi ruitUlicpu^utccit ^tiuMK piixliicetl bv utiltcinf( the oidui<u)' 
Lal)tiratory Stnpr<naccm /fmff«/». Tbe chit-f objet-lioti to thi» |ti»oty 
» \hv j^*ieiil dirfcfenct* which cxiatt; between the ' infediuuKnow'of 
ery^ijpcUs and telluJiliin Nonurceoti wmtld object to the preaenct 
tjf^uj^esEif tht- Uittei iiibivnauU; uuiit» permit tlie prewucoof 
the former, exuept uii c<.lmpll]^i^Jn. 

in lurm(*r d^iyb thrL-r varifltiOB ^^f «ryupcU9 wore doscrihed, viv., 
the i:utaiiL'uub,i:4r11iLl[j'iLjliiiK'i-'Us tiiid ihr cellulai. In ibc ftnt ibc 
infei-tion is piolt^b}} bniilr^J lo the lymphatics of ibe skin : in tbe 
lattt (ctfllulitis), the sutic-vit^ineou^ lymphatic spaces are ak»« 
involved, whilst thi- cg)Iu1o-(^iU:uk'ou-i Miriety i& prohnbly due to 
iw ijtft:t:lii.>n of biHi). An kiwpuihu fmiii vibed id^ lo Xur deKiitbodt 
In whirh ihr diteii^ir ^tart*i u nhont any :ipp.'»rr^m lora! origin ; but 
when cnc eonauliTt Ih.'^t ink-ciinii t\\'.<\ ikcciir thr^jugh IbehlightWt 
AboLsion, A^d cvon tbr^ui^b sound akm or mucousi nK-snbrAne, uid 
that ihe rncd di> imt ntM, Aii jl ru1r\ In the b|iH>il, ii \s rvidcnt 
th;ii thr tbf^iry of liMr.i! infer.tinn it in all mfiwi the more pmbahlc, 

TheCftOUicfetyi^ipchfiniay be briefly i^tMcdnK follows: (i.) The 
rxintcncc oE nn nbrii^icn oi wmmd in most ca,wji, and particularly 
of »n unpiotecteil >opti<: ^mmd' 'i hti-%. il is not itncomrunn lo fiad 
it assiKialed with neijleirted *r.ilp waund*oi with tlius^e commust- 
eating with the? mouth- {\x.] A weak. depreM^d t-latc of the con 
atilotion. tt?i from Alttrholianip viciun> living, diabetes, AlbuBUD< 
iifia, i-lt. Home jjeuple. iiioieuvcT, wynu iintorMlly predispiwil 1:3 
lh« difteJise, paniciiliiily pl^Chorie :ind ^ouly indivi^uaU^ And oar 
attack aK'ii)'B '^emt^ lo rtiider the individnnl more b&ble to rccur- 
rcnct;^. [i\\-) f^ad hy>;icint; aiinovn^diiigs acu 4 \\\usi iniiKirUnt 
aiUliriimal failoT in ll^ prciduetion. cspt^cljilly oveietoiviling in 
hniipilah and bnd venliUlion, Hui ihr^^eurejill merely predibpodng 
conditions ; tUe only excilini^ »x\i\ Absolute <jiuw: id liv,), the inlce- 
lion with the specific mirri».Orjiinisin. wlii^li »> veiv DviJdy diQosed 
in Nulnie. When ome an rntranrr bfls liof^n erfpirted, ihe cocci 
det^'Iop in :he lupertici^d lymph channdSi pinducing a Iranaeni 





SSP^IS AND iSfSCTIQS 



99 



r-i 



influmiiatory condition of (he ^in. md a concurrc^l pyrcxi^-l 
All* of Uic nulL^iilu^ frnrti the :ib!U>rptKiii ol specific toxincii. 
Tbc or^utums arc of no great vitnJity, lince it ^ppcan that the 
bical rracttfiH vrhidi they v^\ up 1^ qtiiit? stiffKit^nl in deslruy 
ihrm, ev«D whil&t lliey 8|jrcr^d p«rtph?-r:Ltl)'. Immcrsjoii for 
Mxeen Bocoodft ic ^ i in 30 solution *A cjirUolic uuid ul^ cii&urvs 

•At i>?4lUCt)(Jlt. 

Tbi' Symptoms c.if th« dii^^AS^* fir*- UMiAlly tii^herf^d in by \\ sU^liE 
chiII,«caicsl>AniOLiniin^T(>;k rigor, and bv iipt^riod ofh^*4a»cht and 
oiAliufc fx Abo»1 ishiriiTy-fotiT Roara> wiUi some do^ci.- uf pyrcxiii* 
Tliese 8) tiipiuiii^i Aiv f-jfl^^cd tiy tlic dcvelopitR-iit uf u mii^iit, 
n»y-rrd r^^, tmrfldinj^ fiih^r St»tn Th^ mar^n nf Ihr wrrnnd, 
or vbo^in^ \\m{ in upp,iTcnl]y imbtokcn i^i'm in the Ro-cnJlod 
Kliopalhk: vArirty, If there i^ n %\oun<l, tt ur^uftlly prcncnt?^ ii 
kkfB)£hy dDd unheAllhy'lojkii^l^ :hurbkcc, ^ilh virry littlinrvidv^ntc ot 
rrpoir. IfthperyiiiprLitoutviruiiUunmixfd withoth*r orRani^mw, 
the healinft proce?::; nuy continue until the null appears, vhtn 
tbc youcc ciCAtibh ivill bre^k c-pcn nttnin. c3ipo!>in|C a dry Pird 
■laggUh 9>urfjic«!. with a ihickenni m^uKiii. The- rash U of a 
duncie«>Uic vivid reri eolour, alwray^diiappt^arinji trn pressure, 
uid b accompanied by a scns^itioii ol ^titiuent. or Lntrr^tnKi reared} 
unotuittDjf to pain. «^c«pt nheii (.lrIl^e ^truc:tm'{r4p »ucU u?i the 
ttitp, ate invdlvnt. Hnd ttien tJie pnin may lif very st^verr . Swell- 
ins i» 001 vety nurb^l, <?xcitpT 10 lav "ineohir'tifisuei^, i;uch :i* 
ocoii in ttic vcTotum or civchdi; the ^fdema may th«n Liltmn 
(Dtinilcnible projKjrtion*, The r.i^h Loniinues to adv^uice nuirc 
or ICM rapidly, wit^i a coitttnnr^nsiiiJirjjin, ;tTid ris it sprt-adft lo uew 
tt^tm^ \l fiJes a A ay (rem thut« ,il ready )nvL>lved, iKivin;; :l sb^hr 
faraimish stam ana .i fai^e br^inny deM]Udnalio». \ chicle ^ uiid 
buUx foiriu ^upeE fiLidtl^. LuuULttLni^ bciuui, wLuh ajjeeJily beLouicrs 
toriiid. but suppur;(lioTi i^ uiK^nimon, exc4>pL in \uy. I't'd^nxitcus 
luatwn, lacii Ab \\vt evohdfr. Oc4:n4ii>nA]ly, from the btv^rity of 
~ if1amm«tk)ii or tnc W state of viUlity uf tbc ti»svies, Iht 
MAy lief amtt ^iingirndtis and sld^ii^b, cspecUiIly A\yo\xi llii' 
cttft and girnitaJn of younjic children. Neighhonrmg lym- 
l^ttod* Arc alwAv^ cnlnrK*^ ^nd futinfid. ;tna thi£ may even 
Ecd Jl a pcrirx) when tho ra^sh has not .^ppcr^Lred. Frvo i-s 
»i a« l«jnf{ a« ihr r;i^h pt^TMKls ^nd mrrely sbnwK sli^bl 
i\ variJktiooc- I: i* noi m>ct>innion for the lemperaiure to 
to 104' !"■• but an>lhio;f nbove tb*it is of (C'-''^'c iitjnihcunci;- 
Ai fnxx the fcvct is iif a ^thenic tyitCn the pidw fail, and ibe 
driinnm Etou^' ;ind .iclive ; but Liter i>n the pnl^e betunies f^uirk 
lad wc;ik. occofnp^nied by lowmuittring di^briLirn *n;t grent pro«- 
UAlMffl of the vital pnwen, Pehnuni is u^iiulEv ^l ^^'uI] marhvd 
bture in rry»pehi^ tif tbe K^ilp. Imi this i^ due Itj the )£CTicr<d 
ntbev than io any local (.-audition, The Lh]r;inf»i of the ;4tiai:k 
« noftt vorvUtlc, lafttiog, an a rule, from on«t to three %-€iek». but 
tdftptcs arc oot uncocnn>oin. 




lOO A MANUAL OF SURGERY 

The so-called Idlovathlc Erydpelu mainly afiects the hta6t\ 
and occurs in predisposed individuals; it ts characterized \if'-. 
the great (edema of the subcutaneous tissues of the facCi wbici ' 
causes the features to become almost unreco^tsable. LaigB 
blebs form, and even abscesses about the eyelids. There is a 
great tendency to recurrence about the same lime of the year b 
these cases, and pain and tlelirium are prominent symptoms- 

Oellalo-cntuieoua Bryupelas is due to an infection of theslm 
and subcutaneous tissues with the specific virus, aad results ja 
suppuration and sloughing both of the skin and subjacent ceUuhr 
tissue. The signs are those of a diffuse spreading inflammatioo, 
evidenced by heat, pain, redness, and a 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 slotiglis. 
The general symptoms are correspondingly severe, and pyxmift 
or septic intoxication may be also 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 the affection is still more or 
less suhjudict. 

EiysipelaB of th« Fftuctt is a true erysipelatous inflammation 
of the mucous membrane of the fauces, tending to spread to the 
glottis and larynx, and arising either by extension from without, 
or in association with some external manifestation of the disease 
elsewhere. The fauces and soft palate become of a dusky scadtf 
colour, and very swollen. The voice is either huskv or absolutely 
disappears* whilst spasmodic dyspncea may arise from extension 
of the tedema to the glottis. There is a considerable tendency 
for the parts to ulcerate or slough, constituting one variety of 
' putrid ' sore throat, and the glands at the angle of the jaw are 
also much enlarged. Severe fever is usually present, and great 
depression of the vital powers. 

EryilpetaG of the Scxotnm, or, as it is sometimes termed, acute 
inflammatory itdema. is characterized by the part becoming 
enormously distended by scrum, but without any marked rednesi. 
Suppuration and sloui^hing are not unlikely to follow. It thus 
somewhat slniulates the appearance produced by extravasation 
of urine, hut is distinguisheil from it by the facts that there is. 
as a rule, no difficulty in micturition, and that the swelling is not 
limited in the Sctme way as in the latter affection. 

DiagQOflia. — There is not much <lifRculty in recognising a case 
of erysipelas if we rememlier the distinguishing features of the 
rash, viz., its method of extension by a broad, sharply » defined, 
slightly raised and infiltrated red niar^'in. Thus, the rxantkoMU 
are never limited to om- part of the body, and rarely form one 
continuous red patch. Lymphait^itis is characterized by streaks 
or lines of redness, not by an area of uniform hyperaemia. In 



SEPSIS ASD tSfECTlON 



»t 



OkUv \hc ftkin 15 ^elfSoin red over die snUinied *«in, wbith can 
it Ul 4> d IliiiJ kiicKirv] LUid loeUiit . A Af^fiV nvuiuf nith ^irni up 
Jivhjtt^ clo««1y bfnuktet» «ryi.if;cla!b : but Ihp [n^rgin of 11)« 
mlwK not CO ftccuriiluiy dcttruxJ, nml lymphatic enJiiT^cirietit 
dKsmi ao coQSlJLiitly occui, Did'uTf etyihrma naia^Hiu is rcco^- 
UkA horn Jl liy llw nlit^nre or sUgH desire uf iTir ft^hrlk di^- 
nirlttDoc^wid th* presence of outJyinf- noduUi fuLt<h<«of ri^dtiasSt 
vbcb, foonover. arc not w clt^uly limticd. Tl^rc \s always 
omidcnbfe pftin in thi?i jfTt^Ltiun. whitli ahna ii^volvcf^ both 
1^ nd usumIIv or^ttr4 in yoonf; wr>mpn rf n rhnunulic 
m w ragwn t. Tho fto-calluJ rrvifi^ma $otatf follows expomrr 
10 Of »3a** mysn ctpccJ^Uy ^hcn rL-fl«ctod froni water, of pajl:i 
t^ tk liody wliich arit, ** a iiile, pioTtcled ; iIkhikIi usually 
tf 4li(ki tmpoTtAiKwiT ii may «om«nmc<E ^i^'* riH to «(t much 
pwr^ ced«mA, And coAAutixiii>ii:hl di»nLrl>ATtco iu; to vimuUif^ 




-^ 






"1* . 



•n K4VC KODixan wn lirrn K>v>CT on th» Ti>sc»». 



■jnptkas. [l IS readily di^Iin^l[i!dlr!d liy the Cuct^ liial ii tt 
JiMMJ to tike pjirrs fvpuMHl ind h;k» no tendency to vpreud. In 
*ndc utrm/t rvbrvv the presence mf .> honcy-likt (rxuiUtion 19 ituite 

FiitbolnglcaJ Anatomr — If ^ pvniOii dEe« of prysipeL»8, Qn« 
^^%Tclv ticdb 1ti« ^cn«rj|l M<ns CLimnKin to all s«<pthC ct««s d«tnil*d 
ilirwivTc (p. 91I. 'Hic r^hli will Jirt\*r Lidcd. but oi» micro»COpic 
teciinu of the skin MilMniirs iif rix-1.1 jrijiii^ccj ^t^ cIiaIrs will be 
ieand tnvadini; \hr Ivmph^licfi jttM tii>yi>fKl iKt tipn^Adini^ margin 
'-'/ t^), wtulst iD titc poitfi which th« itiliAinMLittim Liai; recf?ntly 
. k'Til iW-re mjiy br n coaviJcrflblc irx".c»i <"l Jcuci^cyti^^i. I'hci 
l}m|^ gUuJ^ *U1 alv» Iw fmim! orlargrd :^nd coni^cj^tHd. 

ProfDNli — Evryvipebi it not pffculijtrly iUnReroijs in itself, hut 
■tyr heooaie »o uotn the compiicnliwis which may ;Ltt«n J it> The 
~ importuit of tbcso arc inllAmmAtoiy conditions of tlw brain. 



102 A MANUAL OF SURGERY 



lungs, and other viscera, disease of the kidneys being especi^ 
serious. Pyemia and general septic intoxication may alw H 
met with. Erysipelas of the face and head is often att' 
with danger to life, particularly in old people, whose vita! 
become rapidly exhausted. The same statement is true 
regards infants, who have no power of resisting the invasioD 
the disease. As a local complication, erysipelas is not always 
unfavourable occur rence» since wounds which have become ch 
and sluggish will sometimes manifest marvellous reparative powg 
after an attack. Chronic lupoid and syphilitic ulcers may lapidlf 
cicatrize, and even malifjnant sores, especially sarcomata, hiW 
been known to be cured. 

The Troatment of erysipelas is mainly conducted on genad 
principles. Prophylaxis must be strictly attended to by observ*| 
every antiseptic detail in the treatment of woundSt espedil^ 
when any erysipelas cases are under treatment at the same time* 
When the disease is prevalent, all operations that can be debt^ 
should be postponed^ Isolated cases should be separated ra 
other patients, and kept out of surgical wards if practicable, H, 
unfortunately, a case develops in the wards, and cannot becon*- 
ptetely isolated, the bed should be placed as far away from othtfl 
as possible, and especially from those with open wounds, whid 
from their position {s.g^, the mouth) cannot be properly protects 
from sepsis, ll is usual to surround the bed with sheets kq( 
moist with carbolic lotion, and the floor around should be 
sprinkled with the same. Special nurses must be told off l« 
attend to the case, and (o it alone, and house-surgeons ssA 
dressers must take extra precautions to prevent the spread of the 
disease- 

As to Local Treatment, one can merely protect the part frcO 
the air, as by painting it with collodion, or covering it with > 
thick layer of starch or flour, mixed with boric acid or iodofcfftR 
or in the more severe raises by ;*pplying hot fomentations am- 
taining opium or l>ella<lonnH (f.^.* i ounce laudanum to i pi* 
lotio plumbi). The local application of cold is absolutely hannfol 
as tending still further to depress the vitality of the part. Whefl 
tension and pain art severe, :ihstraction of blood ty scarifi 
cation with a lancet may bt advantageous. Attempts hw' 
also been made to cut short the disease tiy the use of antiseptic 
applied lo the inflamed region, such as painting the part with : 
lotion of corrosive sublimate, or rubbinj; into it mercurial oiol 
ment ; but perhaps the Ix-st results have been obtained frc" 
thiol, an artificial sulphur compound resembling ichthyol io it 
characters, but without the objectionable smell. A 20 to 40 p* 
cent, aqueous solution is painted over the affected area as we 
as over the neighliouring healthy skin several times a day unl 
the fever disappears: such treatment is stated to be usually stti 
ccssful in checking the dise^»se in two or three days. 



SBPStS AHD mpeCttCS 



v>3 



Vtvmun lee cm* to be of s»imv V3li>r in limitbije Ihc apncnil of 
iit mbducCi Etcting proUnbl} lv> comprc^^.^ing the lymphniici^. 

\ iftiilf IqimI iif H4lllr^ive {jhiMFi wcutij ;iti}[|ii(1 .n limb U^ytrnd 

tfitvtir^ii of the n&h ii often cITi-cEimI- ;uid il m;iy he poi^tiible 
vtbiiwiyto check its omwiifd iidvitncc from the scfllp to the 

TW iaiiodui: I iuii i^r M.'f<i'llier.'t|X'ii(ir^ h»i^ l>crn urilij'til 111 fhis 
aiktiist with tmiicli bwncfil. An OHlintrrfU'tvietc trrtim^ prfrpurod 

nUniktni^ tt» lilixnl deiiim, hits liftn iimtiJ ii ^ixiil drdl. r^tt- 
iBHjrift FTancr, whpiv MarmoTek and oftiws hi^vp tn.iii^tiriT^ 
ihii fktn of inmlmriiil- Ten or lifl««n c.c^ of this KorAtm nnr 
«wi Milxtilnorooi^iy a* 4 iIo*<, rtiid repealled -mux *jr twice a 
dp;. A^ a tuV't lli^ P'^in Mpldly LJiniiitish^rs. tbr r^>^h rr>()«r'^ tn 
iprad. the icmprraturr- t^ll*, and in tw^-firy-fniiT to forty-Hirbt 
boon tb< disca.ii« it ni ati end. Although \he scrum has not 
hn lugicly tinted in ihiT^ country, them ciin Iw: btit Itlilr doubt 
thai n tht* fvitiur wi- ^haW dr-pr-m1 rin this i:ithrt tlii^in nn iuiy 
ti fkt «iore o|d'fciihitin«! pbnt iMdioitcd nbove, 

0aMllaUoEi£U TrcAtmont muM Uv i^f a tonic nnd suppcirtinf; 
ihfvter- t^ijod fi>:xl. ca^y cf AM]imLitinit,)itimuliuiti .ind (Quinine 
tUM li* frrely inlminrMprcd. whil^i the Imtture «f the perthldride 
4ir«ft m \ dricfim doKn. repeureJ tlircfc or fc^iir Cin:ev a day. is 
■im keokcd OD by many n.t .1 ^pccihc. 

b ffriUMt^rvf(UAiii» trytipthi r-wXy ;tnd free mci^uiiv iiiu^t l>c 
lodr to rrlicw lenvon, :iiid. if po'tsible. inticipile vuppiiT;itJmi. 
Hi h4M>e«. tvbeu iDci>^d, look f-clatin[>ut^ from the <Tdem^ 
pttaeni, jumI much fluid of .-v icro-punilcnt type wiU rscapc. If 
llu b not uudeiliken, cunwdt^ialile lA^itiiiLin of skin and sub- 
ntiofciis ii«que in^y slouj^h. Anliseplir poirllires ^boidd \v* 
■nploffd aEt4*r the inciitiiMi? havi^ l><^4^n madtj, unEiJ ^rjinuUtionB 
Uvv Tormcd. Probably bcrcf ul*<o the nnti^lieptucoccic ^runi 
«9I in thr fijliiir r^ndef 'iuch troitnit^nc uniioces^ry. if the c»«e 
*• «e»r e»rly moHgh, 

la mytipiUi *f tkt Uktt^n tho pfirts rmisl be p-^intod or freely 
n«£dwd over Mt^craf limi.'^ a t^Ay wilb An:i:«pllc loiinns, Mich 
B liqtm ar^nri niir;4iiv (30 ^rainc to t nimrr-l or liq. hydnxrg. 
perdue, (t m i,ooo), wlitltt n high tracheotomy m^y be nt^eded 
' ij>e K^*<^ ^*' \ii\^U<\\. Di^Ksibla AtimuSniitK and pUnty of 
I DOarifthnMrni aic iti)*i'iil]y umi'^^iry It* romb^U ihc depicisiug 

h 



SepUcCDmia. 

StptMJcmiji i> itA iiciit? t^;;nci4il infective di»oi(l«r, arising frum 

w acv«ln|)9nmt v4 hitup \-arirty of pyfiK''iiii" [>r*:anism in the 

It diffc4> from pyst^mia in tht abst-iitt cjf wtondary 

tfcvcWAM (ailhoiiffb, a-: explained later, it m:iy lie ;i>iec^.<iacrd 

E). and from «aprfnmia or ^ptic intOJcioitiDii l>y the f»cl thni 




ID4 A MANUAL OF SURGERY 

the latter is merely a chemical toxfemia. In septicxmia, if L 
minute trace of the blood taken at a distance from the tool 
focus of mischief is inoculated into another animal or individodi 
the disease is almost certainly transmitted, and often with ifr 
creased virulence ; in sapra^mta, injection of the blood, excqita 
large quantities, does no harm, 

As 10 Ihc ullim^le atvse of sepiicaemia in man. much discuasioD bia tnm 
owing to the divergenceof theresultsobtained hy experimental research. KdA 
and Davaine have each succeeded in isolating separate bacilli which prodM 
fatal septicxmla m rabbits and mice re^Jectively ^ but nather of that i 
nece&sanly fatal to other animals^ and neither ia the aune aa the orgaiiBM 
usually found in human 9eplic<emia. although the symptoms produced m 
practically identical. 

In man various bacteria seem capable of producing this diKa» under ^ 
able conditions — viz.. the ordinary Stteptoiocaa pyogtnes of acme tr"™*^ 
suppuration ; the Slreptoantm itptUm of Flugge. which ia probably idtniH 
with the above, though more active; the Streploeotcus u^tofytmiaa, '^itiA 
b more nearly allied to the eryapelas organism : or even tha Wflai ^ 
maiignant ardrme (Koch). 

Ifamouseiainlected with its specific bacillus, it remains apparently usaftoi 
for a period of twenty-four hours (incubation stage), but then becomes luifiA 
its eve loses its lustre, it refu^^es to eat or run about, the respiratiofU baOdV ; 
^oWer, and in about another twenty-four hours it dies, all tta fuDctifl* ■ 
appearing to be more or less paralyzed. Anatomically, one discovers b«l fa* ' 
naVied-eye changes, except a little focal inflammatory enudaiion at the pant d 
inoculation, and slight sweliing of the spleen. Microscopically, manyof Ihi 
red corpuscles are found to be invaded and broken up by bacilli which oif 
even be seen withm ihem, and the capillaries, especially in the lungs, are men 
or less blocked by agfiregated masses of organisms. 

The pathological pnxresses in human septicaamia are infeTFcd to be oJ » 
similar character-- viz . development of organisms in the blood, with dilii]ta|l>^ 
tion of corpuscles, especially of the red ; tibstruction to capillaries, particolii^ 
in the lungs: formation of toxin es as aresult of this development , andpanly* 
of [he functions of Ihe nerve centres thereby. 

OUnical Hifltory.^Septicitmiji occurs most commonly from 
direct inoculation with suitable organisms through small le^oc^ 
such as post-mortem wounds, or from scratches or punctures witb 
infected pins or instruments ; it also in rarer cases follows opefi- 
tion wounds and severe lacerated injuries. It is the usuai «■ 
companiment of acute spreading gangrene^ and may be met wit^ 
in cellulitis and c>mcrtim oris. As a rule, the indix'Jdua] At' 
tacked is in a depressed and debilitated condition, often deteno" 
rated by alcoholic it other excesses, so thai the inherent gernu" 
cidal activity of tht tissues is markedly insufficient to cope with 
the inroads of th<; disease. 

The point of inoculation may be the seat of any of the forms 
of local trouble \s hich we have already described under the title tA 
celluhtis, which may vary from a mere slight inflammatory blush 
to the aculesi form of spreading gangrene. 

The 0«ner&l Spnptoms are those of fever, often ushered in bj 
a distinct and severe rigot ; the temperature reaches 104' oi 
105' F., and usually remains high, with but slight remissions ani 



SMPSiS ASD WFBCriQS 



m 



lhiatflfimMk>fi>. Then- a trrrat m^lAi-ie with bis of appetite : the 

be ikia, yeUow and •ct«»ric in (X>Iol]i. be<:<imps dry Jind hoi, or ih 
"tT'*'"ffl covorod with por^pirntLon, DkrrhifH oftun unttuus 
■Ad my be l>loud->tAt]ic(J. Hbil<»i tlic uuav ni^y be aibuiimioua. 
Md OOMaiD NmhI. PHvclii^- ;\|T|»eHr itiirlt^r the ^ic. tod the 
piiiaii after a ptriod of d^lirmm, {aWh into a Mate of coitia, Had 
dii^ PjfpDoca may precede llic fAial i*fn;e, nhil^ the temper*' 
lure Amy bv cxcoediniLEly Iti^li, ur ourdHJtHiAlI; Mibnoimal- 



hn ^■NNr'* d*^ tlui iiho Wl b«n siun^ nciir Ihc iiuicf cfuiihtu hy n Il>' 
fb^v tic aAirnaJ lad oc-mp from ixvmc.- inh>cf«l material . utd ihut pulHMil 
>t ■WftJ Is Iic«al7'-ln(ir haan vh* ua* l»«linK ''^ >^'' rnviimlMUld had 
at eUlt umI iutboi ; ihtn wxt a pqJnrul luvllln^ m rhr Iniitfr cMtthuti. 
■W i^tdlj inueued in titc ajjiJ v^c^ii l^^^vukvaILb At tlic oui of Ebm 
Af\ *Ma w ia«> bo, tbe c»« wa> iKtririidiiii; Aful niuch (uniiX9l«d_ uud a 
Mitt bond of infUnnutorf- (hicUnin^ coiutd h« Mi iHChint from ibv 
■DNc£ite*r«f>MrnM <ho fncv to the necl and jUfCuUr rtfinn. probably rh« 
<B<i'u>d l>ciaJ tvin the cloi doutnteu aJv> nimdinft (i-' ini- r»k«mnni 
■^ Tlr tcmptraiuK am bi^b. and the jtirl wu dtljriout An incluun 
■««idesMi ilwurbJc wTib lh«vi«v g[ rFliavitw uuukfli mid ititiin; ct^t lu 
** femihU pDf. b«i wiib iti> rceak She rasnaly bacamo occnnaci'tuh. and 
M«<*ina w»i 

UtUotr nun. jdi^tivl t<j dnnk, htl In ibr Mnei, anti anif^ (h« innnr 
ad* (V bit Whl Wiihie i*Boiy^fiLir Tujiii> ifit wbol* afm ^^b* r^^'J" '^'^^ 
■nte and in ivu day<t gangvne bad mulinlQd liwit ihi; ^nfdiiAtum 
'HUube)xi«d thcihouUer Tbc p«ilent mu d^ ffDm a^l^cp wpticffikJi 

The F»«i-mort«m fiicDB at% simply ihoae of ^icute »eplk poison- 
■Bf. dcActitieiJ .ilKAe (p. 91). wjlli the aJditioii that uu nucro^ 
■OipacrxaminAtiock hacttriji am he iJemun^UiLteri in ihf hlooH uicl 
Qtenul orgwu* 

Hit rutin Oiilfl bas to be inadc Uotti tafr^mia and the more 
*vdcu fixrnv ()f the fKiif/ rtuHthrnuUa. in x^hidi iho [utient 1% 
^Tond beion the cbnr^LCieri^tk app^nruncs are nxAnUesXedi 
3 tticb cn«#4 an abtiolulc condufion m? 10 lUc n;itiire of th« 
liKCion ia often inipt'sViblc, if tbcrc i* ro clue a:^ to the origin of 
tW infection, Sipup^nb rarely pxitiis imt(rs« thrrr r^ sonic veiy 
DbiYnu Icciit of putn^faction. whikl sppticrmia may octur u'lih 
hu dight ii>c«i] reaction. .Sr/'^t franmatu- fevet^ ,\s^ A^uytLrAifid with 
•oond itifecCion, oiat be »o jcvvrr a> lo v.tiiise icrnvc .irxicty for ;i 
Imp A* to vhetber n>T not wfiticr^nii'i 1% pmrni ; Inil rf tVir 
*>od ia freely k^pcned up ;itid druincd, th« raptd dis-ippenrflno- 
rfihe (ever jifovcs Uial the mi»:bief was merely sl liiciu, iii>d not 
IbcBKm »cnt>U3i icecicr^l. aiTcctioii. From py^rmui it is known by 
llfcilMfllcP t>f re|Fe.-iied rififorH nnil ?vn(md:iry nlhcessen, 

PnfDOtUH Septtc.Tmi.-i tip to th« pr«^enl b-i^ been ;Llma9it 
aJ«ay» fatal ; but it ■!» ti> l)C hoped tb*t the modem pkns of treat 
nou incDliiJiici] 1>::|o«, enpecially seiu - tbciMpyk iTliay prove 
WnafniiJ in dinkinUbmg the monabty. 



toe A MANUAL OF SURGERY 

The TmatnMlit to be adopted was formerly merely general a 
symptomatic. Dealing with the wound is like shutting the staU 

door when the steed has Rown ; the case is usually seen too U 
to allow the surgeon successhilly to grapple with the disease, sbm 
blood infection has probably already occurred. Inasmuch, b<il 
ever, as the diagnosis from saprsemia cannot always be nui 
with certainty, the wound should be carefully purified, and fn 
drainage provided. Incisions should be made into all infiltnti 
tissue, in the hope of being able to limit the local activity. 1 
addition to such means, which, after all, hold out but little bop 
tonics and stimulants, with plenty of suitable nourishment, coa 
alone be depended on. 

It is possible that even this grave disease may become ama 
able to some of the therapeutic measures which have been SU| 
gested of recent years. Thus, the antistreptcxxKcic serum ms 
be utilized, and cases have been already reported as cured by t 
agency. Another plan which has been adopted is that of t£ 
intravenous injection of con^derable quantities of normal salii 
solution, repeated two or three times a day ; by this raeai 
diuresis and diarrhosa are induced, and it is hoped that theieh 
the cocci and their products may be eliminated. This treatmet 
has* however, l>een introduced so lately that no dogmatic statt 
■nents can be made alxiut it ; it will probably be of greater valu 
in cases of sapra'mia rather than in those of true infective septi 
c;emia. 

Fynznia. 

Pytemia (Greek irvoVf pus, and aifia, blood) is a disease ch^nic 
terised by fever of an intermittent type, associated with tin 
formation of multiple abscesses in different parts of the body 
arising from the diffusion of pyogenic materials from some spot* 
local infection, 

k was supposed nol lonE ago ihal pyarmia was due lo some specific micrt 
Oi^ani^m. bui it has now been definilely proved by Roaenbach thai any ol tb 
pyogenic orpani^ms can pwe rise ici it :' in fad. theorttually, pyyniia may in* 
as a coiTipUcalii>[i follo^^^in>f any acute abscess, which, as u« have aLi«ady isB 
15 alwavs duTf lo bacterial aclivil)- As a rule, however, there is a suffiocBll 
rapid develi>prneTi| nf sranulalitm tis.'^ut lo hmit ihe spread of jnfection. Tl 
organism most commonly Tnund is [he SfrifiUtoccas fyagnies. but in a tff 
cases the Sraphyl-'iiKiui pyoafv^i ^utfHs has lieen observed The mere injd 
tion of cocci mio ihe circulaiion is not suflicieni lo ^ve rise to pyaemit; 
they are fe%fc in number, a transient pyrexia may supervene, and th^ l! 
germicidal powers latent in the blood destrov them , but if the dose is large, < 
the individual is no) in a very resistant condition, septicemia, and not pyKDJ 
will result, unless sjtecial conditions are present which can determine the fc 
malion of embolic abscesses H the t^ultivation of cocci (u be injected isfii 
mashed up with ^iome jHJialo. *<o ihal the organisms are carried on partid 
too large to pass through the terminal arterioles and capillaries, wherever th 
lodge abscesses are formed In human pathologv ihe infective emboli cons 
of zooglgeamaAse;^ t>f or>;nnisms, or of infected particles of di«in(e[ipratinK blof 
clot {¥\K- 15)' 



SSJ^iS AHD WfBCTiOt/ 



tor 



TWtlMlBB of pya-rnia may br sljiTe<1 to l>c Any <^iidillon whirh 
lodi to ibe formation ami i1rl-Khiiirn( «if iufc^<.livL' cimIkjU in I he 
canilaltun, nith ctnuiitiont ticcuTrin^ mainly in ihc veira from 
infilimton ami ^lisinteRtivlion of a thrombus iiefilu ^Ubititi, 
te OCctSKKudly iQ the hciri <nia/i£Mijn^ rit/i>i'iirj^if(jj. The 

•penEncH \yy %urg«vinK hni ntiw l>rcn prardrally h^ni^hrr! frimi 
vinery by anlistrptiis. Hul Iht iti?en!^- is ^till occuiionnlly aitt 
mb caauallj woiJ;, whcic cflicicnT nscprds is difficult, and 
iiMib tnfcclive ttidaruiti;itiim <ti tlir t-;incclbu% li*.sut? nf lilJnc^, 
*mW fdiofxathir or liuurriATir. oiA'tnfT to th« vc'iiu L>t;ing abun- 
^1 ^d thin A'jLJJed, iind coiiAiil«r;ible lonHwn prcjwnt frum 
rtt ii^|<|iQjf con<lilio[] of liie mriomnlmK l»ony ?ilr(icturc&i 



I 




TVapcL cd Ihe clot pmlkctt Imn « lRr>;»r f nml ia mMi^h dptalitlkug Hm/ 



Htt^acnic nerrofiis is vn^ (fkTiiRii>iily ^KMHi.dt'cl wit^j py-<-it;i^i« 
41 ■!■» nrfl4mm;%lioti ni Ihr rrAmal hnnv8 coming on in ih« 
OBOne o( middlc-tT^r miftc^icf, And lending to lhrombo^& of the 
hknl ttikux The pr«M;jicc of Utf^v apfiviuoulhcd vein* in 
cWfMeqiefal utcnii^ alui npUiat ihn rr'^dinr^s with whirh thf^ 
teM uccun after parturition, when ncptic malcrinL ih allowed to 
ttJEcct or Tctnun in llicir vicirrty. 
ft^bcn at* infective rmtxjkis Wcomca U^djEril in ;iny region of 
liody. a ihrumlm^ Idmii*! \i\jfm tt. and in ihi% ihe micro- 
lifting rapidly d<*%'eU>p. md t^iou pui^ fruia rlie llirombufi mto 
t«6bc1 Willi, antl theni=c into ttic Mirruun<lintr liiuuva, cauNm(j 
tkju. whiub IH Hi tic^i ijf a pluhlic type, Imt latti un 
bofinnkM Ulppt^r»ti\y.^ In tht J^m^ ni.tny surli Infl.immflTi^rv fnri 
<uy occur, dintribuled mainly alon^ tba poslenor iMird'jr ana nrar 
t^ ht»£»rc : cuch ("^ ^MtpJy liMiJlcd to n Aud^v-shjipcd urcii of 





tiwiMi with tlw hxt* dir»ct4d towftnlft ibe ptrlplitry- It k at 
firvt fodditli in colour, from cffuaion of bmi {t hanwrk^ 
infami). but *ocjii iHrtonR-* HMyish-jx'llwvw, from tb* EofnuliDQ of 
[>UR. These nliscHtf-K art' small, and r;ir<»ly R^ivr rise to zny 
physECAl siens. Similar ooll«ctionK of pMfi, pT-f«r.i^dcd or not by m 
ntaf>t of inmrction. miLy be found in ^ny or^an rif the bodv< The 
lungs, actmg as a f\\lri tn c-.Tiil>oTi dcri\r(I itam I he hysirniic vam. 
nre naturnlly the lirsi orgiin* to Iw affccic<l. and from ihc many 
Ab^c^sc5 formed ihcTf^ir, infoclianol the Arterial syntcm iHAy take 
place, re^uhinjf m ixcsth ituppurative foci in the liver, spleoa. 
kitUiey*- brain, ;iml in nr ^irtiuml jnims f^tr. If. b»wcircr. the 
cauKitivc phLebiliii i* tituMed in the portal area, the emboli are 
lodfccd prim;Lrily in the liver. iT^vio^j riflc (o nfchat is kntswD u 
PfUphiehitK. If llie ctnUoli are in:iti> \\\ luitnbet, llie cOPStitW' 
tioiiMl HvifiploniH will Tie S4*vrre, anil acute pyBtnlJt i^ presMit : 11 
n Ufiuullv nii8cx:i;Lted witb ^k dewlopnit^nt uf Tnicro-orpinismt iD 
the blooj, oonMitutin^ a condition of pyo^npiitirmia^ an3 tbCD tiM 
^Itciit rjid> die Ivfcjic riiiy *iCLundLUy nbiiceBHrs Live funn^: if 
Ibp fmholi ;iro fi^vk' in nnml)#*r. and ilii^r^ !<« liTlI^ or no develop- 
nK-iLf of oii^roln*^ m flie Mood, ihv dJsejLSfi is termed oluo&ie 
pynmlft- 

OIlDlcal History, -Thr nuihi m;«ikrd Hyiikptfim indicaURj^ the 
on<^rl rif .k <^Aitr of Aeut* PjiKDia i*^ iU«- ormm^ncc durinfc « period 
of fcbrilo dist\irbiknc(i of a »€v«r<r t\\io\, which is rep««t#d with a 
sort of irri-KTulai prnudktty, moM frcttLtcntly at ioCervAU of itboul 
tvrnly'fnur lo ffiny-ri^Iil liotirs. Mimtuhal wlmiilaiing An aUacli 
ofagu«. Tlif rigXiiT^ do not <liffer from ihoiw nccurrina in oibcr 
diHciuw^, biLt llivy nrc very severe, nnd nrc u^MalJ) loJtnwcd 1>T 
profuse NU'ciit I n£, Brlweeu the ri^rs the Irmperaiurr may faU 
to ihe nornul> bui motfr L^tjrninordy rpm--iin% almvt it, Tlip iJtin 
'\% hot uud putiKeoi, ^nd itoon de^'elops an e:irlhv oi dull yellow 
icteric tint, tocher with erylhemalous or pctcclnnl p>itchc9i A 
ewe%l. tnaivkish. luy'like uncll of the brenih l^ veiy chflnicteri^tici 
Syiiiptmn« (if ^r^iVF de|>iF<e<ioi Hixm «how t^irmwIv'TTHv ^>nd the 
patient wAi^tes ripidly. The pulst< b«coni«^ ioft And t\'«J(, the 
excretion!^ are diminished, and n c<rr(tiin jimount of nocturnal 
delirium ih cioliLrUi but no Iuh:^ of (.tiiiuiouMwv*. llicr lUii|^ue 
varip5, but i"* often rei with ^rry prnniinpni piipill^v.ind tend* 
to bocoxne dry and brownish. Tou-vtrds the* «nd of the firtl wt«k 
accondary abeccsacs begin to fkppe'JkL' ; they :irc n» n nile utuccori^ 
]>Atiird Ln loc-al pain or Iri^dcrnejiK, iind irinn very rnpidly ; th«i&. 
JL hnnc'joini may fill \fcilh pwt in the miiriie of » night of c|uiot 
il<**-p. They are, a* a rule, »mftil and mimej^ous; if they occur 
ifi vital rrgjin^, death may result from their local dL-v(]t>|>mcfiL 
WLtn cicriirtiTiK in the ^upciJicial ujft ikiUn they are cKintpTlerised 
by th« alnioT&t XoXaI jibstnre of a liurrier of f^ranuialicn ti^ue. and 
h«nct», even wh<?n o|wiicd cnrly iind asepticiilly, hnvp a t<nidcncy to 
extend and continue ^lecreting pm. instead of fDllfi-ninfi tl 





SEFSia Attn iNFECTiO^ 



qniOf of an ordinary SkCxHe :ib\cess. 

Nd UBCOcnmonlv iit Ihrsc c.-isi.'^ pivmttil p^ttc^ie^ occur hcrt: 
lodlhcre i& th« suticuianfutiiT ti^ucn L-t<-Cuiiip.itiit(J \ty liyptt^^Eiiu* 
«U £iife« Away ufler >i fcvr ib^H: miWi utr \tyo]\i\*\y dxit^ lo 
ihi n^acnoo of ««nu)] infective ^finboli, wbidi [h« piitient fii» 
wfionl vitahty to get hd of without the •.ui>E;rvviilion cif »up- 

b Ohnftlc Pyi^nilA rhr frhrilr tiyiripinrnK ari> miirh If^^i* mnrk^rl ; 
Ikak owo tt are fbv in nunih«f, uid iiat ctangorous url^fifi fornt- 
Et ■ iBXporUinl »tfuc1ijrct^. Thus, a IntAl rtr^nh *^nsuc^ from a 
Ufle Atiicc«s uhich ctrverkiprt] in ihe IhU'iaI vrnuulr of ihc 
train ri a pLktif^t who had no other tymptom nif pyemia f xc^pt 
UMolUuiu; tcmpcmturc ; it folloH^ an oTwrelion on a nimie 
UtAngi to A kidney Alruidy diitort^nnircd and hiifhly iioptic. 

tlttODodiliciii of ihr rwnAr/ <tl lli<? oomtI of p^-i-rniA if^ AlwAys 
m uoAiiilftaory. If the rt*uit of an o;icrati<jn, it will ipvps 
« ftfcwnt an inadivv s]ooi;hy ^rny T^Mrbcc, anii any newly- 
tarwdxar ti^nuc will readily tJtc^iX liovin. A Uycr of h&thhy 
fWiAilHX)^ IS an :thiiusi cciuin luiriki ;igain!(t ilitr Trj::i]irtit<K of 
pjevvui. on accoifnl of lli<^ K^rmicidul pinver uf thi? cfIU oon- 
ctiKlNUU; it. If lltc di^4rav: any^a in tonat-ctiua with bL^tir, the 
WiMr Urudurc i^ ii!.uiilly sctu lyin^- bale at llie Wti^m fif the 
«oakL dennilec! of its pprhfiTPiim, ind the rancelli fij|(*d with 
ilniibf Icvttd medulla, or pus. 

m Ami/ w i i of a cam of pyaemia is very %-anahlc- Acute cauck 
hit tfuJIy a Utile- ovei a wet-k. vvhil^I the ^ulxicule fonns may 
nm c« f or thr«^ or four vue^k«. and chronic caseft rontiauc for 
■caihs ^tt'i moy r^'i-o (*nfl m complei* recovery. 

Tnc pDat-Qiort^m App««juic«e may be ilcscHUx!] b.» follows: 
*H Tic »x)ond ib unhr-iltfiy, thr ■^urfflwr Iwing pisy. diy, nr 
lUi^by ; if hone ift implicated, nn in an umptiiation or eKCi&iun, 
mdcKc od inlUmniatory mis<:1iiuf, either of tho pvriostfJUTn or 
■eduik, will be prr^nt, lu the boncAof the ^ull ttic diplu^ 
Ctt/Ui infitrratrd with pii-^, i. The \t^\nh Ir.nlint; fi(in^ i\sf wtmrul 
iiy br ID a holitiy condition, luil more comnionJy aro in a filatc 
<i Brpcic phlebitis : ihv coftl}^ Arc thLckrncfif and UiC lutncn HJlod 
•<h toSt diNnt<:Krating clot, which cil<:nd* for a considcmble 
&lAntE; the lU^irs KiirroundinK t>ii- vein ;ir<r ;i]ui invnlvctd in 
llw fUppurative process. 3^ Seoandar^- abscc^fes are found in 
mooa pdrta of the body, most frciiuenily in the lungs, and ihcir 
^§attA ttages can be clearly ilrTorjn^t rated fiLTiii the embolic 
nlonleft of micrococci, IbrDUffh tlie stiif^t of ha-iiMirhagir infarct 
fkm 10 the comptfite absce^. The contained pus may b* of 
t%e normfitl type, 01 thin and oily ; it ia always, howovorH swaTmuiiL; 
vilb cucci. 4. I'be ^eiirral Kjj'nK cuinnio]] to all U3»rs of aepttc 
pnoRiog irlU tw manifr%t : they are (.lei^rilicd at p, 91, 
The IMifBMli od pyu-mia should not be difticult in 1h« majority 



Il» 



A.MAKVAi^itF SURG£aT 



w(jU[iJ. d4 lit <a><v> of df^-Mfttcil abxcsMt, ui vvt^cir Llir iiu- 
portnnc* of snmi' Ifwal If^oti h^m nni hfM^ii »ppr^r\mei\, (hr inhU) 
ttymplornA hnve Itc^n mii^Uken ^r thoM; i>f ncLitc: rh<TLim;itUm or 

Thr^ ProgaoHia eIcijciuU U|X)n ihc iiibm^ni vtliility of the pftlicDl 
xhn viniltncf of the cli^wioa-. )n actitc cj.tct it i« rurfmcl^ 
vc, whilrit iti Ihc chronic tj-[x-' recovery is nol only ponsihlc, li»l 
prob.ihlc, if the IocaI ^ilisccssfi iitt favourably Inc.ttrd. 

In thi? TrMtmeuluf iiaitr ]i>.t-mi;t rhi^ Hur>;i?»i] is m^tin^ at a 
conddcnibk dis-iclvantui^'c, hi tlut the <lii^e:i«r is only rn:Dgni«ablft 
when il lias obtained some holil upjn the p^aicot- TIxe recurrent 
rigLirs, by wlilcb it !-*» kmiwii. nsv the evideDce of h icr^vx ifenent 
infrction of iTie IiIimhI, fur ;illtiouuli only -a few emiKih roAy Ivw 
bven detached, aiiy ont* of iht^m ift capiibli- of re<i*K(abti!iliiof^ th* 
riiscasL't c\'i^n iE lh<- onj^inal focua haa Lhh*ii ^atisttctohly dealt 
wilh, Uy n stULl flsetisis pj-riuiia tatu an a julr. I* prci-eiiled. 
liuT if in ipit^of orapflft from tbU The pitlif*m developi^ ^ympturnft. 
ihfi «uiyei>n muM i^ikv rtio miifi vigorous m«amre« In check it* 

Local Tieatiuont i^ iiiosi iiii^joittLiit, unci remembering tlicr Dtct 
ihAt the dH^^M- U in Ih^ m.ijonly nf miii^fi due to th? detadiRMiU 
of infected cnihoh from a vnn, the futt i^ucnliril of Rorj;ictU pTftc- 
ti<:ccuQMfd^ in prcv tilling tht' fucthr;! <.utiTnminatioii of the ^enicfal 
lil*M>d.Httwim. This is u^ U' HttomphshcH], m the cui^ t>f a Limb, 
either by ^immj lotion wcU abovr thu local IcaioD, or^ if ib« ntMlul- 
Ury cavity of n U^nc i? the 'louror of trouble, it may be powibk 
Ui Huiapr out ihr L'-nnKi^cnoiif^ and v>frc:rLsi^e DkCflullAry Ii^6ue. aod 
rti^iT»ffri ihr r;iviiy wiih pun- rarl^iohr arid ; or if ii tk diu» to a 
wound in the f^ift pnrtK, it may be feasible to difi<iec1 out thv im^ 
CRicd vicin^nd furroiiodiTi|;:ti9AitcH.orntnny rale to remove tbedii^ 
iritegnitiiii^ clot iiftei pUcioR.t ligature upon the vcrAcI hrttwrieii llw 
thromlvut :Lnd the he;tit^ A typical illu^trnruTn nf tucb treAtoient U 
thnl adopted fot septic throml>o£ii4<jt the laleinU »nus compltcaling 
di&cn^HT of the middle c-ur. where, uflcr tying the intemiJ juifnlar 
vrJTi lu ihPiieck. tbt wiius IS ex[>JJsed by ibcr trephine. oprn«l, and 
nil the geplif cluT rpmjjv«:'d. pirirtly from nl^oi^. t>Mrlly from below, 
:Vdinifflhie results have Iwen tliereby obtiiinwl. The ahKfuet mud 
be dcfllt with, where pr.icljc.iblt, by oprninc them fiiirly and 
wnHhin}/ Ih^in not , Mtrh nimnds ofi<^]i hi.Ml well, and even jolM^ 
which \.w^ t>wn di^t^n/Ircl i^ith puK may recover with fr»e 
inobihty. OcCfibi'^iudly, however, L^vcn whea ri^d a«efMi« ba^ 
breii iiidintAincd, ihc ^iippur^ttion conliinieb for a lime* oud evni 
Hioujisfiiiti,' of iIk- ^|i>,re«^ waII nay fidlDii'^ If lliti general raitdi- 
tion c^w \^ inipfoved, a hurrier of ^Aoulation tifiwna will form m 
lime. iLMil re-piLir lie rMjibii:^hcd. 

Coiutltulloujil Trefttawnl corw^t^ in sLijiiioninh: the paiieDl'a 
strt^n^ib by noun^hin^' din and Ktlmulants ^nd lii taking Spodal 




SMPSts Asxf tsFscnott 



pOMralioM to avoid hcdsoresi or 4n> local injury. SiUJcyUtc? 

a B of imich ^-:ilut. Tht imtiMrcpiococcic *icr\ijn may al&o be 
iilitin4. awl dfubtUiA in ccrt^iin ^rn^o^ which hate fiot proj^tteM^d 
leo Etr it mifihl do s^d, 



Ttdftiu is a local infE<:tivr disuiL-^. Jue lo Uk- mtivity ol llic' 
Aidifin Irtten, »nO the crmrMCtt-fiMiL- symptoms arc of a toxemic 
tttatt- Tyro v^it'Urs Ljvi^ htcti Ucfsciibed. viz<. llirr uautii4t)c 
and ihr idiofvithic; hiii ir i* prtibahle Jhm ihos^ cm^^ps which 
wfii bs cla^»d under lh<r Ulter heiuiin^ afo really dim to ^ ^b- 
Mueoiift tniama bccomtu^ iufcci^jd Ctotii vhitliiii the body, or 
ibo^h wme slighl a^^asion, &nr] ihe-rrfore w<t shall not d'tscuSH 
iWfii 4»pnRitf^y 

fMiipoimg GftTuei — i. Climatk Inflnmsft^ — Jl is mofit com- 
o»ly 9KXX1 in ih** tiv/pic». w1l<tc it niHy bccoiTic alnui^l cpiilciTtic, 
fiulolil V owin>: tn thr hf^t favmirinsj ihe* clrvrltipimTic iinH vim- 
ifBC* « llic ortfanitmK in the soil \ hot scaiions aMitt itv .ictivity, 
*d pnrt>cukarly nhm hi^t days aic frjlIoArd hy cold m^his. 

I. hnomd i'rtxiivUy. — II wa). formerly conxidncd ihiil TLc^octh, 
hcsst, And Btal>!e attrudiimi wrrc ^ppnnlly Hablr* Jn thi?; dise^ise, 
nag to laome peculiar idici^yncnivv : Intt ti-ith th^.^ recent ^ddi- 
>ieBi lo our koowlcc!)^ aj> 1o the hnl>it.-iE of the hMciUnt tctujti, it i-^ 
cUTfovly iloubifiil wliPlhi't iirch iiii idr-i ci*ii lit m-iinUiotd, 
Thr w^^nisnt ta a facwlutivc laprophyie— i,f,, i* t^apablc of con- 
Ii3u:ng ita dt%elopmtnl Apart liom tho Iwxly and ii almost con 
«*nik (oudU in (C-trdcn noil nod dki^t or dirt of any kind. Tlioiw, 
tW«£jie. wIh> nic likdy U» U? much litouj^ht in tuiiiiid with the 
pi«fc!. *T^'-, Di-^rop«. horirs, ind ^^iculiuriil labourers, are mo*( 
uihW lo the dcvckipmrnt of the di^cab^, owui|; to tlicir moro tran 
lani utpwurr Ili«ic1iy ^** <'^« lutcillu^. 

y tiad fyffifat n h most in^poitEini |>:(;i1i?^]^x»^in^ orvnditioii , 
'E»«y bygienic vrror nuyaui^t m its tltveiopmeoi, l*u1 ttspectally 
ifcc uvcrctoi^xttiiK o' ^lii f^^ Aoundcd pvopic into u Imnicd &i^acc 
ftWe full ^ittM-psib ii j[|jpu%3iiLilB. Thia i> the «ca?Ma why it is 
nfe m military M»rg*ry, 

Cauam- — I. Tho «xui«aceof a atocni. It may follow 
i%hich rai^scs no hrcAch of surfncc. such i^ a blow with 
[, or A bruUcr but in thr grrAi nujonly ci( t;iiM;s there in a 
ikfmit^noJufkincif coQimuity of the i^LJn. Any rp^ion ol the Ixxly 
my be thus offcctod, ^nd there is clu clectTVe a^nity ff>[' on^ pjiri 
•vcTAMtbev. The old tdcA that noundn of the »vb betw»cii thu 
Itannb and indrx^lini^rr, or iif ilxa b*ill L?f the ^if:Al loc, m^' ^&' 
tiin lo be lo3k>u-cd by letanut his no Iwsis it\ ha, althrmfih 
bnrtated Mptk wouada arc exircmdy conirtiori m thc^r rE?fni=>ii^ 
more open to infection* It is mrc fi>r lutiina-t tj 



e"firt. 




Ill A MANUAL OF SURGERY 



occur in any but septic wounds, and where asepsis has been fuif 
maintained the occurrence of tetanus is almost udIcdowfi. 

2, The infection with the Bacillus tetant. The first clue to te 
infective nature of this disease was obtained from the observiiki 
that, if portions of soil or garden mould were placed under dN 
skin of animals, they died in a short time with tetanic symptom^ 
and in the pus and walls of the resulting abscess characteristic 
bacilli were observed. Experimenting in the same way, it htf 
been found that the bacilli or their spores are very widely dis- 
seminated, and, indeed, are present in almost every sample at 
garden or fteld-soil ; they have even been found in the grime on i 
working man's hand, and on dirty surgical instruments, Gitf 
difficulty was experienced in isolating and getting pure cultim 
of the bacillus, but at last Nicolaier and Kitasato succeeded, ^ 
heating the pus from an infected wound to a temperature of 80' U 
for an hour, thereby destroying all the pyogenic septic micmbei> 
It develops in the body as long delicate threads consisting fif 
and breaking up into separate bacilli, in which spores favv, 






Flii 16— tiAClLLi uy TKTAM.rh PkOM AxrinClAL CULtUHE, SHOWIMC tM 

Spohfs i.ocATRn AT THt Ehds OF THE RoDS (' Dk umstick' BACrixi). 

(TlLLMA^SS J 

usually only at one end, causing such an appearance that ita 
microbe is known as the * drumstick ' bacillus (Fig. t6). Tbey 
are anaerobic, i.c., flourish apart from oxygen, and, indeed, are be* 
cultivated on nutrient gelatine at blood-heat in an atmosphere d 
hydrogen. They are not endowed with high vitality, and hoK* 
will not in\'ade living tissues tmless these have been previously 
bruised or dama^^ed by the presence of septic inflammation. They 
grow in the neighbourhood and near the surface of septic woundir 
the septic organisms absorbing all the oxygen present, and so 
originating the anaerobic conditions necessary for their devetop- 
mcnt- The mode of iwium of the bacillus consists in the productw* 
of a local infection with general toxaimia ; that is to say, by iM 
local development in a wound certain toxic bodies are produced 
which, when absorbed, act on the spinal marrow and brain, pro- 
ducing toxic eflecls very similar to those of strychnine. The 
actual tetano-toxin appears to Iw somewhat of the nature of a 



SBfsrs AUD mFscTiotr 



"3 



fattai. lis viruleiK^ being readily dea^^yed by «xp6tur« to a 
iwn t at low tem^Ature, ^x.. one of 6S' C, for about five 
i&inQlrt, It U in.ll mflu^Kt-d liy fifyiiii;. ami ils achviljF ^^ ^ucli 

nUlaiHe f>o>si morc> n Anatomical Cliuig«a but Httlo novd 1x9 
wit u (^crc i» iKJiini^^ >p4.^j.iliy L.ii.i[,Ki<.ii>lic. The muKt&s 
1^ often pole, or sht^w e^^iilr^nccH of nipEun* and L-xIravnh^iion 
Vbtood Thtt p«riph«r,il ncri^c^ ^tendin^ from tli<» woui;d am 
ledudoonirv^tcid for ^oicic diaUncc.bLit ihijj in piobaMyonly i^uc 
tOKptic ninAmmAiion. The nci>c i:ciurfs Crcr|ucnl]> present 
ins»(if wfti^ninif, and prnvftKnilnr rrlliilnr ciriublinn, with w»nf- 

A frw obrv:n-%tioiu arc on rccoid in which the l>ncrlli have been 
anbcedon the pin in.-itrr a:u] ar^dmoii:! ai tlic huiiiim »pi[ial cutcJ, 
ud aih«rs claim I" h^vc n^niannted the diw^i^c pxperirt^mi-illy 
hf Aacuhtiom of the vubdurAl space uhithnnemuldon of thefipinul 
nvil or medulli. If tbcae £act» he true, ihey Litdic;ite that u-c 

^'t\r still muc h lij le.Liii .ik Id the natuie ul thi^ ilisf;!.^. 

CJlDldJ HUtory AciiK Tetantil iiiually nutiiff^M^ itself tw'o 

KUfM dnys alter uiJi.-^u<j» ihut soniebmcis a» early afi a fe^<- 

Wvtitoc a* lat« a« three iveck^) l>v a diJHcully m openmi: chc 

■oatb, R*6uciatrr(l uith a ciani{)-llke |Niiii in ifit' musilrs of 

vmiatkin. This scon t^com«& su ni;trk(?d th^ii it m.iy tw 

tfoill t\tn to inieri a paper biift K-lweoo tht to^lh {trtimtts, 

«Iock>iift). ax»l to it j> added ^ Jrxetl aud li^id cuuditiuii of iho 

aovlrri of llw Uult of the nrd^ iuid of the Ltt, lfj<.' letter pm- 

Mfig 4 curioiid |-rin hke uppisititucv {mm sardonirm}^ As a. 

tde, a con^dcTablc Jct^itc of fcvti is L'flfly timiiifi;sted» htit in 

MDfc few c^?<^ an iip^[E.vi:il cuiuaer ib iiumla^liicd until (icjfiily ihe 

nd. Great diffiruliy in the admirimriitinn nf nurririon is nx- 

pM^cDctd. Spasint< of the mu^^cs aroittid the ittjurcd p^tri ii\ay 

■I the iir>t -^^i of the disc&ic, and ^pcciAlly io tn cs^pcriincTitnl 

<"3^ oa Animals ; bni sooti spasn^odlc cnmrHctLuns of ihc trunk 

'Mlotn^milic^ ari- dfivflloped, arrnmn;im(!d by rfamp-Ukr* pain*. 

^^ta fully C!^.ttih!^h«d| thoy may Ik exces&^ively painEul and 

uikttU ki>d ihr rcmif^ons bct>vccii lEjem but pariial. They 

ita be exdtnd \vy ^uy form of f^liciiiilus, MLch as l!ie %hniiiiUL^ 

rf* door, a draught of coJd air, or tontc voluntary muveTnerit, 

^ ar« alwayr. of a tonic [i.r., continuous) character. '1 h9 

My in cootcirted in various diret:tir>n>. und i»pi[MLun much 

inprJttl \ix tlir ftxAttcTn of ihc thiarax. OcL-aiionnlly the Wly 

f» arched bacicwardM l-y thi? contraction oj tlie ttih^I«'* of thf 

Wk, the recti ibticininii bdtm linn und tanso- *as hittti or 

btfd$' {vputJiot'i'Wil , sometimes il is doubled fgrward*. [mprM- 

ilNiBU), a«<J tfl rare r^Mrs laterally ifJ/vtiiyfhi'U'rm}. Thi^ muuilrs 

Rl»jr CODtnCi «o vi<i]«f)l]y ;is lo Lw mptuted. whilM teeth have 

wa hn>l(cn attiS the tonf^ur almost bitti-n oiT. The iniei 

£ai:iijtje*> usually lauain ilejo. tu the tiUl c-cul. which ia 



I 




114 A MANUAL OF SURGERY 

generally due to exhaustion from a repetition of the convult 
or more rarely to asphyxia induced by a prolonged fixation of 
respiratory muscles. Before death the temperature somj 
runs up to 108% or even, in one case, to ria* F., and it 
continues to rise for a degree or two after death ; such h] 
pyrexia is mainly due to the continuous muscular contrac 
The surface of the body is bathed in sweat, and the urine u^ 
albuminous {from contraction of the renal arteries, according 
Cohnhdm). Death may occur in twenty-four hours from Ail 
onset of the disease^ or not for four or five days. 

Ohronic Tetuuu usually begins later after infection^ is ktf 
severe in its symptoms, and more likely to be recovered frt«t 
The course is usually afebrile, and the spasmodic contracticH 
may be limited to the wounded part of the body whence tbB 
infection has arisen, or may be general. A special varietv of tlui 
is known as cephalo-tetanus,or T . paralyticus (German, ^Tf^-^fdO^, 
It follows injuries within the area of^ distribution of the crorad 
nerves, and especially those about the supra-orbital margin, «id 
is evidenced by the association of trismus with facial piLralysv 
although spasms, both tonic and clonic, occur in other parts d 
the body. Spasm of swallowing and attacks of maniacal frenn 
are sometimes present, and hence the name T,hydrophobkmyi)M 
has been applied to it. The paralysis is supposed to be due to a 
ascending neuritis of the facial nerve, which becomes compressed 
in the aqueductus Fallopii. The condition is uncommon, and in 
the majority of cases fatal. 

The DiagnofliB of tetanus is rarely difTicult, In the early stagn 
it must be distinguished from simple trismus arising from dentil 
irritation, or from inflammatory ankylosis of the temporo-maxillarj 
joint. This may lie readily accomplished by noting that there b 
also present in tetanus incipient rigidity of the neck muscles. In 
the later stages sirychnitu poisoning leads to a very similar groupd 
symptoms, but is recognised from it by the contractions being 
more sudden and violent, the relaxation of the muscles betweeii 
the spasms complete, so that the mouth can readily be openeiti 
whilst the hands are involved in the contractions, a rare si^^ 
tetanus, and the muscles of mastication often escape. 

No difficulty should be experienced in distinguishing tetana 
from hydrophobia, owing to the very different nature of the oa 
vulsions in the latter case — r.f., cionic and not tonic; moreover 
they affect the muscles of respiration and deglutition, whilst lb( 
history of the case, the early hallucinations, and the absence o 
tonic muscular contractions, are also characteristic features. 

The PrognoBla is, as a rule, unfavovirable in any case, but th> 
so-called idiopathic variety is less fatal than the traumatic. Th 
longer the case lasts, and the lower the temperature, the mor 
likely is the patitnt to recover, whilst hyperpyrexia, sleep lessnes 
delirium, and strabismus are l>ad signs. The length of the ii 



SBrSJS At9D WFBCTWS 



"5 



'uUrictt pcnod t^ a]v> a most imporUnt tacir^r, ^nce i[ bas been 
4io«iaibal if it i» tindci ten days, only 4 pexccni- rccavct , wliilsL 
J ii lut£ for t-levcn to (aftet^n diiys, 27 per cent, of cures may b* 
e>pK|t4. aotd if Ihc oull>r«Lk is d^LiyCK] ftir Jiftecn I0 twenty i^Lys 
45 per ccQl. of the pnttcriti may live 

frubpnt. — CjucTuI aiili»(;p»i» applied to vrouiub is the ituretl 
Dttn of fnnmtivg its oc:curr<-nce, and tlw wurw tlie sanilary 
(tMiboiu m wlucb pfili«-nt« ar« iouiicU the stricter sboutd be tbc 
acftuns employed. In orjiiury ciril surjjfcry icianvia ia (exceed- 
ingly ancomnitia. exc«pi nliEti fulluwlu]^ a luolusni. puiiLtuied, 
^liCmMd Vp-Dund wbxh has nni Ivrr ^^rirnrly rlt-ali witb, and 
MSKuIr wbeci mud or dirt hn^ been j^ound irio iE. 

WbcQ it ATiMft from a ^cplic wound which i& acccs^blc* either 
diewouiLd should tw freely rxrised or ihr limh ^nipaiated; bul 
nrath«Q tb^ triAoic conviiUtont may rrm^iin for a llitie, nr ifvfn 
pni* iitJiTt from ibo poii^on ^Ifondy circulnlin^ in the !iy^lem, 
Where fiucl: incii^ure^ are impowiblc. or when the diWASc is well 
aliUUbed, ibr irc:ttmr^T of fhr fiiHur will pTotutbly tie ihe in^ 
ir^mJLMi of a apccihc tctanut antitoxin [sur:h nn that prepnred 
tiy nuKCii from thr Hao(\ »crum of on immunized nnimni). At 
^otm the n^ulu of this treatment are diMinclly disappointing, 
m ihit no case of ;w:iite ittanu* hits tjp*Ti sAvetl by h, ami thr 
d^ evcD in the more chronic caiitfc U net :^t :i1J crrtacn^ Im' 

CD^emcutfk, however, arc Mirc to be made, ^nd then \vc may hope 
:hetler lhin£:<^. 

The evpUn^tion of tbe poor recidtv bitlierto obtained lieii 

f>r*(ahly in the foci thni tbc ^rum irt in renlity an tmmnni/ing 

Uat|(iy.oncuhich prevertts tbe development of the organisms), 

ndt> nm cap^tile of lU^linR with the luxk Lw^lies dTLnbiin^ in 

lit blood-Ktre»m ; sa that if ;» ceit.iin dost? of the t^FJnO'loxin hns 

(Act been abMrbe^d, It will produce iia norniul ctiucta* i*\'vn thouf^h 

tWuidtviin prcvtrniii any turthez deverlopiiiL'm of the oijjani^mN- 

Thf oTittnnry mF^iitT-^ of frralrrK'nt luiisi'*! in kt^^pinu tht patient 

lUofutely quiet, and free from ihe ndvenc of all extrinsic ^itmuli, 

foad should be nutritious 1lu;(l> and iinstinuilutm^ ; it Has been 

Nl[;C9lrd to feed llx; pAlieiit Iwii^c d d^y liy a stouMt^li-puiiip 

nMiir chtorofriTTn^ Wh^n thir iHimtt^ i* vptj mark<*fl^ rhe p.iTiflnt 

My he fod Ihrou^i tbo now- by a l[iit<;!hinton'i^ rLLht>'Tr c-'iEh«l«r 

(uvod into the pharynx, unless there in i\ <^iifhciem ^ap bctu'cen 

tW lOTlh to mIipiI of its cnlrancjr. Opium, t^hloral liydrAie, 

tvcBiide of potash, pby«o!(tigma, ;md curare, hnvr been %'Annte^ 

u hcotlicuU dfU|fx, hut probably cases which have reco\xired after 

Iheii exhibition would have done so without. Chloroform rn^ty 

It v^miniMeieil lo control ibe spa.Mns- 

Hydropbobift. 

HldrnptedJa Is an mtittv cvnrcnil infccijve diw^iw Linfinmilled fcrrii] animal* 
IV Am. m^t in It I Iroft rkbtd *i<rr^ vaKci. nc 1 1 CQntisL» rsHnnally m an 
ifcVtcw oi tb* ccaUftl ncrvOV ay»t«in. v>i\ one of fu nanl anrkal fcol Df«a h 

8—* 



116 ^ MANUAL OF SURGESY 



the long and variable incubation period, II cever origiiutca idkfAthi^ 
flitherin Animals or mui, and although the actual virua has not yet beenixd'a 
there can be no doubt that it is a micro-organiam . The poiaoa has ta< 
shown to exint in the secretion of the salivary glands, in the blood, spituldi 
and brain, tear-pasaages, pancreas and other visceran and, ind««d» appcani 
be widely diffused throughout the system. Infection most uauaJly bUm 
bite : but if the leeth pa^ first through a garment, the virus may be wipcda 
and the individual may escape. It has also been proved that if an infaca 
animal merely licks an abraded surface rhe disease may be transmitted^ ditf 
when the animal has not at the time shown any of the more typical sgnirf 
rabies- 

In the Bog, rabies nianifesta itself three to five weeks after infection, bat thl 
period varies considerably, the original wound usually heals perfectly, ifl 
there may be some inflammatory thickening about l(. Two chief vwtfii 
have been described — the raging or maniacal, and the quiet or dutuh R«ta 
ii'iifi fttnzy commences with a stage of depression, which is manifested by p^ 
snappishness and irritability, eapecidly towards other animals, by a chiiacl# 
istic restlessness, and bv the dog moping in dark comers, with a dejmvd 
appetite, eating anv kind of rubbish or din. and even its own excreta lU 
period lasts for two or three days, and is perhaps the most dangerous. ■■< 
there is nothing very suggestive about the symptoms. It is Stowed b^l 
period of irensry and maniacal fury, and this in turn is succeeded by a sti^iJ 
paralysis, K<}in^ ^'^ to death During the whole attack the mouth is filled wiA 
ropy aaliva, \^-hich the animal vainly trieii to scratch away ; the bark Unci iH 
ring and becomes hoarse, and as the disease progresses paralysis of the lo^ 
jaw becomes evidt^nt : finally, after partial or general convulsions, the aniod 
dies five or si\ days from the onset. In iheiwfiafffAo/jf or dumb form theuuvJ 
dies mure rapidlv. passing through the same stages as the abo^'e, with Ai 
exception of the maniacal period The disease lasts bui |wo or three dajnfc 
this v:\rieT\- 

In Van che incubaiion period of this disease is most variable, lasting InM 
days to mouihs or years, but a-s a rule it does not ejiceed si>h weeks. During lU 
intersal the vMiund heals, although the scar may remain tender and neUTalpt 
The disenisc is ushere<l in by a vague sense of terror, with illusions of ih 
senses and dt^-Uirliancc of the mind, lasting for about twenty-four hoon 
Kestles&ness. slerrple^ne^s. loss of appetite, and a repugnance to fluids fc^krM. 
l*erhaps iherL- ma>' be si-rat fehnle disturbance, but this is not very exccsBifi 
The more cliRracieristic svmpr^jms of the disease are inaugurated 1^ aooovo^ 
sive stiffness of the tongue, neck, and especially of the muscles of deglatiti« 
and respiraliiiii, which Itecome^ more marked if any attempt is made to awallov 
These convulsions are clonic in character, and ihua differ front these d 
tetanus : the\ becomt; more and more generalized, being after a time broifhl 
on by almr>si anv afferent impulse, howe^-er slight -such as a blast of coUair 
a flash of lii^hi. a sudden noist^. especially such as is caused by the movenKoB 
of fluids: whJhi swallowing is quile impracticable The mouth is uauoUj 
filled with rop^ mucus. ^I'hich is very difficult to remove. The reapijatifl" 
become catchv, and a hiccmghin^ noise ma> be produced by the spasm of I^ 
diaphragm, which is sometimes ihou^hl to resemble the barking of a ilo| 
Finally, the convulsions may entirely cease, and the patient dies, reoi* 
ing his consdousntss lo the einl, the fatal issue tieinjj due to the destnfcclrB 
changes taking plju:e in The mmlulla. or to exhaustion , it may. howevei'. oc^ 
earlier, fnrm spasm of the j-loliis The disease lasts about a week, but m| 
be more rapid, killing' even in lw<t davs. 

The ?<iit-niOTt«m Chasftfli :ire inainK' negative Ev'idences of acute ipAiJl 
malion of ihe In^^or p:irl of the mediilla. including the centres for the erf 
loth. and iilh ner\es. are oh^^ned on microscopic examination, the ^-fiisC 
l)emg lhn»ml-ist.\l, and thr cm nee live tissue infillrate<l with leucocj-tes. TV 
ner^f fibres ami j^anjiliiin lelK ma\ als^i be fimnd degenerated The salivu 
glands arr al"av^ soim-iihaf tnlatiied 



wuM lie Adoptifcl ta all cam* of biu* trunv tkus wfaidi 
VI «iM^i|dbU «r BBf naiblr bccom* w>. Tic <ircubikiA in m« Unb 
■hirilt aumul bf 3L<inn^oT butd^. fnt blcpding «Acottrii^i«l. and aomc 
fHstil OWOilc. tf f , pan arbollc nnd, applid A (r»- rvt-inijdi of rlio puTf 
vlU.fcDneiti Ijc pKifmhlff Tbv lmvvrtiLm:ii \tl ^uch immi'iliAt'p irrntrnFui 
btiittike IkI th«i ihc m^ivc nru« ifi ntwirLnd HJth Iht? utinoti rnipidky 
Tkm PMnr in JMicd lomcof tlic h>drciphab4c ptilton tntu iht »r<jrn rabbiL 
M^mmdit/Uky olinvmrdi cui ii on . tnciai. ha^^vcr, dv<rcLuped a^ oioftl- 

VrimA Ite liCt lh*l Ihr itijrriion nf mi Arr>niiaif*i! «-imK m mrn^idnj; flrfviq, 

M<h| ftf — IK imcramtnv >i(vi]|rlh. Mill protHt na animal or indhvlval froni 

AidBMa. Add. mmh^i iMt* ! *\\\ cvra cAich up itic ^isfui AlriAdy Inocu- 

IftAittl d«c the p«ikni frwn [l*«ulncitLwril<fevclopfncat, ii iuo Iim|; k itiLri 

kvM ^tc« fixva Tbe mMhnrl aniployBd it u I6llrmt ; A virun n( cr>iiHUinl 

Mi ttninnm larviWTy \^ ^Prt r»btflinrr1 bv pauin^ ihv pfLtvm fmm n f^r^H 

tavrii a fortaB *rf ranfativ imni ilf <ii'«?-i\r appmr* wUh r^K'jliHiy on ibfi 

*«iiltF. tU nm» of LbcuEi^ tiduK liicn m^u^llv virukm ,T]ap m^ucriaJ 

-^ Etml b otfUlnctl \rf muhioif up ■ piuim »1 Etut npiiljtl cml ur tiioJuIIa 

■ Ik difeNMd do^ tP McritiaaEl bn>rb, ami injncmiR it wiih a bTp.>*lnTmic 

fitapi hrttAtb tlw lrac>inmi4 ifur trpphining All (hnl ■■ riri«v Tf^mlvii u fO 

k4»tiBif«Df ihriup imiEmt rnnit, an^ (tr>' rhpm by hai^^irif m a jcl.-i« Ivll'j v 

■<*»oe cauuic poiuh ki thi? tiotiom (nr varlitik ptrirfbt of turner, the virus 

tifaf Ibn waikeved jh ii-* iuLrrniu, uritil hi x\\c unt uf lEiuirti:]L iIh^m it i» 

coafJttaly doMrovvI loduicliuU nrc m«ulATaI ^hh fKjnJnm ol luch cDrrU, 

PMM w in 0*rilTa«d br^ih, Iw^nnine wiih Thq wMbxi, nnd grnHiuilly 

MMiif Thr vtmfftlii^f the (njvction imiil a pr^pamlicn ofa^onl uhich ha^ 

nnff tnn( one Axy w nv<f ThK mnhrxt of tn^tmcni ^vAt intirKlui^nl in 

1%, Md ine it!:ciilc9i lUibcirn obuiitrt] \iA\c \vxn iiutli h^ In i^xUcair thai t^ 

b^bn* a laiffi p^nci pnimiLvc uuni lUAimi li;iJivpVi<.ibiA, I'f? w ihc«iiiJ 

*fllu* 14.4^ pariemt* bw bees in^Ecil &i ihi: I'uirur luaiituLF m pAri^.kod, 

■ "iv f A.« »K^rc tJw p*ti»ni dinl tluriag 01 immod^atsl; altpcr ibc iroai 

LKcitrra), j^tv-jri*; a mortflicy cf o 50 p*r cml- toHtoivl o' 

tjpf ' ' 'I '« tbr Limiij clnirh-r^t^ fnirnuintE K'T''^ fntm rabirl iifTfiTUlh 

b.A>^ Id ^1 firntiAbiliiy, bowfrvpr, the pT>H^uiiciii>i inkra in 

ICC niu^hu: v{ lIl^s whrii dJ^i 'jutbirAli lA ihla iliv:4x occurs 

' pTotmiins vi k^»J rebuilt th^n iout-ulniion Ittfurc or after the 

vi'^atl haafevm brUu VHuin lb* dwau* hi4 alEiifku^J lui imlividmtl, uiiJv 

IIIiiiHb mUAmt oin b* actopi*d All vmrrv* of irriTution ami c^KitubAncn 

«■< bt rmDOved. init ibr p.iiitii( Vfpl ib^olijlflly {|nlFl With n v-ipw to 

■^niibh Uw tfaMU*. E^lpr^l nmy ^ic idniiinlficrcd liticnulEy. 01 chloToforin 

Uilsd, «r inriitni k^aioI i.)ii lEic fnniea. All the nocirUhniciU IhrU the 

pMtcaapeaiMr in^ ibcjuH l» admjmitl*nd, with tha iHldiiLon of Htimu 

■>H Cv'U* f) III ^if'^i'^t'^^ry tbinj hour, nnii mtrriiry pii^bt^l i<i >(ihvi.- 

iKt . k«*v ahn Itfvn rvrooimpivtMl 




AStbTUC 

TMbdbeMc txcnrt te nun w h imuh iJ irtfRiEMQ wUh lhciiiiirf/M> hirifArorfA, 
■fbeb pfoducca U vtrub, &ip<cU]Iv in hhccp EinJ ci\1lb, ibc w uJIcd 
fibnte tffw- ' II iiif micK^bf ■» jin^ut.-viort [brough xhn Hkin, U pT«duceii n 
HW4)J ^^huvlo htiOi^n »k 1 ' mali^R.inl [iil«|liI#,' or charUm, allbnugb of 1:2- 
iBdlf a cmlrTkcci knn-in w ■ maJV^flm ~ or ' BniTirah cnlrntn ariHrM fmin 
i^IdcbI InkclM, v%IIU if El Ih iilmorlinl by Ihe Ikjii^i ui iJHc^iinJi] ciknd. it 
i«(aicr«) bil1jinicaAioi> divjniFr. ih'j^n ju ' wuoLtorlcn' dl«iK/ or 



Tltt jUnfiWitfi'iAbii iFiR 1;} i«oneaftbolArffnl nf iba paEhu^«nicofffUifiniii. 
— niWtfliM J to w>^ in lt«4rth. and 1 ta rjo^i Tn tuy^HiH ir ih found In the 
Unod of ofcMMd mImAlt in ihf» frirni of tiv\% nr ihrra^lii. compowd o( a \^iMl>U.- 
tamta nliadivkSua] vlomcuii f fruin iw lu (fjiJ. Ii aiv:m1ji<.,irQmcbikHKrn»-7i 
ttH M Abovl Uood-bCftt, And Ui^uvfis fcUlin?. WEU-mnrkcd :i^jr« nrir 



^ «/^.VC'jfL OF SURGSUy 



i 



} 




osvKon ' bul rtxww ferm*tion hu noi bom fphiufvwl in i\w livins Ltsun Ton 
tMcilll *w war^tly killftl Itv UHMna tor n few twands. whibl liie tioco<np««io» 
tif thft ctircuc in vnhkh Lhry arc t«»*"l i^usca ihek dealb in *boi*C « "■«■ 
Tlw •»«T», liu»c*ei, ate vtn iwstut . lor whll« fc i ptr <«m toltttifio of 
CATboliciLcii] Will* the UcJlU in t«o mifii"** tb* «pem nntaTn nliv# ^fli^A 
wf«Vfl imm-rtion Murcovvr. alcohol aflH cvm x j prrt-c*ni ifllmJoii «( cir- 
bh^icbcid, ttox-ff on wifcet no th#m i!» monw u inrenUCfJ, *M.ftt the ro«fl* 

Ibt lAl] Willi n Tivnllc cb? |>ohil «f 
whicb hu fc«n dippvd ia th» 
h\'X*\ «J an ifilmal »hich di*d of 
tplpriic (ft^r, Ir \ii«uiTth« in 1a» 

«.rr found Hi rHMfl> nretf ^KAH 9a i 

Some luiipijiharc imman« jvuitfl 
the aitac^h of itnihnjL. ctpffvMfr 
thetlnxamtoi. ;tAi! rnw; ivf Pai«nJr ■ 
rrva-i awful dlwjtTiTtiet 
ATiiAdftlly j*TJviidiiu imaBQH 
»(llv And thwp Djr ioM 
thvta with u oiiBnuAiQil tirw. 
obuiinod bv vtr«intf i nltinba 
for ftoiTie lime lo a tilfb l«in|«n- 
rur* 

ajmpUia> - DIkuc* dv* to A* 

occur airirtusiE Kiaoin wbo UM 

ditji.1 with rhEurcue- LtlsabnnM 
witli hmiiriir^' tofjrker* id bkls «i 

wujI 

ftQ afijiiy tv3 pimple IT ih« M* 0I 
inrcuUtian which ripMlv vpaisdL 
wiih miirb mfiUrtiiidii <ti the hav. 
whilst The umiiT Uxmwft cot^nd 
«nih vBJdei. tba vonin witlw 
4liich cuBUklriB the t^pioftl badHl 






Ah II rule thcr Are unitoil inb^ ruEhcr 
Innupr fViAimt thm &r« hnra rvpn««*n]*d 




Th«v ic no pain iMiociat#d with thii iitA^,but ui]lyj;TV4l UehiDK ahiI Ir^niUo* 
An 1I viipnrit rhr rrriTml pnir limiinn Rtav aii'1 IiiimTIv blAfk, L^tAhibnikaif M 
ncbar. wTilKr nronml it upum qn itrea of dfvp ^viwny cfincntinn hihI imlviu 
b a DAmiw ri»ir uf toicln Tlic pioccw xndiuUy becomn niuiv *iid raon 
iBAfkcd lucdh- %vlilliT Ehc lympUAiIi; itlivid* ium4 veuchjvc aIm cBlADi^aftd 
lawlvail Ltt llw iiKBUHr c;i:nvmlly, Iherv t* n ccrtvn ainauiU al ftfvc* ittd 
tfrhii^li i!iif-» nc'l li«'i"mi« |m.irniiinr»d imlti :i>aiui lh» <r»ullb d*y Tie 
iMlpniUFF thriT n-irtTn ti?2'iir toy V . ihepnlv brcompi rapid wi Irr^guUr, 
Ihe RBplmLLons ihnlEo^t ind morr uid mnrfl cnitamBOl, whllu tisiW of xim«« 
tonitlcubuTuI nilKfaicf. iucUJiiu; ilclii Kiiu nrid tiFtriH iiufiilol 1beaD*^^«tts fl 
ai> troblnienr 11 adopted, or II il be undertAlitn iao Ute, the unbHiuiufit 
iDdKidiui npull^ luccuDiba in « ctAbe of ciim.i, and (^otnlly in U^ tbA9k « 
wwnb fnvD ilw onwfn hut vnrWimp* in ihirfy tf lorty h*>(Jr% ( irruiomJIf 1 
I--UH niri%» iiHiiv Eavi.iurabl« ooafw, IiitiItItii- 'itwlf 10 iVliv^l nijnlAni»bv*h 
Mhid) vradu^lr ckot up, ibencbAJ te|>jirMLntf «ni1 ibc cnlcmA dtuppewtaj 
When u oulbrtftL ul iht disuK bw (xxtir«*l, a ifercUlcd .inMrdf 



iBAy de««Eop, ntoninu on rapidly 10 a Intil ivmt It h utunlly ^aca at>oDt tbc 
fAfa Uid ■yt'Iiilt, Ihi' xltLn IwL-Emimf} fr<d Add brawny, lu in ^nwiprliu, Anrl iflff 
A dfiiff I'jjinrrrl wiih vt^irlr^ whil« htrnUv a»njr''T^'*"' p«tcb« Jirf*"^ ''*' 
tynif^aiic iiunliv ind cluid* are a\ut Snvulvo], 



SBfSJS AND INFECnW 



U9 



) 



VMinflnL -^rb vfirM a4ii» acL<^^ iu eW »itcm chlivi ljy [he tlriad iponi 
Uarilibkled,«r thfuuxit (he inloiiiijil nmcoun tiii:m1»r,iJiF [f ^]«y enlivr Uie 
WMBary tad. Itw ivtwni c>ciin|)Iam-^ rtf fuL-nr A.nd malaiqi> fort fvw jftvv^ 
■iJltai Hro^N-itioci pnpLimonia t< vi up. m the vT^udabnii of which iW 
IjKflldtotvlop Khuinrliml). aTid vnifi ii a vroat pleurisy Thin mnt a rnpid 
COM vllb nljcb t^cf. ^nal dytiwird. tmpjdT iriflTl i^f tlio cirvalitlioa. And 
WIrcoMipK If Ibc Ijttcilli onMr thv ««gj:n«i(h. (h«y w usiullr dntn^vJ 
b) iteKid chyoie : buc thouUi «nir«f iKrm ot their vporv* nuch the uii«BnQ«, 
AiilhliDt coiiMfitv fbrvn AcuiUblc broodkic ^r™!!^- *^^^ ^ho trdls otiho tsut 
vtvoiKUidwl a.ml ihecontiuutior Af.'jicEtid. CoJiCh ^nmpti. vomtUngH Bind 

TVftninaai niini l>c iKii^ And imrtviJUt: »'brti.^ |xjb?ible tti (h« IocaI 
ilkaM. fiw cMiwon «f rhc n«r\>iic p&L(h, anJ of At! the iofiloaltd Uaouc 
vonliiri tiM ^ipliukiJon of cither the uiual cAatery ar of pim CATImUc 
rtLudaonly ho» !-'■:« ihc ijcnctftl di«cAiL«, iikDralyhyniplomAtictrMiaimi 
tu b aliwiwrl KaOtnlly, (MffiAtitorl i]wv!UJinha hu hHUi much ncom- 
>vW, tioLti MA A loot Jf^illcaikHi aiti^rrHci^r^ri. afkI ^vo JntemalLy In urcioT- 

W't Dcm' romr to ;i group «f rtispft*ipJi wliji'h havn Iwen r las»*ififffl 
In Vircbow under thn t«rm iDActlva OrftQUlomAbt^ The/ ^Tt 
m doncicrizcd by ihc formntion of <rr>wths rcstiiiUlifig grjinulA- 
■Mlisvuc. whkh dthcr pcrNSL or Liitdcigo vaiioiis Jtrj^c-ncrattve 
cbucn. Tliey ats all infrrtivr in naliiro, nml mntx of ihem 
ttawc in ihcir prof^rcn;. ^llhoiija^h nctilc innnif<^tAtionR urc occa- 

tvmllv rod with. Five cof>dilJQna Arc included under this hc&dinc, 
lit; Syphilid. Tulwrrulo^iis, rilanders, Ltprnsy, nnt\ Acilno- 
nivccsift. Sy|>hi)i« i* dealt Willi elsewhere (Chapicr XXXVIII. ). 
Ta« rcnuifiiti}; foot must he described bcre. 

H TubercuIaalE- 

H BytdberculEHiK i\ Ttir^ni ;& t-j}T]i]itiim rrsulUii^ Troiti llie UtVElup- 
^pnat wflhin the livmcK uf the body of ccrt.iin dtifinite auiitomicai 

■ ^tfyciujD. tcncwti as tubcrclcsH tind caused by ihc gTowlh and 

■ *."ti^Ky uf the lijiiiiui tuUrtahii^. U<;furc tb(? fatl wa> eaUblUhtd 
tftj* Mich Wkmi wtfie the rc.iull «f the development of a micro- 
'(pmm, th«y i\«t« usually termt^d strumous or acrofuloui, and 

^cnittbc prdMTnt dAylhe^c tvio haui^s arcoGCit«iounlly employed 
Er that cuudttLuii of uJiistUutlonal ^CtikncSTt which pre- 
to tlip appearanre of luherrubr manifrvtiilinns. It iii 
r, howflvvr, TO avoid Ihe us« of such a mislitfttlinp Icmiinology. 
Tfctt JBllolOcy of lubcrdc may be considered under Ihc same 
g^fTifTJiX br^din^ which vn* hive employed el&cwhctc m 
:rihiftK fbu c.iutition of v-anoui infr^ciivp di^jcase^. 
, Tbc mdivUttal m often pr«diipOficd to Ihe drxeloprnt-n t of 
clisc4»c by *omc inherited wcnJ(neits or * >-uinenibi]ily/ .1* 
crd by ihr fnci ih^t piiirnu, tP-hition^ or JLnL:estoifi hrtvr 
from tome simiUr iffectian, or lh:4l it lias nrcurrcd in 
mto- bnuKhc« ot Ihc some Umdy. Connidernble ingenuity ha* 
in dcsciibiug various fonns of pliyslo^iiomy ^appotwd 






tn 



A MANUAL OF SURGBRT 



to be characteriMic of a tut>crculn.T inheritance, aotl althc^ugh not 

I'wo cbief varieties .'kre d^ricriticd* viz., lh« ttm^ai aiuI tb«» 
pfUti^matu . In iho former, tlit^ individual t^ ^tfE^t iin^j wtLl 
propoilioncd. pusar?i:^i»i^' a iIiicl Jdicjlc fJ<in, oflcn fre<cklc>di *dJ 
40 ir;iiiHjKi]t:'Til Eli;it tlii^ Hul>LiildMeous vifjiiy ;iEir renililv writ. Thr 
hair i« line :uid >-(iiburn-c(ilo4ir«[]. nr ^ven roddi«lv Th^ c^njiindivv 
thin and pearly, ihc; cvcta»hc3 veil developed, and tlio ftn^cm 
lotJ^ and Upciin^. ^ixVi diildreJi aie iii^iialJy excrtAble aod 
pT*rr»rinns in Iheir haliitt. and poMptit i^ldn^ mannpm. Tht 
phJ«|;nialic typo is chaTactcrixnd hy a ^oft, sluntcd (iitiirOi wrilli 
somcwhal course fcatutcs, ftnd suong thnn^li -^◦nicwlMl iboti 
limhs- Tin- skin in cijat>c aud iTiuddv'Ioi^king, [lie lips (hJclk, 
th* hftif rough am! lirou-n, Oi^cadonally the«.' iwo typrt are 
conjoined, conRtitutinf^ what is known as 'pretty «lninu.' to 
Mich children of cither l>-pe there ip a considerable tendeweyto 
the devrl[i|)mprl nf et/pma of tlie ^kir, mflamm-ititrti (if H* 
mucout mcmbrAnes, and a siitucutc tnlarRtmcnt of the lymphatic 
jiiondt. al] of ^^-f]Jch arc simple in tialuic:. bui rn.iy coiuitilutc i 
suitable nidus for the development of lultercU, especially if tht 
child is itiri dijwn by ^tHue picLediiij^ ilhie>'fc, ^utli ,is iTira<ilr(«l 
iKnrlel fcfvcr. The^' al»o siifTer fr^j;[iiently frum cractced hps. and 
OS a rcsull of the imtation c;iiised theiAiy con*iidorablc inliJtra- 
tion ami ihkkei]in(( riiay fullow. Allhoii^h luUriculat diieue ift 
inoHt frer^iienriy w?**!^ m ycjunj^ |>r<4i]e ui chddn-n. no H^ ^ 
exempt from iti attacks, wen elderly pcr^onft being affected by 
what in known aa senile lubercvdofeis. These senile nuLiiifesO- 
lion» dilTt^i in no way from iIiom: [iieL vhilh in the yuun^. 

5, VnhtUtk)' wmtundiap anA Itid hygi/M reruinly nr«dispM 10 
iEs developm^l ; h<<ncff it i^^ pi^rhapi^ more commonfy sMn in lb« 
poor ihAn in the neh, alchoLiffh it i* not rare unkon^t the \tlta, 
nripiin^ usLtally as a lesiull of improper f^edinic ami iva;it of fra$h 
air in the eaw of children, and not unfrr*]n*"mly from buhy 
hyj^onc or carelcssnef^T espedoJly as to judiciouR clothing, itt 

ildult]^ 

3- A kKat sidus *iuitu1>le fot thf^ developmi^nl «>( the^ iricn> 
OTR^mitm most, Jis a(jener;il ride. Ive provided, ^lUhou^h tuherculai 
infcc^tion occasionally fol]o^tE wounds and punctures in prcvioudy 
healthy parts- Thus, as already muntioned, lympHjui^: slonds in 
i'L cundilion of chronic hypc^Td -min and eidar^jement form n sbtiitaTiIie 
l>reeding' ground for the bAci|lu&, as also bcmtti and joints wbfcb 
are in «l state of congestion a^ a result of filighl and often o^'Cf- 
looked injuries- 

4, The \illim^te eAcitin^ caust: of lulieriziiTosU \s ihe devdop- 
iDtnt withm the ti^sue^ of the Itaiitlm fnhcnvioitt. T bit ofK^ninnt 
which wa.1 originally i5obi<?d by Koch, is Ai^\-ays prcseot, though 
not always lecofm^uiblc, in the products of the di>wa3e- It 
txj«t!^ in ihE form of tine !ktrui^hl rotb^ whirh st» only cuttiv^ted 




SBP9SS AHD tSFSCTiOy 



Ml 



tf^ftlly with dxffictilty, gro'^inir l>c-st on coagulated blood 
wrum 11 ihe tCffipcNiturc cif ilic Imily, and even iWii bill 
Jwrlj-. The Offfini*!-! ffiins adrniwion to ihesjsiern in a variety 
il V4VS cither through ^Lnni- abraAiuii t»f tliu skin, ^v hy the 
tiSCtWD tract with 5umc iiiliclc wf fe>oJ. cNpctially milk, or by 
Bublion. Tlie L^ijnt^i-ioiis ii;ttitre i.>f \}\v i\\s^a\i- hjs been 
ihndlAlly demorffnaied by clitiical arnl L^xperimeninl wcirk 
duraf Ibc Usl few year*, lliu*. it cun be rt^idily Ui^nsniittsd \yy 
isxdilioo lo AiilniaJs t:spt-Liall> to zAbbils <Liid g\iineA-pig^, the 
lUcnnr chamhrr nf thi* cyr of ih^ rabbit lieing a very t*vouriie 
I 1^ owing to iho (acI th,il ih«i groivth of the dur^ictetiittlc 
Mcpdum Clin 1>« rr-iidily watfhcd. nnd tliai sponl^incoLu; lubcrcti 
Im pew ocxTiirs in lhi« i<t|;ion. Tiiin^misMon iff the dl^icuat 
lofchcman subject has fr«iurntiy ocrurml frotn difi*i:t inm^uh- 
iMA tbroufsh n puncture? or AhmKion of Ihi; kIcih, aa in thv c^fte of 
wrgKoawhoKc finiccf* ha^-c been wounded whil.*t i^peratin^ on 
Itteoohi tiisti. Anollirt wpll-knovin e\^iii|ik i.-. tbiU in wLicli 
i ranbtf of Jewish cbUf^re^n nf tc infected wiih lubemiliir ilise;i*ic 
W Ihe Kabfn who pciformed the ntc of circunicisicii. Th* 
Ax&i^ in tills ccrrmotiy Is jirrcMcd by suction, and in this case 
IbeRAUn !*'»'» in tin; Uil st-i^t^ iiJ LonsuinjHiou. ^tvcial of tLc 
hkatt dM from acute luberculcxii. whil-^i othvrs cJevi?lopf>d 
titoctibkT ulccTAlion of the pvnis or tuWiculiii en lur foment ot 

?Mltt1atfMl Amrtomy,— Thft tulvicular prfic.-e«e^ consists m the 
■inclcfnent of the socolkU Rray ct miliary tuliprdf-s, which 
tod iQ run tot^ber, and produce Ur^'cr maMca, whith m Uicir 
tunndervo !t«(.o]uhiry cli;in^c^. ivtiilH ibe ttSMU's Lliu^ invaded 
bccnn«lD&lt)«d and grj,dtjaUy disappear, Iving repl^rerl by P"1py 
pmohtiott tb^e. in the niidiat cf which tbe tub«Tcidnr foci can 

Uinry luberctescan lie rec^j^TuHw! liy tbt- naked eye fts K^ayisb, 
vtiU'tnttclucenE tiodtiles, «Lr*ly e:iceedini^ n millei-sced in si^e. 
^procttis which k^ds to their formalion alnioht alv-ays com^ 

»>Bttoe« io or Around the sinill vch«icU. jtnd CAn perhaps lie best 
^ulird in th#" pia matrr, Thr baolli are prcsUTTiably bmu|^ht to 
ym» arci of lowered vilaliiy. M'ltlin^ i-iiheT in the tunica intinia 
f in th<! pcnvascuLkr lynipriaiic ?)pftces. This Iciid^ Co a.ti over- 
Jptmih cf the cndolheliid cleiTicnts—j'j., to an cndarlcTitis, which 
n» spnwd itA (some distance----ind thit in turn 't% hillovLeil l»y a 
pswnklion and inlUlration of the surrounding connts.-ttvy tis&iies, 
^•Oltioc in the obliteration of the .iffcctcd r*^%5cl, and the fonna 
to of t!»e cbatactcrl^tic tubeinibr nodule. The slruiturf of a 
CtBy'de\-r-Joped tuberclr (Fi«. I*) i* a* follows ■ h^ ihc oentre lies 
* giant ceU, containini; a larfie numt>er of nuclei, which ;irt often 
ftftaji|;cc| arotind its periphery, or uronpcd Vj^lbcc At onn or other 
polr. Dvlicate prtMraa^H extend bom tlic t^wot *-cll, and form a 
Jbe aefvforlc, in the m^^^n of which are siiuatrd the octUa uf the 



121 



A MANUAL OF SURGERY 



surrounding zone- These arc rather larger than 
leucocytes, with a granular protoplasm and a clearly -defined 
nucleus. They are known as epithelioid cells, although they 
derived from the neighbouring connective tissues, and are, in 
identical with fibroblasts. Around them are collected a 
number of smaller cells, probably leucocytes, and these 
into the surrounding slnictures, which are gradually changed 
granulation or Rbro- cicatricial tissue. In many cases the giaM 
cell is absent, and, indeed, it must m no way be looked upon m' 
characteristic feature of tubercle, since such cells are often OMt 
with in syphilis and other conditions where active tissue chaagoi 
are taking place. Its origin is a little doubtful, but it is prob- 
ably derived from an enlargement of one connect ii'e-tissai 




Fig, iH - Tt-HERCULAP Ciast Cell containing Nuubrods Bacilu. 1!» 

WITH THt: NUCLEI AKRANGED AROUND TUB PERLfMERY. {FitOK GuKX'l 
' pATHOLOCiV ■) 

The branching pivjcessK'^ are not well ssen in ihis preparation. Around d» 
gianl cell i^ a layer of epithelioid cells con&titutinj^ a nbru-ccUulaT capmilr- 

corpuscle, or by the union of several such cells. No vessels are 
present in the tubercular neoplasm, and as a result degenerative 
changes are certain to follow. Not unfrequendy a number of 
these tubercles de\elop close together, and under these circuK' 
stances the interveniuR structures disappear, being replaced by 
granulation tissue, which may in part become further transfomttd 
mto cicatricial tissue. By the use of appropriate staining reagents 
it can be demonstrated that bacilli are present in the giant ceUi 
and sometimes in the zone of epithelioid cells surrounding it, bill 
as soon as degenerati\'e changes commence^ the organisms can nO 
longer be recognised. 

It the disease progresses, cueation always ensues, owing maiiilj 
to the defective nutrition of the part, but also pos^bly ariang 
from the specific action of the bacillus or its products. Not only 



SXPStS 4HD SKFECT«}K 



«^ 



itnr of thp miliary 1tih(^Tr-]fr tindi^tfro tIitc: rhATigfr^ tiut 
lUlion It^ue jiroLird or b«twcrn ih« wpfltA[<» noduUfi. 
focus of yellow or cn.idc luhci'ck, a« tt usc4 to be 
Bimli cnisistKof 4 ilcrkjcnciiilini^ cr-rin- sLtrroiindril by i< zone of 
piDfditian or fihro-ric:4inrLa] ttmic, m which are ^ait^red 
■iorf hibonicR, ^nd nhLCh in turn Rtodu^lly runi* into normal 



The oIlitnAlc rpKult of ihU (itocrM ilqie-ntU tn^ Urge eKTciit un 
ibepiwfal health of the mdividu;il ;ind th« treatment which is 

t If ihe pirt? arc kept Ai fcnl, ami fret from c-\l<^rnal irrlution. 
mA d Ihc cuD>titut)cj[Ml nr^lkoe^^ U rJiminiited Uy ^uit-iMc 
fWv&m, lh« il(!<irQCti\-« pfocevv itmy coni^? to aii c<tid. In »iich 
1 cu« the peripheral layvr of i^ranulationn b convx^rtM into » 
ioMt Slxo'Ciciitricial titoue. vrUicli forms a wnl of CApWc, and 
(hcdi lh« acIvaEiceofllit distfaKe. Thei:as«ou>> iiuK^riMl f^etlhci 
N«ov«d hv an iBvi^on of kucocvies, or becomes c;tlcifi4»d, iigiiAlly 
invvkfA hrf%\ 6brDUd nodule, perhaps mtcTspcr$<-(i uilh cnlcarcoue 
pankle^ r<A»iMf ^unie \A tlie tubeii-uiar iM:itciial pers)»^t» in » 
bivni KlJir in ihi*> ma*iR, jiltr* »n 'pviinrr volr^nn,' irndy tn 1)r 
Uitd up into aciiviiy if ih<» opporiunity is giv<Tn, In les* 
wuccd oues the di«eaKd tiuitc m^y be »o completely removed 
ttbtdTc scarcely axiy trvtcc of it^exi«t«:iicc behind. 

J^ tfort commonly ihe caseon^; malpria] k tranvfomed inir? 
pti by a proe«!-« of <TiuUi<ic;4lion, resviliinc cilher from the 
irtftTly of ihc tntxTCidar or^diiisni^p or possibly from infection 
«ih ordiTury pynRenir nr M'piir h^irieria. In such rjjsps a 
fiswic or subacute tubcrcnlaf abscess resdls, Ihp smicture 
uddBmciers of which have Ix^n alrc-idy dcscriberl (p. 4)|, 

One ctf the dnef fc<Murc& ijf tubcnulfir disease ia itti K^eal 
InOnary to dinulofi. This may occur mj hcaUy. a-i j tMsiiU of 
ted contiDurty of tiuuc, nr pauibfy by its extensitm alon^* nci^h 
bom^ }ynf)hAiic?i or hlo<^d v c^»d5 ; iir (^) dutUNt viscera ot organs 
°VT become infected. pmUibly ;l« a re^uh cif dissemination by 
IW Hontv^Utflt. Thnt tutH?rctilar phthisis \s .1 nol un(.'iT[timr>n 
ifquracuof aumdar ^iHcctionofbonet. joints, 01 lymphatic gbnds. 
;^l MofcoTer, any tubeccnUr leaion may lead to the occurrtncc of 
a* ffnttrd tmUfcnltfiit. In wblch tlie diseast is scatlered widely 
[^mj^houi the body, fJfivin^ rise to rapid emaciiitfon. high ffver 
^ an inlcnnitienl type, and usually sevvic diurrliit?^, dytipnrra, 
ud delirium or com^. A fnt^l iuiue foUo^^s in tlie ccursc of a 

TIm fn«oifiMcatioi» of lul>ercl^ a^ ii atT^i« apeclal tagant ntc 
fMll nth elCttWhere under Ibe appropriate hcadin^;^ (sec di&eaict 
4 hjoet, joints, lymphitt'ii: ^laiidb, Kidiii^y, testis, etc.). In lhi> 
pbce it n only nrrp*i5ary to df-il «.-iih tidwrciilar aff^ctionii at iljc 
*Jt':i rind muroHt men--br:»ne!i. 

TtLbanolu A<«cUooa of the Skia—Lapua.— Although the term 




134 A MANUAL OF SURGERY 

■lupus' is usually and correctly applied to a tubercular aflec*^*'^ 

the skin, yet it is also sometimes employed to indicate anycE^ 
inflammation of the skin which has a tendency to spreac^i 
results in replacement of the cutaneous structures by ol 
cicatricial tissue with or without ulceration. In this plac^ __^ 
shall deal mainly ^vith theordinaryLupuaVulffula, which isa/iii^; 
universally acknowledged at the present day to be of tuberca'*' 
origin. 

It is met with in children and young adults, rarely comnwnofll 
after the age of thirty. Its most common situation is tf'* 
face, usually starting at some place where the skin and mucvlf 
membrane are continuous — £.g., the al^ of the nose or theinae^ 
canthus. It is rare on the scalp, but fairly frequent on the tnuk 
and extremities. The mucous membrane of the nose and mcntk 
is also liable to be attacked, but in such cases the disease usuaDj 
spreads to it froiii the skin, 

OlinlcAl Feftturaa, — The earliest manifestation of lupus conssb 
in the formation of one or more shot-like nodules in the deepa 
layers of the skin^ which are surrounded by a zone of hyperzoni 
and infiltration. These nodules are not particularly hard to tlie 
touch, but when of any size can be demonstrated to be of i 
brownish -yellow tint, especially if they are compressed by a 
glass siiile, appearing then somewhat of the colour of apple jclly< 
Gradually the process extends, and usually more rapidly in oot 
.special direction, following the course of the vessels. At tbs 
same time the integument is gradually infiltrated and transformed 
into gnmulatiou or fibrous tissue, covered by a layer or twooi 
epithelium, and owing either to defeneration of the tubercular 
nodules, or to a lack of vitahty, arismg from the compression of 
the vessels by the contraction of this new formation, ulceratioois 
very liable to follow. In the extremities the lupoid growth do! 
unfrequently takes nn a warty aspect, somewhat similar to lb* 
'anatomical wart' occasionally seen on the knuckles of post- 
mortem porters. 

A Lupoid Ulcer tends to spread at one margin as it heals at the 
other, and hence under typical circumstances may be found to be 
of a crescentic shape, although this is frequentlj' interfered wili 
by various causes. The surface is covered with granulations, 
often of a protuberant n.iture. The edges are raised and infil' 
trated^ and scattered lupoid tubercles are readily distinguishabki 
extending into the healthy tissues, which are usually red and coo- 
gested. A considerable amount of sero-pus is often secreted, wrf 
this by drying forms thick scabs. Any cicatrix which resultt 
from natural processes of cure is always thin and very vascular, 
easily breaking down from any slight irritation. The process 
extends gradually, and usually slowly, from the seat of its fiRl 
appearance, being, as a rule, distinctly limited to the cutaneous 
tissues; but when it attacks the nose, the cartilages are oftefl 



S£PSiS ASD S^FEGTiOS 



*»5 



BtvK-«d ukd d«scr<>y«d, wbiUt if it «KteD:l£ to th« palate or 
sipnun usi, pcrlcraUon i» \^t>' likely to ensue. The di:scA:« ift 
pOKtta]]} pamltrss, Aiml Iv^ads. n^ a iu]«', Io nu ilrLrrbrAtbn of the 
lEBtfal hcalih- Netgliliouriiig lympli^tlto t^iTiTitU m;iy l«coni« 
vnUfKed aitb n lub^rculnr dL^pdsit, bin this is not a coinmati 
«cmtca«- Left to itself, ii iciid* ^uuncr or lutcr tc> come to 
UtfiLtheukcraled pans ctcfltn/in^, hul Ir^viiij; indelible trace* 
»i ^li nvigcK in lh« shape of ob^ioui^ i^cari., with often eon-^lclf t- 
ttiAitnea of nabstAnce^ OccA^ionritly it may pcriu^.t. tn ^pite of 
tmUcnt. Dud ibcn aa cpithcliomfi in^y in time develop on tbc 
Blcof tlfe cM misrhirf. 
lUUocr. — CoQtsderabJa doubt hskA l»Mc exprei«ed aft tclbi? 




'■-■■■,;<.- 



Fib ta— -SmvAPiaiG MAH<it)i or a IUtch or Ltri-vs^ (ZtKHtMA.) 

', V^^ul vpidanni*; 6. nonrul cnniiin u-tlh tA«aii gUnd (i) : e, locui ni 
h^Bld 1MB«: <t ^-as'iilAf nnlulv tutrni^njIrH) hy <]ffl[ti« c^^llulir tnAltnb- 
MO. f aan-^aKLilaf oodule . /. Khius oi cdU In coarse of ly-mphMlcs . 



fthrcolaf nature of the diM^Aftv. owioj^ Co the fjLcl thul it m l>ul 
'ijdy u?4x.uilnl Witt] tulHricului .ifTc^etiuij^ ^WiAlieie. All pulliu^ 
iwuifi auXmti (hat it i^ due in a flpi^ciftc bsiciHi^is, Mtnch Is prncti- 
cm i»t|bt«i|fu»shabb from Ibc H^ciiivi tniMf€hhHS ; ihc only 
Mkuhy lie* m the somewhat distinct clinic.il hiMor> of kipu», 
Ob IW whule, (^lihtiii^h chc^ iilrnlily nf ihr Iwn iliscT^isf^ c-tmicH 
tr oolMideriTrl lo l»r ;iitwihufly c^tflbli*ibed, for praeikAl pur- 
yitut Jtipti«< may Iw Imked on an of n 1ut>?miUr nature cf a 
KQevlijtt DkiM l>]>c- The charikctrristic microscopical feaUifc^ 
(f lupirb lir m ihc imnulinn of m>rliilfv .^luiiml the tnullet vhssri* 
■I Im *Jrin. connslinff chiefly tit a \nx\s.s vA rotintl cells, wilhiti 
■fcilfc oiay pcrhup^ be obscnx^d i\ ^\ax\l celi and epithehoid ccll:^. 




ta 



A MASUAL OF SUXGSBY 



aiTftDg^d in tW i&inc way m In tubercle. Th? «trurture& around 
are InliUiAlctl Ami hypcJ^'tiiK, ^id im Lbt; (]tM.'d.^e pLu^i^i^cK tbt 
firiginAl tiAcuo of the pan di^Jippear^, and U TepUc«d by grRnuh' 
lion tissuB. The baciUi »re b^ no moans reaaiJy foundt ttt6 «n 
Always very few In nv^mbcr iF^^. 19), 

T)lc Dl&cuoais i*f Itipiis from syphilitic an4 olher desifucim 
^ffretiorjft of the skin turns on the presence of oiillyin^ nodulri 
beyond {he i^preniiing edge of the lesion, lo^ethcr with uic appfc 
jolIy-Uke j^rAnu Lit ions, .\m\ the thini ccngcstcd cbAr.icfcr ci anj 
cirjirricial Iiksuc present, whilst the slow though c^anciniinui^pn^ 
gTCiuj, nnd the tendency Ko heal a1 one part a^ ft kpreadn at another, 
are al&o suRgesiivc of its prcayncc. The age ord tharACtcr of tl*c 
individii^ilH and the pci>i&lcn(;c in many casc^ of the dixaiw ia 
i^le of Err-itrnienT, inu^t ulso hp taken into act^uunl- 

T\iv Troatment of lupus is often a matter ol caa^detMt 
difficully. riifoTctically, it ccpslats in the free rcinoval of all the 
discasT^d tissue, eillici l)j ihc knifc. sliarp spiiun. or cau^tin. 
Wheri>v»>r pfi^jsihle, rrxmiar of th* uhole mjis* »ihoiild Iw p«f- 
form«d> the Aound h^^ing vithtri drawn Eo^Hhur hy 4Ului«6. or 
allowed to litral by n^rauuhilion, perhaps asaistvd by skin-i^rAftinj^^ 
Suf^h lii:'j^tittc]iU ljowcvi!i, IS mirly poh^ihlr iipun tlw ti^e^ Munr 
commonly the surgprin ha\ to dop^nd on trraping and the U(c ol 
caustics. This mnst h<i iindorukon with a free hand if th« ^-tiok* 
di»Cdtc iji tu bti «[ddic^t(.'di Miicc i1e« growth extends Iviteath the 
layer of libiii'cicatficiiil tisMio eiipOHird by the ^poon. Hmce 
scraping ^hoidrf alway* he acconipariied by the f^uba^qumt am^' 
cation of uiasiic-s f^^., sohd nitrate of Mtvcr, a paste conipce<aol 
cMoRiii^ of /'-'iiKt pyi^iC'dlic dcid (5 10 lo per crTiI-), or even Ihv 
arrnal rjtiiirry. Thr wounfl rhiiK prodnc:nd should he drefified 
with an ointment containing iodoform, and allow^ to hval bf 
^ranuLalxin. CJntlyini^ nodule^ muy be r<-movcd with a ifaarp 
iupu« ^pcxiii, and the liulc cavity formed in tltls Vtiiy covered with 
chloride of rAnc pa^tp : or f hi?y may he cUiff out tviih ihe diaqwncd 
end of a match dipped in acid nitrate of mercury, 

Lupiu ErrthematoBiu i.i a disuiae the nature ol vrluch U not 
yet ?j[i^f,iLthnil^' tkicimiiiwl, ?tfiiiie authoritiffK umnideTinff it ik 
practically TdeTilif::i1 wirh bipu*^, whilst others ajfrt^t? with Hcbra'v 
ohginal dictum tfial it ts merely a form of scLiorthfEa (Scb, 
coi^estiva). Tbc uppctiT^nce of the aff^Ktion ih lokrahly 
charactenstic ; ii is iisu:illy sitn^ited on ihe face, And in the mo«f 
typical caB9S ftymnieihcal patches ure Conned over the r<>ut of th« 
0009 *Ad di««Ks, corrtjapanding in ftppoarance to a butterfly with 
outspread wint;^. There is a considerable tendency fur it to mrade 
the forehead, cars, and scalp, and occa«ional1v it appears on the 
trunk, and m^y then be itniUteral, Jt is evidenced l>y a smooth 
hypcr^cmic surface, covered with a branny UcaquamAtion : the 
scales consist of inipiwatcd *cbum, ,ind Jtc tommueJ as deep 
processes, rihidi can lie traced into the mo^ith^ of enlarged 





SEtSIS AND iNFECTTON 



V 



i 



ttbficcoufr loBkte- As the di^Af^c sprcflds peripherally, the older 
404 ccacn] portions are tr4i]bfonu(.-il uitu (.icdtiiLml tissue uf a 
pub, (ti!f] jtru] whilr lypp, c!nf]ET;iMJTig very forcibly u-it1i the 
hypenonic appearance of the ndvandn^ mar^n, Ic is usuuUy 
seen lo adultly and more frcqucmly in wofitcn Hun mrii. Pio- 
{rrMisexccodinifly iloiv, ami ulrr^r^iion Is ut)Conm)i>n, 

T^ TTMitmmt cnnsiKU in nitmtion to ih^ general healih, 
K^hswiih the local Application of wcnk luny tnd mcrcuhal 



It Mvcdllcd TaborcuUr tT1c«ni dtfTe.r from thr. lupoid in ihr 
£wi ihit they always feiult from the lircalcin^ dawn cf a tub- 
cuiuKUfi focust, and hence iriay l>c connected ^vith di^ea^s oF 




4 HndU' t, vblnniMKH . «> Inner Biasuvn* EnuKvUr nqit . if. uutvi lniijfj> 
ut^nal maacalAr cott: r. wttctu : f. mhrrcular focui rn »lh&r^ (tlji^d ; 
t. ■■mi iBAhntcd viib cclti; A. ivt^rcmLux ulcrr: ^j. f'OCiM of H>flcn 
nt or lubvcalar abBCCu: r. mrly tiilnrclD, ^sl1h jflnnr cell m L^tqirr: 
V OHMS* lubrrd* 



t<»«, lotnis, lymphatic gkndfi, nr simply of the connective 
DMncA. W bat ever ihcir orijipn, they are characterized by 
thr mxoK fcdilurc?!, \\?..^ an irrc^dar and rngecd maif^in wttli 
OideniniKcl and cong^rrd r-d^r« ; the luse 11. fiiimril by Jitilpy 
fnaubbOD tinfiue containing ca«oout mas^^ of Uilwrcle. 

TbeTWAnuat nccesicuily t:on:(i^tT; m the remcv^kl bnlli uf the 
ludwitlfay Diid itndrrrniii^d «kin, and of the iiibcrcubr ;^rariublion 



I>8 A MANUAL OF SURGERY 



tissue beneath it, the wound being puriJied by some strong 
septic, and then dressed with gauze covered with iodoform. 

Other cutaneous manifestations of tubercle are described, bi 
need scarcely be mentioned here^ 

Tnbercnlftr DlBease of Uncom Hembranei may be met 

affecting either the alimentary, respiratory, conjunctival, or 
urinary tracts. It always commences with the formation 
tubercular nodules in the submucosa (Fig. 20), As these 
in number and size, caseation follows, and frequently also su 
tlon, the abscesses bursting through the mucous membrane, 
giving rise to shallow ulcers with undermined edges. W 
practicable, ihey should be dealt with in the same way as tvAtS- 
cular ulcers of the skin. 

Glanders is primarily a disease of the horse, ass. or muL«. which a W* 
mitled to men bv direct inoculation, and hence is usually seen only in itaUl 
attendants and tfiose brought in contact with animals. It is cbaracierittd tff 
the development of infiammatorv swellings under the mucous membnats 
the respiratory tmct, vhich break down and ulcerate, ajid by (be fbrmatiodrf 
similar growths, embolic in origin, in the lungs and other viscera. 

There i^ now no duubi that the disease la due to a definite mirrn nrpniM 
the liaciUvs, indllei. which was isolated about iS82.bv Schutz and L5ffler.fld 
has since lieen cultivated outside the body: the experimental evidence as to i* 
being the c:iuse of the malady is quite complete. 

In Bonat -ind other animals, glanders manifests itself by a fbnnatiaaBf 
targer or smaller rounded swellings in, or by a diffuse inRltralion of. themiKDB 
membrane of the nose, ami sometimes of the lower air-paasages. These bnik 
down and ulcerate, giving ri^e to a thin, sero-puruleni discharge, whilst Ifci 
ulcers mav bv s er>' e^teni^ive, and even cause destruction of the bt^ies Cii 
cariilaK^^- The tuna's become implicated either bv inhalation of the fiiTcharp 
or by embolic infection, and either lobular or interstitial deposits form, iriiia 
soften and suppurate, as in the case of tubercle. The spleen, liver, and kktneji 
may be afTeded in the same way. In addition, the lymphatic glands becoBa 
enlarged and pa.ss through similar changes, leaving ragged and foul olcerttid 
surfaces, those under the javi being first invadal The same pnxa» ibo 
involves the hmphatic trunks, constituting the so-called 'corded veini'sf 
farriers, whilst the enlarged gland'> are known as ' farcy bud^ ' The diin" 
runs either an acute course, killin;- in sIk or twelve days, or Vi more fnqDcntlf 
chronic, lasting perhaps for years 

In Htn, glander-L usually starts alout the hands and face, but QcCaTiccallTJi 
Ihe na^l mnccus membrane In the muU cases the incubation period IhU 
from three to five days, and i'^ succeeded bv the occurrence of malaise *nd 
febrile disEurluuice, fo11o\ved bv severe pains m the bones and joints, similirtD 
those m acute rheumatism The site of inoculation becomes swollen And 
infiltrated. ;uid suppuration and ulceration follow The lymphatics leacUof 
from this to the nearest glands arc enlarged and infiamed. These phenomen 
are succeeded by a copious liapular eruption on the skin, which somewbi' 
resembles smal1-p4>\. but each papule goes on to the formation of an ectJif' 
matous-lofikin^- ulcer It is not an uncommon feature of these sores, whtf 
placed oier ?i Ixmv sLirf:i<:e. to in\oh-e the periosteum and lay bore the snl^ 
lacent bone Similar changes occur in the viscera, muscles, and joinls.ABd 
these bring associ.itL'<l with high fts'i-r of an a^^fhenic l>pe, may sug^ceU 1^ 
existence i^f pvnTmia In -,iich cast-s death inav ensue in seven to ten days. 

In Chrmio Glanders similar s\mptoms arc met luth, but the course is slowtf. 



SBPSIS AND SNFECTtOtt 



^■Tilbciror EK>&rvtT . \ht tWmaaa \-9 Ins cifodlvt. jiid intpimioloni are 
M VEaoBon Tola] fofonry i* ^lAiod lo uctm in *)y f^i oeut- uf ibc t^acs 

llBiafonMC to^cttrnito ihcDkMOiii «B«rlr a> pxnble, fa <ir]cr lo 
MdHHto cHVB«Clc local inotOMCil t^«m mrif nhrwufuv it it lo !« dintin- 
tfE^^WtVrmu'n-^' ^i' tlu* Incal Irvioni^ whirh m tommiiy h» Hi«ittigui«hiM 
m «A : .Tier nf ihr chflracii^hfliT tucilll In ihp flKtwrue, by 

otbatkit 1. iijaivdv infcol^'cthcinjtJCLJUnrfru* tlbuu, and l>y the 

itMiiia 4f 1 h I >: 1 1 \ M a. The cbfotiic cjuei rewmbliirn'^iltiUftmultislicrculinaa. 
^httary oJ Ibft pAliviIt^ aiui ihmr ov^icHim to mf«;iii>ii itnm uiin»U 
froa Ite Jhcv*, 1m cnciti impnrtiinr, a« a1^ ifac r^alt i>r culrn-aiionie 

rf<jdlHiili>bcMieV'l5ncharacffr toTnulatwonrihrpgdaj^t, whlcb Ai-utiiaDy 

w odI^^ be of utc tnlLon iJn<JcTt4k«a «ftHy. and bcbn wncnl 
Ittt vn«cl, Hk Idcsl fbci Arc lo bfr thorou^^l y vxiirpDicd,«i»«r by 
^ bA or by < « aHa| t aod applyiog UMta Jicilvo uQifd^in^ a^anr. TIm 
■■•inBinail ihocild beadopicvl tn rtin-rnlr cim 



t^ifttir {^, 'i/M, or i/di 



Ld^rM7. 



ivetolbr AAAUnlr/vtf, «rt Hiaranrrwl by itie ItirmMion of gran uU non-1 ilw 

^ Wett cJ Wprmy clowdj- tt »■ mblc ihi>M of tvWrck. bciiif: 4 t^^ u long 
*>l I J tnod (P^fi, ai}- TW an vlAinod by ino« of (ho ordinary moxhc^ 01 



to rk^tlnuBt. hai the 
fivit Itti P0( yvt bean trafi4iTUEtci] 
(■ BMab 

tjfrap | . iko«cb fenDiriy ooia- 
•OL * lUa ooaniry, ti ncM bat 
mif «ec«. md bu ih*n uiuaIH- 
IviiSpcnad In trrjAnr K»^v^^'. 

'.p*nvion ^f lepon #n 

viy ti raueb dtBUiiMh- 

' I r MiTitirf in ihAl Hinnm At 

' :ii-4suii(in. but Imlr li iinijwn . 

^ .-r-Ti^.rfv jnciinl akan ihaj it 

' 4ith *D etclu^«c1y Asti 

iiaJy Hg!Lti*Bd hy the 

. -p » kfiowti to tw 

en ruvH *fn»rB 




1^0 



ii.—LKrtoAT Bacilli ooMTAi^vtu 

WITIirit I^rlTIULlAL CnLLd. 



'A\> L'. L/IE. 



It 

..,uBh 

liH^ijrh. mvl then i* «>nctd«nb]a dilhculU' in 
. !h* uTni-iimlly lotijj ^nciihatinn pfriml— pKrIiJtpt 
. iiu [o wfirihrr r>r ivr ^t ii Tr:tn>i]tiit"nt hy br^rcrl^^y 
'.at period it w<ii c^^iicr^ly conccdtnj lIui ibc fatbc< 

mil ;im ll 90(nC^h4^ JuublfuL 

- Tw« mi J van*i.ii.-« ^A liijiri^y h»ve bw-o JnKrtbftil, vi< , rhc 
'^WrqlVvd. lad ih' Ar:riTbrlii:, rir nonliilwrcuhil*! . bui th* l^ci Hri* (ifl*n 

Ttbctv«lat«4 or CtUcroai LepCDiy la tbe Uitm OKST coinriioiily w<9n in 

I ^ /jK N^hiUK xn.x.\ lie itulELoJ |ui rtiuiiltl* gr ydTi ftftcl ciuuiuic lu Jic 

rE:*^^fn, «4-{ fW^ LiitcT 4 (Krifx] cif nivlALkc. UBP^iAlCii vith i-ly-pcmijl. 



130 



A MANUAL OF SURGERY 



period — from days to weeks. Ir may be uahered in by a rigor, 
peralure is usuailv of aremiltenl IjiJe. This is follovfed by,oraa 
the appearajice of ahiuy, red, hj-pcricmic spots, which are from 
tratec.slightlyraised^andhyperssthetic; ihey are usually located o 
or cheeks, the eyelids becoming (edematous, on ihe outer side of 
on the front of the forearms. They may fade away and disap 
and then again become evirieni, or fresh patches may be A 
always wHth febrile symptoms After a variable period ' tubercub 
numbers of Little pink nodules form over the site of one or 
erythemalous patches, and these ^iradually increase in size and i 
possibly ihey become as lar^e as a walnut or hen's e^g, and 

brownish - ye 
Almost any pi 
face of the \ 
invaded in thi 
the face is eaj 
to be inv-oW 
resulting disi 
very marked 
leonine appe 
imparled to 
(Fig. 22). Tfc 
u^unlly more 
thetic from 
of the intiltr 
ner\"e3, and 
result of the 
vary consid* 
resolution som 
or the nodi 
transformed in 
and pigmenie 
ulceration ma' 
ceral complia 
Largemeni of i 
glands follov 
deposit bein 
rt'iih febrile 
The testes j 
seiual power i^ lo^i in both se\e!^ Df^ath is usually due to sepli 
laryngeal obstruction, or discas*^ of ihc lungs or kidneys, but th 
live for many years 

The nodules consist of masses of granulation tissue, and scat 
(hem are numbers of lar^e tells, containing inuliiludes of bat 
Considerable difliculty o\isl*i in cultivating these organisms, bu 
succeeded by usine an ^dkaline meilium. and excluding air. 

ADBithetia, or Hon TnbsrcuUtedLaproiyis much the most com 
with in hot climates The t-arhcst phenomena consist in a cert, 
malaise withunl appreciable fe\er. lOf^elhi?! with sharp tinglinf 
ing pains alonn the course of certain peripheral nerves, ai 
along their course The ulnar, median, peroneal, and sapheno 
those most often affected. This i« followed by muscular weakner 
finally to paralvsis, various rnodificationsof sensation, and trophi 
involving at first only tht skin, hut later on attacking both bon 
muscles Circular yellowish -while patches are observed in the 
ing peripherallv, and lentling to run together, forming large irr 
the Doraer is often raised, and hypersensitive, but the central po 
atrophic, dry, \%hite, and anaesthetic The ana'sthesia gradually 
serious lesions, p.trtly due to trauma, partly arising vcom (roi 




FlG- 22- — TL'BtPCULAlf LeFPOSV OK THE FaCE 



SBPStS AhlD WFSCTtOlt 



'be liudk irmectmci Ifroming ifMrkcilty 'cU^cd.* M in ulnar pAmlyvtK 
lFc fjt rri**niiliil tbaOTiiCiai of Ih* honmt Af itir ptriphwnl ponbiH of dr* 
ln«irl«d llw bMM«.lOM. and nfhrrpnrtiOTKtivhrtivl up and dioMMar 




ix ?'3i>Ri>H Eth^KiiihH wittc Tkurnic Bonis a?^P An*«Jtriic>!« erf TnK 

Ut 'fti^Kilj anlar^s) 4*1 icn Jer Specific vbecrnl lHa<mi on cot to rnAJkpd 
ttiiiiMtirhectlter larval tha dWiw. Hnd tht pMWdl may nntJn a con- 
idplip jgyiti of W*llh and uirrifih. whif-ri hft «tiiuJ pDA«nitnf]£]f much 
^■dsod vnb Pinsl]> lie <}in from craeial ^v1)>^itT.c> Kum V4ttjuutt tx/myU' 

>■* BV«1 tit RCO^vt. 

T^traiMm l4MilE in )& mam tin>citi«fiei(V7 comllTifin ClhAMlmpc^gn oil, 
d^Mlmd both tnatnaMj Jind viivnilly/ i<i ihp Hniu ino^t fTrijD^Qlh 
^padd on. bm butcfty Icod iiijTxtlunk d habJlLuuic lut'e bwnempkryvl 

jLcticomrcovli- 

^^asmrtrnk* h n Ionian nuinh of ullIc but occvJonAlIv «cn m rnnii. 

TWteKit tnj*femli<B| laaaJmaUunth ttmr lood. havtnR bwn loirn4m<rtl 
4i «m» ttm bulk. lY ■hKith, &f harbkT, 1 1 luhaDv aI tiif bi< IhA nDnffue or lent, 
iato barti l*4liriMd nun-i {tJut ■ tfomln^ mn^uD ' vi L^niiry in 
« Ume. wppumkiQ U m4n> ioci appMrs, proilDcJnM mnluplr 
vtli^dbclMmalenullvi umX lenvc a dvfluw JnflunmiLtQry mui- 
vnb rtna*r«- Tlw pvii frvin mmIi atncowtB !■ ol ihv uniol type, but irv 
ft CQi tain * fir^ wlt"-x-i^ ei^tty lA)itf«. -jthich can I* iujlarnil by ihe 




cal ank in^ 



[FHuei^Hvii In [hpctmtn?<:l w1uch1.}if:dumt"< 



Ift lu lb diiiaiL ocean nmt^h mijrx commonly tluin wa* apcclcd when 
Mttoa «aa ftncl ilnwn in il, af^ 14 prubablv du* 14 dirtci inocuUuon 
*il te im||ti« from FmA^c^n whirb hAi fv#<i c)ir«r¥lnr «,T*fi U h*4 N*ii 
^BdMlbB nmttK and naalMi. auuru; dJfluv imlankTlon uuj ^ippunukm, 
MllilMc^ Vbcrc locft£ud cmpjvtTUtAtutvc ictalioJ . in vanoui [iu<i of tha 
^Mbd canJ, capociatly Uut vctaiir^itiii'ipiiiTnrJii, luid m ihciLTn Wherevor 
^Wlad.llM mtae puboMipcal phcnomcnn tnanilt-vi ihi-tnHuWcv. *if., dihcr 
^frnialion oia IocaKbviI tunicur. in ihr jirn pni^ihly vmnlnTmg ;in rpuliv. 

Thv b(inmKvaA*C*n|*ciiEHl[vutrh iVi«^(i ^int-ond may be rrndeml 

lad B«tvn>jv«ly ijhwrojrpl In ilwlf l1u- ikikcv U mil iI^ikdjuux l>ul 

■M.' (vcoma 90 by ui*ol\inf imjionani oinart^y. nr b> vrptii: ctrnrAminntlM 

T^ ocatoCOMt «te br h it dew: I0 ili? ui^laof ihejaw, cnniiituriurf nCdnK^- 

r. tlw ftfrwan^c* of which Lt lolaniMy ctutrMlorWic At finMbt 

9—3 



i3» 



A MANUAL OP SURGERY 



maas haa a smooth, regular, and even surface, and merges gradDAll^ 
surrouoding liaauea : the skin over it is usually hyperaemic. As tia 
little nodular HcreKences form here and there on the auriace of ihe 
and these 6nalLy soften, point, and burst, ^ving exit io a aioall at 
glutinous pus, in which the actiuomycotic nodulea can be demonstrfUa^ 
all the fungus has been discharged, the abscess contracts/atld the wovi 
The dcatrization induced by Ihe constaat repetition of this process n 
surlace of the cnass curiously nodular and puckered, and this conditii 




FlG. 24r— ACTIf OMVCOSia op TONGtE. fTlLLMANHS.) 

showing : a. the mycelial development surrounded by the club-sh^ 
ing processes - b. a layer of granulation tissue aurroundtng it ; f > t 
commenciOB suppuration. 



presenl. is almosl paihggnomonic Trismus is an exceedingly constant 
in the cervico- facial form of the disease, coming on early, and beingA 
independent of the size of The mass and its involvement of ucrves. 

The TrMti&Biit most recently advised consists in the adminianatio: 
doses of iodide of potassium, which seems to have almost as great an 
in this disease as in syphilis At the same lime, surgical measure 
employed. Extirpation of all the inliltrated tissue, cither by the k 
vigorous scraping, should be undertaken, and the part freely cautc 
fact, it mufii be treated in exactly the same way as a di:Q'uae t 
mass. This can. however, only be very partially carried out in th 
affections. 




CHAKl EK VI. 

TOaOURS AND CYSTS 

AiTUot'CH ibe teim 'tumour' is applied i^cnoriUy to any abnormal 
^nihii^ which mtiy he met 1^'itb in (lie body, yet far ^iontitic 
pupates iu upplicdliui: ta itiucU moic timitr^l. A tumour iii;iy tic 
masA tw ' a nu^ of tt*v/ formaiion tSiti t#ttd* to grow or ptfrii'it, 
*iiboat fuUillIng any phy«j<>iof^icAl fi^iction, an(j wilh no lyf^Cftl 
tKmJiKaian/ Th« fact that it Imn ro typical l^rminHiion dis- 
lUfnUiica It Eiom iiilLutiiiLit'Jiy Lf\tE^toivlhb, ultj^l) ulwAys tend 
•OMB Of Uir*^ lo ihtf ^mation of fihro-cicairicial linuc, or 
■arc (DocU6caiioci of ii; iu11bmma1oiy growths, mor&ovor, may 
4«ppe4f c<xiip?ctcly. and often tcmporcirily diminish in ^ze- 
^^ lif%nro4)hte« aie exckidtnl l>y [liis rlefinilirjo, since they 
ii^tj^ wpora more or \tis on &omc< incr^&«^ phyiilolo^cal 
Amod. And arc comjXMid of nn iiicrcAMid development of 
>Dnnd lusaCt <&, £ur lUHLLrtLc^ iltL' bU^kbimth'^ bicep^^ Con- 
fokd n vig g r i>w ih of a limh or pon ion of ;i limh jl]^* (^riir.<^. ;tnd 
■ kuwn u 'f^ganCifm.' It cannot t>D looked on an of thr n;ituro 
^Aluncur. bcin^ mt^rely an cxA^fcratc<i dc%-clopricnt ot noroinl 



\i to lb« Cknwi of inmoiu^ but littti^ U knnwn. I'roTmbly 
<hiy arc all in tbc htti inntxncc Ilxi^iI .■{rvE^l^ipnicnU* .icid ruy he 
UM np by «amc form of bOonr o^ initAtion, which dctcrmicr^n 
wratu (lr\pli]prni^mnf uimr nf ihr li«iir-s fif the jkjji. Tliti*, 
oo !h« l)tfe;»s( i» oftrn rcsponiiible for an adenoma; fh* 
cau!«d by nmokin^ 4 clay pipe may produce epithelioma 
Sp, and many other illLi^triitirjis will rcadely su£|p?at thom- 
■J^-n. Murmsvr, irvf?n if, .is !iiipin)sH) hv H^iue palliolo^iMs, thr 
uscMnau and ^orvucnata result from 'tura^itic liifi»etioB whh 
PKiWftctms, it it* probable tJiat some local irrilatton or brwich of 
W^ a oeedcd lo allow rnttancc U\ or dclcrmiiie the ttctivity 
■f- ihv oTKantsm^: thus, P;igFr« i-c/Fni;i of th^ nipple, whldi in 
Probably SA o\'kli':vr<^ t.>i pnorospen&osiSi is ofton followed by 
■otrbuA. The b«ro(litaiy nalur<! of soonc maliKmnt lumount li 
4^ mcnliunufd as aii rvideiici? of iholr coustinJlional oiiE^in ; but 
illhanglilt may iodicatP a pre<li*posit!on of ihr- p;viieiu lit iheir 



134 ^ MANUAL OF SURGERY ^ 

development, some local condition may usually be foiiD^^ 
determine it. Cohnheim has suggested that tumours may be ^ 
to some excessive growth occurring in small portions of ^ 
developed and undifferentiated embryonic material, or, as he ttf^ 
them, foetal reeidnes, left among the normal tissues. These lafl 
remain in a condition of suspended activity, until some loCl 
lesion excite? their development. In all these conditions* ttafll 
some local irritation is present, and a constitutional dyscraatt 
blood change, if present at all, is merely a. predisposing fador. 

Tumours may be divided into two great classes from a clinia 
standpoint, viz., the benign and the malignant. 

Benign or Simple TumoniB are characterized by their deveki| 
ment being strictly local, by their more or less exact limitatio 
being frequently encapsuled, and by their method of gmwf 
which results from a proliferation of all the cells constituting dM 
structure. There is no tendency to infiltrate or invade surrooi 
ing tissues, which are merely pushed aside and compressed, givi 
rise to pain and other pressure symptoms, although the tuma 
itself is painless. The capsule is formed by an ensheathing U] 
of fibro-cellular tissue, caused by the chronic irritation and i 
flammation engendered by their growth and development ; het 
they are usually enucleated with ease, and recurrences t 
uncommon. They are not unfreijuently multiple, and may 
hereditary ; but these characters are no evidence of a constil 
tional taint. They never give rise to a fatal issue, except wb 
their continued j^-rowlh causes pressure on important stn 
lures. 

On the other band. Malign&nt Tumours, if not removed 
operation, are almost invariably fatal- The following are \ 
chief characteristics of mahgnaocy : (i) The primary growth 
usually single, rarely multiple. (2) It tends to progress stead 
and constantly, bnt with varying rapidity in different cas 
(3] The local development is characterized by an infiltration 
the surrounding tissues, which are gradually replaced by 1 
tumour substance. A capsule is thus rarely formed, or, if at i 
only in the early stages, and hence the limits of the growth : 
not clearly defined. Moreover, many varieties tend to spre 
locally along the efferent lymphatics, and hence, although I 
growth may appear to ha\'e been completely removed, rec' 
rences are very common, owing to the non-removal of tb 
prolongations (or, as they are termed by the lay public, * root 
of the disease into apparently normal tissue, if a malign; 
tumour, with all its ramificalions, is completely removed, it d- 
not recur. The impossibility of knowing whether all the groi 
has lieen removed, or how far it has extended into the surrou 
ing tissues, is responsible for the frequent manifestation of rer 
rences. (4) When a malignant tumour invades the skin, it usui 
leads to ulceration, and then not unfrequently a foul fungal 



TUMOaJtS AUD CYSTS 



>^ 



I 



miflfuyrvsa]lftbefuii^?ihdrmtt(MleiortliCT(JilErpi£Fuili:^Ar9;). 
(3i SeoMdM^r d^p>srts Are usually fuLirnJ in neighbouring 
ikiQphuict or dbUjiDl vite^ru. {b) Au apyre^iai i:^;:hvxu b pro- 
ouoodi A»A roault purll)^ of the pjurr, partly uf the ptc»urr uf ihe; 
{Kialh m imponant sinicnires, inlcrfc^dii^ wlUi tlitrfr funtiion. 
ia4 10 pan poftcably due 1o tho Absorption of lo^ic prodLJcti^ 
iKV^/j^ ia tb< (umotirv Thi; patient looks Ihin and iimfLciatoi. 
Ebf W drain) iui<l ^ilh aw ap^i^^f^hcf of buffcnitf; upuu it : th« 
*l>limie ii imjviirwl, .inii th^ *ikm nft^Ti li^llrwAnrl iMrthy- looking, 
i;) Fijully. d»th ends x\w. sccno, after a long<:r or «horc«r p«hod 

Tte decree ol mALi|,ituicy viirie^ with different tumours. 
btome ihe local phi^numctui preclomin^tc. whilst in others the 
AMiitiUiriUl fvtnptonu are the more important^ Thu}>, rodent 
okkf ibtlow m il» pir^rci^i, and pioduceti i\o visceral deposits; it 
domip life pietdy liy iiiipUc^uoti of \^ita] pjttts. McUmjtic 
un):inu. i>fi tht^ other band, may produce only a ^mikll primary 
PO*lJ>, c*ut the nwtl cHtiinsJvx:ly diduEcd tccondary de^poBit^ m;i^ 
w» o ibc vtwcro. The sarciainata arc very frc<iuc]Olly disscnij' 
B«nl by lilt* bluod'i^UBUi^ urn! Iieuce wcuadaiy ^tuwll» uit not 
oAoon in ihe lympluci<^ glaDdt. whiUt the rarciconiatA spread 
I7 na>&« of Ibc lympliftttcft, Even arnoug tho Icitter con- 
*4fnblc diiTcrenc^} aie itiec with ; thu^, in i^UuduUr cancer 
scocilary i^ifwihs oiicur Inilh tn ifie lyitf^jfiatiris ani.! [lie viKcra : 
rtfa m vLuainonft epilliphotna iiei^hbourinj^ lymphAlics are 
^''Tfcd, Uit the vi?<:eM i;L-nerilly csrApt*. The \cfxr\ aoml- 
^^fnmt is Mrciifrlmie?] upplkxl to (hose gruwllL* which ari; ua 
rdrtl;Lrid }wfi*'»'4'n tlic ndignant Jiivl he-nign, 
OliMlflcjtti^a of Tumctm is coriductii^d viloiig liciftS partly 
kl, pATtly i-mt>r)olovica1 ; aiid on iho^ j^ound» tbo 
KPrjUp^ air ilrsi rit>F_\l l 
L Tnmr.urt Aft'i\<-(\ Ucu\ int.^^bla^lk Hssiie, or, as tt m^y hci 
ImnMl, the CozkO^ctiT* Ti0«u« Oroup : 

(1) Embryonic connective titsue tumours: 
(4) My 10m A (mucoid tunmiir]. 
\k) SareoonsL. 

[JJ Fully -developed connective tinue: 
(d> LipoitA (htty tuitiour'f. 



ift) Pitsrom^i (librtin^ t«movtr). 
tf) Chondroma (cariibji^doiaii tvmiour). 
{4] Osteoiiu (bony tujnnur). 
{t) My^mia (iniisilf: Iiimttui). 

if) Neuroma (tiimrHir in cntinecfion with neivcs), 
{g) Ant-iomi Humour composed of blo.>d vessels). 
(A) Odontoma (liimoiir connected with the lucth), 
(i) Ly:apbadenom;i« nr lyini>hang]oiiia (tumours of 
lyi^P^Al^c origin). 



■34 



A MANUAL OF SVEGEXY 



IL I'umoiirs dcrivcfl from cpiblAsCic or hypobU^tic ^inKlurcit 
nr fipibliell&l Tunumirfl ^ 

(i) Innoceni varieties: 

(d) L*Api]loma (wart-Ukc i^owtb). 
(£) Adcnain;! (gUnciular new foniiAtioD)* 
(a) M:klLgTuint ^rfiu'th*, nr the c-ircinomalu : 

{a) Epithdioma (cnnccr of «kin or mucoue 
hranc). 

{£} Ccliiinn:ir carcinunvi (€»nc«r arising from tuhuUi 
fzUnU^;, t.g.t LicL>erkulin'« folJiclt^, or Emm 
tlucts IJneci uilti colunmai ^^Ihctiunt). 

(d) Acinous carciniVM;! ((.viiicct 'irUIng in g^nfU 
Willi fiplieioidnil C'pillii:hnm*. 



t. Tho Connective TiDPuoOroup of Tumotui; (rt Tuaoun 
cr>mpoiQd of Bmbijoiuc ConnDcliv« Tissue, 

Hyxomft.— A iriyif^iiid i^ a lutNuLii i.uilaLMtnt£ of CQtttlCcti' 
rif^Kiie rflk, tdTTormilHi ^nA *ji?pnr;ii<*ri from «k:Ii oihrr Uj 4ii 
mtorir^IluUr siibftiDce of .t iiiucotd character; n MmiLu type of 
material occurs aornun)' in Ibe subfslftncc ->* tbc umbilical cord. 
ThcccUf^ ar<' uiinlly (Hflngiihr in Oi-ipc, and prrwiil long l>iaiicb«il 
proctssew v.hic^ inlefbcf wiih thoi^c fr^m ;ic1};icfm celh ll'ii;- ^^* 



4 




BitAMCJIthO I'kClCCdU^ &£|'4KA[LJ-> I-^ ThAPilLC^EXT iHTEaCILtl 
SCMTAMClC |TlLL>rAfl?Jit.| 

The inieiccllLiUr aul'niUiicc is honiL^rXieiiu!s And UAnslucimt, con- 
taining waiulering ttinncrtive ii*;sue corpuscle*, And iravensd bv 
blocdvtfiiieU : tht? dvniity of the tunnnj-r VAriot iDvorsoly wilv 
the umount ol Lbi6 in tercel In lai substance. Myxonuitn occur «i 
ruuiKlevJ tuinuurb, peiluti? loimKitcd, in the tidRbbmirhnnc! ni 
mucous momUrflnos — f.^,, the face, iniestine. anil UloilJcf; tb^ 
«l83 grow in the «h«ath& of ii«ivct:, un<I are tixt,- cammoncflt farm 




TVMOVMS AXD CYSTS 



tv 



fl/vnpletmnoarof ibe sf^at rord. Mucous polypi of the nose 
tn hj mo6t surgMOA coneidorecl 1o bo o( thie miturc, althuut;;h 
a«n:hiaok»6U look o<i thcni a^ nictf 1y consiMii^^ of a^^lcmatoua 
CnmlitioA tbsiu. [c i» noi uncommon fv ihis fittu \ji ;^rowih 
V t« ttSOdac^^d u-Tih sarcomft^and hence :i Thorough :in<J early 
fMunl <tf iho iiu8t is ftlunys aillod for. 

'fcmiM tumour fortnod from somo form of imm;tturc connc^^tivo 
ti IImI is to !»y, it consistrr of ccll^ of v^iryinif mzc end :ih[LpCt 
hrfdtQSctbcr by a liiclkjitc rctictilimi, ^hidi pr[ic:lr-hlr« tx^l^rrn 
oAd tlie ccUuhr fflrmeni^i. Tbr Mnrrtiirr h, thus, uni uiilikr 
Ibii «f inAunraalocv new Carmacionv. but djffbrt item it m that 
lkE« is a coBsidfniDic (cndeacy to develop into higher typev of 
liwic^ such AH boDC, catliU{[c, ecu, »ltliou^'h the emiirvoEiic 
(Mulder of Ihi^ p-<m'th Mill per^^ts :kl the [x-nphery- f'Voni 
cmDou it lA lecuf^nisifd by the fiict that in ;UJ tvxccpt tho 
imkr •tucurulA ih^ Mmcturc is more or less imiforni. and the 
oMi Alt ijul giijtjpcd m dvFuli HEjiuiated fmtn uiie ^ujllier by 
<r«B: mor«ovef. llif* inr^rr4>1hiUr &ul)LU:iric^ tlne^ stoi penetrate 
bthNn \hv «picb«li;kj oell« of a cancer, vi'hiirKi»> ^^tth fluitJible 
ptoMiooi. it can aJvays be <knionaratcrd brtwccn the cells of a 



Atircoma .ilnayK aritM from pr*-existiiiR connertnt ifswe, 
odhncoi»of nir^^bU§tic on^in ; [»:ciL;3LomiJlv, howcvir, it ^t»r1s 
ban the ilrcpci ptirts of iKr ^Jn, l>uE cvtn h^rc it j^ prol-AUy 
Aaiicid fmm ihr «^mo pmhrynlnfiiral liati*, Ir msy lio il fir*t 
^delncdt Aod rwn in i^onif cjtt^K rncApRuled : buE m^ny formR 
bon the hnit luid nil Liter on^ tctni tc infiltrjito the s^iLitrDi^ndini; 
*■**, rcpUcijjje them i*ilh ihrif oaij p,irtic;iL*i stnjctvirc- a 

n 91. which c^rt tic well obitrvfd in ^iTcom;iui ai muwlrs. The 
«My ifi wry abundant, and. iTidcod, may be so free aii to 
(Me tDO lumour to pul«atc. The vessels prncti<:al1^ consist of 
Vtcnocdcfu b'lthm thn lumour ^ulistrtntc. and arc hncd mci^ly 
b* ibe rtkoat dt^iraip rodmhehum ; [he iirtf-riEs nnd vein« in ihr? 
ki^bouTbood arc alM> much diluted- Intcnjlitial ha!niorfh!Lffe 
•frofiently met with, owing to the thmnc^ks of the vcsat'l whJI*, 
«d cyila may m (bis way be pioduccti : iii tases wlieie ibu 
bnonhaipe is mixed with the dtt^ri* of ^'»rci'>mat»'nift tistii^^ ii 
^ constitttto what is kuonri a^ a mAki^TiaEit Moixt-ryKt. DiS' 
iduMiall) dcpe»dciil oil th« rcUlJon of chc lumoitr lo 
Q*T«is, As alrvjidy f4.<lrr], tbi.- win^AivKimpIy bp^tc^ hollowed 
of the tumour suhfil.inrc; into and alon^ xhp^v the narctinutou* 
ET-ay burrow, linbl lh(^ npoH of tbiit intri\-cnon!i i^rowth 
prtf&a» into ibc lumen of a vowlI ir *^ hich the blood is freely 
omibting. !l i« ihrti likrly lo br dflndird. po»tb]v a^ the 
r«Mdt of 9amm mcchanicjil it^jury, and may hv earned a£ a 
unbohtb to nny pari oi Chc L>ody; li a large portioo ifl 




138 



A MANUAL OP SURGERY 



set free, it may lodge in the right side of the heart, or in 
lungs, and cause a fatal result. Smaller emboli are either de 
in the lungs, or pass through into the general circulation, 
rise to secondary growths wherever they are arrested ; it is 
possible ihat general viscera] implication is secondary to 
pulmonary growths- Nothing is known as to the existence 
nerves or lymphatics in sarcomata; occasionally, however, 
semination by way of the lymphatic glands is met with, es| 
in melanotic sarcoma, lympho- sarcoma, and sarcoma of the ti 
testis, and thyroid body. Various secojidary chaages are apt 
occur in the sarcomata, €.g-^ falty degeneration, mucoid softt 
and hemorrhage, whilst calcihcaCion is not uncommon. S«i 
comata are also very frequently accompanied by a growth of oB 
tilage, or even of bone. 

On naked-eye examination, a sarcoma presents a more or l« 
homogeneous appearance, the colour varying with the amount «( 

the blood-supply, from a grayish 
white in the tibro- sarcomata to ■ 
deep maroon colour in the mye- 
loid. On scraping the cut surfei* 
nothing as a rule escapes, excepi 
when the tumour has been re- 
moved from the body for soiw 
time, and thus the cohesion of tl« 
cells impaired ; a milky juice nu} 
then sometimes be obtained; i* 
myeloid sarcoma, a sliniy fluid 
escapes, which in no way resembtea 
that obtained from a cancer. 

This form of malignant disease 
occurs most commonly in young 
and middle-aged people, espeoallj 
affecting the first and fourth decades of life ; it may also be o»- 
genital. The degree of malignancy varies considerably, soi« 
form^ Ijeinfi; almost benign, or. at any rate, only Jocally maligoaiiti 
whilst others are exceedingly virulent in nature. 

Sarcomata are divided artificially into the following groups, 
depending on the sii:e, shape, arrangement, and character of tbe 
constituent cells; (a) The round-celled; (t) the spindle-celled I 
(c) the myeloid; (d) the alveolar ; and (*') the melanotic. 

(u) Round-celled Sarcomata (I^ig- 26) consist of a mass of loond 
cells containing a very definite circular or oval nucleus 1 the inttf' 
cellular substance is slight in amount, and often homc^eaeoua ii 
character. The mass is extremely vascvilar, and may even pulsate 
it IS soft, like granulation tissue, and usually grows rapdlj 
Several subdivisiions are described; (i,) The small tMtnd-C4ik 
sarcoma is exceedingly malignant, infiltrating surrounding parti 
and early giving rise to secondary deposits ; the lymphatic glwn^ 




Fto, 2O- -Small Kound . ctLi.EO 

SAKCOMAINyiLTHATISf. MUSCULAH 

Tissue. {Tillmanns | 



riuoiTks AU£^ citsrs 



t» 



vtM IIBfrvi(|ufDt^ ^L»>^i7t«ji in this varielj^. Any part of Ibe 
todf BUnr be mvofvod, oiul a may \^ met A-ith ai nxxy a^ 
4«.| TIk bpf rvmid<iUrJ Mnama is made up of Lui^er cc11», which 
cecOui onr or Iwo hirgt o\iil nucic^i with aa abuniliint proTopI^ism 
iTBcni A %<ell«inuik«Hl aromu is interKpcxtod between tli© c«Jlf, 
u^ttiJineoUr oTTJiQ^niciit i> somctimct prcTtrnt; it occurs in 

mt poajbom nn the ioxtnct. but i> t.ithct le^» iiulij^nuit. 
yLptfn^iOTt^mit rt ^'ery Minil^ir ii> slnicTuri?: the i.>*lls ^OW" 

an atnatl, :ind tht' mt<.'rc«lJular fiubslancL- of a <l«licatc 
EUlturc. cones (H>nEhri;L; lu the rf tiforni lia^uc' <ontmoniy 
VdmA tn lyii))FlMltL i;Liuc]m. Sutb luiiium^ l;i[)%v lapidly. c^nd 
ttconrdinKly mdtj^iuni ; ibr^y iiMu!ly tanfl in l\'inph:iiir ^bntUf 
I* o Uif ]yiTii>hui<l tiBdUO oX mucoi^iH iticrnbraiK-s j.nd -iri- dii^fienii- 
lut^bf means of llic lympbMk^. For the clinical ; bjir.^ctcrs of 
I^OcEutaOMT^H^fircCh^pief XL tiv,| GhrntavJ ^iui-ntrttana i* ptob' 
Mf ■ laricry of rauDCKVllcd luiri^oma which develops in connec- 




rWlrtlid cdU bfti« boeo «cp«(ed, nad ibv chAroiClaritfk nuctd cftn be 



<>» vtlii Iho borvouii RyiUcm^ niLhoUfih there U uomc btlle doubt 
iAtovhcthrr lI sbould lie con^^iiicrrd n urcoma At all- 1l consist* 
•ti toaad cclU iiKim whkh a iiiimlirT of dcliuKc fiUmt:r)1oijf^ pro- 
""*i we fiif&Ubcd ; :hcy pralubiy ortj(inulG Irom the neuroglia, 
ihictib ol wlticblbcy much reurmblc Gh'jm^ta ;iic lound ^^row 
bf^Dni tbr retina in chiUlrcn, forming lumount which, riituatcd 
M ii«4 «ittiin the r.yv, Irtul l» (w^n Along tlic lynipU -^paci-s 
vnoundi^ tl:c bUnd^-eswIs inio th« orbit, and aUo to ^pri^d 
hKk«ard» iiJoiii; tbc opt^c nerve to the optic chLO^mA, rtnd tbt'ocv 
dmnntds to the ojipo^Stc eye, or apw^dfi to the brHiii. Thc^ 
«r ilao fouml an pnmnry ^rawth^ in tbi; c«rv^bra1 MibsuiicTn ;ind 
■*Rkpliii«« in tbe Kpma.1 cord. Tbey havt dcj general m.ilign.-incy, 
Tur nky tend to destroy life a» a rc^tult oJ tbvir local development. 
fK 8ptiidl«-<«Ued SftJCcmiAto (Fi^. I'/i cunsiM of Inrec oi »mall 
ifiMIt^ Crib, ti'hkll are oilta anangwl in a somewnh^il fiscucuUtud 
Quotff- vith a greater or lesa amount o<f intercellul^j^ Eub^^tance- 



140 A MANUAL OF SURGERY 



When consisting of small celh^ the tumour grows rapidly, and 
somewhat firmer and less succulent than the round-celled variM 
In some cases the intercellular substance is very abundant, j 
so fibrillated in character as to cause the tumour to be knowa 
a fibro-sarcoma (the * recurrent fibroid * of Paget), They a 
originate in any part of the body, but more especially from fibra 
aponeuroses, fascia?, tendons, etc., constituting localized growA 
which are at first tolerably wet! defined, but later on invade 
infiltrate surrounding parts. When growing rapidly, the 
tend to become less fusiform in shape, and may even approach 
the round cell in characteft after passing through a stage knom 
as the oval or oat-shaped sarcoma. These tumours, consisting d 
small spindle cells, are usually very malignant in character, excqi 
when of the fibro- sarcomatous character, and then the tendency te 
become disseminated Js less marked, although there is usually * 
considerable risk of local recurrence. The Urge spindU-cM 
sarcomata are softer and of a deeper colour than the former, Thej 
grow from the fibrous tissues, and not uncommonly ft"oni tat 
viscera. The congenital sarcoma of the kidney is of this nature, 
though some of the cells become transversely striated, looking like 
muscle fibres; such lumoursare sometimes called * my o-sarcomata.' 
(c) Myeloid Sarcomata (Fig. 28) are characterized by the pre- 
sence of large numbers of multi- nucleated giant cells hnyehplaas), 
imbedded in a considerable quantity of round or spindie cells, the 
intercellular substance being usually of a gelatinous nature- Tbe 
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 ce]is of 
tubercle ; they may be regular in outline, or prolonged into 
numerous interlacing processes, although these latter are usuallt 
not very evident. There is also no definite arrangement of cells 
around them as in the tubercular giant -cell systems. The* 
tumours are soft in consistency^ and on scraping a slimy fluid is 
obtained. They are exceedingly vascular, and may even pulsate- 
Ha:'morrhage into their substance is commonly met with, 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 liieW 
to the appearance of a pomegranate: when preserved in s[»rit, 
they are always of a characteristic brown colour, owmg to the 
formation of ha^matin. They are the least malignant of all the 
sarcomata, but rarely or never Riving rise to secondary growttSr 
either in the lymphatic glands or viscera. Their growth is 
tolerably rapid, and they may attain enormous dimensjons- 
Myeloid sarcoma is almost invariably found growing from bones; 
for the particular sites, symptoms, and treatment, see Chapter 
XVIII. A certain amount of doubt has been suggested tt 
cently as to whether these tumours should be included amoogS 




i« ar«mu. ^vkc their clinical hUtoty And pn^grcss are fc 
i*n^*pi! tlv irmi - myrlflm^ * luR Ihvh «iik){i!sI4?<1 fnr tho-m, a« 

(/iAhwkr Buconft U'^K- 2^) i' t vAricty in which ihc <%|]s 
mfiaqal lORcUtc< in jUtoli, M:parAieil h\ a diMmct filirLiu^ 
ftnsia- Hence, nr micTofCCij^it ^xantirulioin Tfiry ?froni4^whot 
(iiMljr (eirvn14c career : bat on carefully ptnciliirg a Mxjtion 
with a cuiicr»-hpur htu^ih. il niJ) Ik found that the atioma 
vtids ddkatc inobti^jitKina twlu-ecn each iif ibe celb. Thin 



1 




tf-SlfiiL;v(i SA»cnu4, kHrnvT3ir. hit MtLTI-wccucATICD MvutoiU 

^ <i Ivinour is i»oat ciTinnianly found growinjc from Ihc tikin, 

W it occaxkmally cf the mL-I;ii»<>lic ty|>«' It i^ ;4lw<iyn exceed- 

oiff mtligaut. 
t'l IMiaoUa BweooM t& pcTtiopi tiic most intcni-ely viiulenc of 

■A Uue» group of tumoufft. h Afmo»t inv&riiiblv crigioaten from 
pipMBlvd itniciurrv, r^., ihe dccrper Uyerri of the ;ikb ur the 
^*Cna. li iit, bi>w«\<«ft somclimct^ met with f>TOAing fr<mi ihr 
vaooof nuimbranc of lljc Upw and fiumi. il Lotmisls oi round or 
VUkdJc cclh, ofleij A\ (uniftd in aIvcoIi, nhU-tt in othtr ^aaca dub' 
>^pecl proc«ss«B of c-piihrliuiti nuy penctiaic iniu lie MibjaccBt 



n 



' t. 



J 



149 A MANUAL OF SURGERY 

tissues^ thus causing thern to resemble epithelioma. The 1 
prominent feature is the brown colour exhibited by them, 01 
to a deposit within the cells of granules of melanin. The am 
of this pigmentation varies considerably^ some tumours beifig 
deep brown or brownish -black colour, and then usually consis 
of flattened plaques, whilst others are of a more papilloma 
nature, and show but shght discoloration^ especially if gnn 
rapidly. The growth early spreads to the nearest lympt 
glands, and secondary deposits in the vJscera soon follow- 
great is the malignancy, that, according to Erichsen, if the prin 
growth has attained the size of a Albert, local treatment is of 
little value. The original tumour is not very large as a rule, 
the secondary deposits are similarly characterized by their nun 
rather than by their size, scarcely an organ in the l>ody being I 




Fir.. ?g — Alveolah Sarcoma (Tilluanns.) 

The individual tells in ihe alveoli are here apparently lyiag in close COi 
hut in re^liiy there is a certain atnouni o( iniercellular substance p 
between each of ihcm 

Other forms of sarcoma are also occasionally met with 
quiring, however, but little notice. In a Cylindroma, or PIoxl 
Saxcoma, parts of the growth undergo a mucoid degenera 
leaving column*; of cells arranged in a ple\iform manner, sepal 
by loose connective tissue containing mucus. It occurs 1 
frequently in connection with the salivary glands and mu 
membranes. 

The Treatment of sarcoma consists in its removal as early 
completely as possible. This may be a tolerably simple nt 
in cases where the tumour is encapsuled» but even here Ti 
rence is very likely to follow unless the capsule is also t 
away, and a good margin of tissue beyond it. Where, how< 
the growth is more diffuse, the only hope lies in cutting wide 
the tumour, so as to get beyond its furthest limits ; the prog 
of such cases is extremely bad. 



TUMOURS AND CVSTS 



14) 



lflhop<Jtaahr i nofffMr cases vK^rncwhnt similnr nurnsur^s have 
becB employed as Tur tlic siniiUr M^tfc of v<e]ii.<:i ^rW^ p. iGj), 
SfMol <iitC8 have nt>\K \tptrv rrcoiJpc! frf^m thf' ^1*10 tif Colby's 
Aaii which conisiMt of n ^inriii^fini cultui* ni the Slftphojccut 
vp)f<UHj And jU4trw«*-vi ^Jifftcsus in l-foiiillon. This fluid i& 
uhuLi vnensrly tn:Kk , am) :1irr iiijrcliiiits rorninir^cini^ wiib cJoRf-A 
cf bu a nunTm, aro gTAdmlly mcr««i^<l : t/*vrrp rrariinn iiMinlJy 
EJiim^ and the mrjrcoo should aim nt obi.iinmic two or ihrcc 
sod dFcci? c<tch week. The fluid i.^ imrodiiccd p-*L-ll> triln the 
ihlnniin;^ unJl* niul }miUy ii^ti:, iri aii)uru1> the rammir. In 
hicuriUe case» the ^owlh gT:irfuftlly tlwimtles ;ivvay. Th* 
i9a»Jfe<clk<l fiarconuta :ire app^trently the tnasi :'jUiIablrT for thi)^ 
Unlnufii, whiUt us^fyin^ anU mfiWo-s^rcurnaU 4xrc bul litlb, if 

(il fimovn coiudvUEL^ of rdly developed QonDeetiTo TtHUO^ 

U>9m».— A ifttly tumour coc«Uu of a localitod ovorgrowih of 

rttit^lulu ti^ue, iafilliutcxl Ailb fut. On iiilcioKiOpkal qx- 

Hinn « cUflnprs Ir n'^ rp^pwt from rirdinary a<3tpoRo lisi^ne, 

tdbftoi v«n fmlr Kxipphei] u'iih l)food-v«48«le- 

Wbeo loctUMd (ri^. fo), it forma n tuniouti soft ftTid »eini' 

in cf^n^fiMenrr, roiiTiclrtl ^nd lobulal^d in outline, nnd 

aceuTTiiig in the Mihrvi- 

.-Jn» tieeuie* ihc ^in 

thr Ijifnntir fruni ^ilo 
|Bd iUe. ming t<3 Th<i lilhc^' 
*aa al hhroits lnihc<u!;r 
[nuHcie frofli thccAptulcflt 
[CuDttUTEnlhrOcui- The 
ih U u«uaUy cncip- 
Jaad ftcpclymi>\'^e:ihk: 
[Ini i cxpOTcd to prressme 
K^kMi^^iN H'bpn »i1ii:Ursl 
tk« fthouldcf of & nuTk 
niblieil by the bracts, 
ngj beu>iiM: l^ftuly 

*nrtun». Such groiMTi^ 
Mtethcr nu^lc or muk iple, 

Bonrrng in hundmlt. Ani 
(i^iMfil commonlv f'jtmci -itxritil ihr trunk or in (he upper bmh:;. 
d hu been f^tiLicil ihiii ItporiiAU irAvc\ from one poiat of thv 
fcofh to aDolhr-T liy the lainn nf Rravity, Iml il is sjitiewbiil 
^Wvful wtielbcr tbi* ever occurs, Occu«onally subcuiii neons 
iBniMm become pcduiKubreci <iikI pendulous. 
By the term Dtffive liponuL i^ mcAnt a diiFuMt fatty infiUration 







141 A 3iASUAL OF SVRGEttt 

of th« Ruhcul^kneoug parts of somo rct^or^ of the l^cjdyt cff^ccolV 
beneath the c^lin julJ .1: ibe bflck of ihc n«J<. ftfid often in ibff 
puhk rrgifin. Somrlimes these growihs an* vcvy numnoui, inl 
ihey src tpecully cbnr;ict«ri3ced \ry being symffictriczL Thfy 
u«uiiiiy occur m mdividu^ils who drink ticcly and take bat Me 
cxcrciu;. Their sijec often diminislics on limiting thcimoiii3t(i 
akuhol :mi1 mukin^ ih<r paNi'ni do uimr phyi^io:il aork. 

CJcc^sionally tb« ccnric!c(ivc'ti«£ue bavis of thicve lumotfi 
nndtrtjots variims modihcarions ; rf,^>, it may U.tome mciVQflOd in 
aniouiil. cL-tiMiluliiifj a Flbto-Upoina. or it in;iy be ti^m^fc^nicil inlu 
iiiun^iil tissue, llms ff.Trinin^ a M]nco tlpoma ; '>r. j^^^m. lh«Mrssr*1' 
riLay br<:omtf dilated, onj^inahn^ a Ntevo-lipovui ; acid t.-%«n a BVM- 
UpOQUk rttBy arbe, oning to H stTLoirmtou^ chAngc involvtii|; ibc 

Loralijpd nr diftii^ied Overgrowths siTt rtfl^rn mer with in Ibr 
tub- peri to neat f^tty It^suCf constitulini^ SiibBordoa LipoQiAtA^ 1~hv) 
occur not anfrciiucnlly in the lowei {Mii\ ut tljc :iUlumcA, Ard 
h'tvi: a trmlrni V lo cxtt^nd into iI^k' inguinal auil cn^rHl caohIs. 
COiifititiiting the i^-cjillecl btty luinour m thi^w ruri«. By tbdr 
iTnelion a proccai of peritoneum may eventually l>c drnwn do«ti, 
And d true hf^rniht produced- A Atmititr con<lilion aIw «rUcs ^ 
the nmmor ;t1iiliiniin;il w^ll, small prrhirrriibtrd mA«v« of t>t 
projectti^ through coTif^eniU] or acf]utTcd opcrtingi^ in the liseft 
.-ilha DT Uiiea ^'mdunans. They arc nomclimcs knowtianPHlQ 
Her&itt of tbe Llueft Alba^ iuid aie usually cvtrcmely painful, owinf 
lo the iinpti(;itiOTi nf iht pi'riJonPiiTn. 

Lipoma AiboreBcanfli;^ llie term apphed to an outE^wth of fatty 
lisiiiic formirt: -~l numbor'of cIcti':Aic \ilii, which U met with la tw 
inlcrioi uf iointi>, and U u^Ulll]y assodnt^ with oslro'^ilhrilii, 
TbcTc is ofien a con*iderabie jnciease In ibe Amount of ictni' 
articular Iluid. and the condition has then been dcsifcoatcd 
' tynovitis Lipf^rnAtoaua.' 

Tike Tnutmonl of lipoctul;! cuiisisl>. ai a f ulc. iii tbcir ivtin^xAl. 
When tlu'y ^rv loob<?]y t'licapiiuled, this i^ a vt-ry aimpW niatler; 
but if thoro are many udheaiona it mair not b*x w* oo^. In ibw 
diffuse forms it i*yf vefylJltleuw operating!, didrlic and hyi;ieinc 
iTica4ur«s btin^ siib^itituied. LlrjuLir ^kA;jhs^*» adrlliI1i^rered m- 
lemolly, has booD recomTnended, but wft havv no «xpeTi«nco of 
its use- Occasionally, An opcnitlon niAy be caJW for, an<l iheo il 
if w ibc to cut throui^n ihf: wbulci thickjiJ^tss of the- tuinoiu ai onoe; 
And dfTAl with rJirh half vp»r;iidy, di«seciing \\ awxy from it» 
deep attachments. 

FibromAtA consist of ovrrgnnvthA of Ahrouc tiwue ; thry wen 
formerly divided inio two groupie, the bftrt and the ooft. and 
Althou^'h chert U no essential difference between thcm^ il is & 
uscfnl clinical distinction. 

TljeHvid Fibroma i^coitipti-u-d of fimi dt-nsc tiiiKue:, whidi creokK 






TOttOURS ANVVVSTS 



MS 



I tOMCtktt Mib xha koife, the expond Surioce showing numerous 
I iribcoiift of i^liatcnaiu- 6brci, sdmiUr in cburacnr to those mtt 
riu b a Urixloci. Micri>?KX>piCiilly^ interlacing Aliiillit aiv •it'vi), 
vM irv tonwitme^ ^rraitged concenlricalty u^ouiid ihe bloo<I- 
i«Hk; tbcfo are but few nvcleatod celk in tli& moio »lowly 
pDvsfi luitkoun. Tltc v^scuW ^upply la, a^ a rule, Jofcciivc, 
thfaoaib i£ht«d veins are Aomeitmirs present, t^specially ui ttw 
a(RiIr,ind tbcM, U opened by ulorrnlLon, rany laad to profa*;c 
lginwfh>jcc> o^ii^ lo the walls being Vcp: opcr hy the dense 
£bniDlttnic. JI>ud fjlnomuu aicmci wjih in tlic k'txM oitftuUs, 

aamm md»U, TbU latter condition U nior« common in women 
tkia men; it oonust^ in the forniAtion of mnity xnnW sub< 
oilueojf turaoui^ nhich die cvklcnL i.-iiItci tu thit loudi than tu 
tic ^p. and iire oftea p)[<tiiii,Tie1y p;imfti1. No Qniint^rlion with 
ncvi hbnilv Hak been tr;iccd, dUbouf^h such proh^ibly exuts, 
^tiKpuD ccnan unmediatcly on removal of ihc tumoun. 

M nbnnnftts de^dop :t& luc-ili/rd nveii^iuwCh^ of tlie Mitv 
lumnHft l^brO'i?«])tiUr tiftiud* or a<i Ihe jiG-callcd BCollUflCtun 
OtMnaQ of ibe skin. In the latter ca» ni^ny diUcrvnt toims 
d tie i^romih arc met wiih i sometimes ^ devdopmcii! of small 
loUo ctfctir^. sc^tc^fed widely over ihr? Mirf^ict, u^^iHlly pmki^li* 
adviih the ikm over tbein wjmewhnU c<:>rri)|;;ited ; thos« may h*» 
4weqt«d with fibroua pseu da- neuromata o£ the ntishlxiunnt' 
■eno- h m*y aInu t.-iist in the form of pendulous folds, pi^rhaps 
Mvdvw e largi! Mrt*a i.if the Inink ; tbe ^to-culZed p!ich3rdviniaict^ 
<dedtBe sodp is of tbi^ nature. 

CtateoA. — Cartil^^otu} tinnouTS arc met with growing 
aiUi jj Luuuc<^liuu y/ilh hi.}t}ts ui iti ttitlmu ^ofl tissuf^^. They 
*-^-a^ of hysLlJne cjltIlI^**. wEiicb, instead cf being uniform in 
'filat And devoid of v«aBcb afi at the articular end^ of bonea, 
^^c*in in the form oi pellets oi uoduica of vuiying ^ze, beJd 
|*fdkr by vAMTubr connectivv tiK^nr, whirli mav «vm peneirnie 
m> iW aih«tan<« of the canihgo. T1i« c«ll& are also 1e«« 
'cgtiu in slupc thAn is the casv ivitK normul cartilAjitCi and arc 
Munmccd According to Any dc^nilcpUn, 

Chundromftli uxr. liable lo hrromn ijklrilipd, and cvr-n oiutilied. 
W^ l^r^, Ibe central parts may undcTRO a mucoid ch^mge^ 
E^io^ ri^ to A ca\-ity which, if xpsis is admttlcd, ticconic^ 
Mc^trimlj fouL Tlicy arc iKit u»t:L)mmoidy accompninic^l Iei 
(Wf piyirtli by Mucowiatoixs and olhrr elemmts. 

^ortt groift-m^ fpom th4 long bowi, chocidroinati usually ilait 
^ bvoMb the purwateum, iUid art independent of thu cpipby- 
^ caniLigi;, altltJUgh it him Ifeni ?iUgtrt^Lecl by V^iivliow that 
^ su« origfoate from a nodiilr? of rriirtiLige whioli b:is bet>n 
^BpbcM from lit UMial AitULit:o]i cluiin^ -^n Attuck of ricketfl- 
iWy cocstitutc htm lobuloted cn^ap?tuled tumotirs. find i^ivc rise 

lO 



(46 



A MANUAL OF SURGBRY 




to no pain, except when they encroach on neighbouring 
They often attain a great size. The growth may 
secondarily into the medullary canal, and thus cause true 
ment of the bone ; or it may erode the compact tissue, aj 
spontaneous fracture. Amputation of the Itmb will prol 
called for, unless the case comes under observation in t 
stages, when the tumour can be gouged or scraped away. 
They may also originate /rtfm the smaiier boms, and then 
from those of the hand or foot {Fig. 3:). In such c 
growth commences in the interioi 
bones, and frequently from the ne 
hood of the epiphyseal cartilages; 
tumours may be present in th 
individual. The bone becomes e 
by the growth, and the parts may 
much deformed. Treatment con 
incising the capsule, and scooping 
cartilaginous tissue, a proceediitf 
may result in subsequent defective 
and deformity. 

Chondromata are also found iff 
parts, especially affecting the pan 
submaxillary glands, and the testes. 
parotid gland they are usually af 
with mucous and fibrous tissue, 
glandular elements being also foi 
They develop from the capsule of th 
or immediately beneath it. and are, as a rule, simple in 
ihouRli occasionally tJiey may become sarcomatous, 
maxillary chondroma \^ frequently an almost unmixei 
laginous tumour, though sometimes other tissues may co- 
Overgrowths of cartilage, known as EcchondroBM, ab 
around the articular cartilages in connection with osteo-a 
they occasionally arise from the cartilages and septum 
nose, and from the laryngeal cartilages. Some of the ioos 
which form in joints are of a similar nature. 

Offteoma. — Bony tumours are of two chief forms ; the ca 
and the ivory. 

Owicelloufl Osteomata are usually met with growing i 
articular end of a hone, l^ing derived originally fr 
epiphy^nl cartilage (Fig- 32). They consist of cancelloi 
and are capped by a layer of hyahne cartilage, from whi 
grow. They may be pedunculated or sessile, and ma; 
to a large size- They necessarily develop in young 
and may l>e congenital. As the individual grows, the I 
attachment may beotinie separated from the epiphysis to ai 
corresponding to the amount of growth which has taken 



Fig. ii - MULTii'tt 
Chondbomata of 

THE FiS'OEff*' 

tiedded in the mass- 



TVMOVRS AtiD CVSTS 



t47 



ta ^. or ii mny fttitl remain altacbod to th» •ptphyseal 11a». 
Ai ^ rule <l«v«lopin«nt ceaMtf a1 mitturity, when the cftrtilagc 
ccfttnnc Ibcni. a^i well a» Ibe cpiphyiwAl c^rliUj;;^. ossirLtrs^ A 
bom oCGMsoDilly furms ovirr the mott prcmineni part of tbese 
mnoiirt as A result of frii'iioTi or pressure, gi\'ing rise to Ihc 
fOfi^ioa ienoM^ m SiOtftCHia Bumta ; this oivity may commimi- 
OEfntb iIk jobil. Occa&bnutly 4U effusion of Llood or serum 
iilo ihr buru is ihrr Tir^t •^vid^nrt of \hv existence of such a 
pvTitL UultipU «io«to»«s ar« nut unfrcr^ucntly met with, and 





TinO or CAHCKLLDCt K.«04' 

ami>v» U datty fa^jn»v| u 
<^^ anilaieiiMais cavcriiii- &tid 

Avvmunmli 

NluhQur K rh« ion^r condyle nf llif* f^mur, close lo itir^ ;ii1iUu(r>r 
Qberd*, An vvcM-dtnuly irouMesome variety in the BubottguAj 
(Fii;. 35}, wficb (lovtlops as a rounded, cbcrrydike 
fftiiii|» under the »m\ of thtr grcaE I0C. ll is very painful owin^ 
EOtte density of ihr li^^iie^ inKftHv^d^ 4iid shnuli he ir^nied hy 
^motia^ ibc nAil, inciKin^ Ihe li«N(i(?ki nvet il doivn to the hone, 
nd dippmR it nwny \Aih cutting pliers. Fig. 34 represenla a 
fb^om gf All CKOMOMS fcjrowing from ibe prosilnial phalanx of 
<b| tkumb, and ilhistratrs ihs vhUip of this procr^sv fiom :i 
fiM0«6c point cf view, 

Tbc IvoffT BxoflQiMi develop mo«t ^cauenlly on the inner or 
ttrttf upcct of the ci;inU] l>Qiie%, cvpccjally tendmj^ to affect the 
flttUi nlern.1l :in<tiii)ry nirAtiis, froii1;il siuds, und fiiiinmi 
(Fy. }y, l^hcy consist uf ma»eft of compjitt tii%iio» covered hv 
pccioaleoiii. from which they (jrow. They arc xi^iially lobulatea. 
lod wheii HJiuJitFj tti the GlhiI^I sjku^ uc ^lu^vIiej^ fioiii the under 
of the *k\iH, may give rise 10 *>eTii:ius symptoms from 

10^ J 




148 



A MANUAL OF SURGERY 




irritation or compression of the brain or its membranes, li 

cases necrosis has resulted, and they have sloughed ou 

bringing about a spontaneous cure. 

New formation of bone occasionally occurs in the subsb 

tendons which are exposed to irritation or excessive actk 
the tendon of the adductor loof 
riderSf producing what is known a 
rider's bone/ Occasionally diffuse 
growth of the bones of the skuU (1 
ostosefl) may occur, affecting eith( 
caivarium alone, being then prt 
syphilitic in nature, or the facial and ( 
bones as in leontiasis ossea. 

The Tr6fttm«nt of osteomata cons 
their removal where posable, ThJj 
be tolerably simple in the case c 
cancellous osteomata of the limbs 
sometimes a most formidable proo 
when dealing with sesMle compact exc 
from the caivarium. 

Hyom&,^Myomata almost always 

Fig 34 -Skiagram oi' sist of «//5rr*y.^i muscle fibres (Leiom] 

Exostosis ghowimj forming rounded and often enca] 

KH(jsf THE liAst OF lumours^ the cells of which are Ion 

PjfoxiMAL I'HALAsx OP fusiform, and contain a rod-like ni. 

AND Opi'iiN NKAk THE 't^to tasciculi, wmCH arc arranged m 
Epii'hvj>eal- Cahti- less regularly. The tumours them 
^'"''^ are not \'ery vascular, but vessels o 

siderable sii^e are found in the capsui 
is exceedingly difficult to distinguish these tumours microsco| 
from fibromnta on the one hand, and from fibro- sarcomata ■ 
other. Froni the former they are known by the fact tha 
vidual cells can be recognised, and by the absence of 
tendinous fibrillar, whilst from the latter the distinction i* 
more indefinite; hence one must mainly depend on the c 
history of the case. Possibly other types of tissue may 
in the sarcoma, whilst Ihe growing edge is usually more * 
embryonic in character ; a myoma is of Che same str 
throughout, AgHin, in a jnyoma the bloodvessels have d 
and definite walls, whilst in a sarcoma they are simply cl* 
passages in the tumour substance. 

Myomata are met with in the walls of the alimentary 
but most frtrijuently in the uterus and prostate. In the 
they originate immediately around the sinus pocularis, ai 
thus analogous lo the uterine fibro-myomala. Secondary cl 
sometimes occur in them, ^.^., mucoid softening, as in 



Tl/MOl/RS AND CYSTS 



149 



^k disease of the uterus, calcification, ulceration with profuse 
baemorrhage, and possibly consequent septic inflammation, whilst 
wxasionaljy malignant disease may supervene. For the characters 
oCthe prostatic myomata, see Chapter XXXV. 

Tumours consisting of striptd muscular fibres (BIuibdomyoDiA) 

rbave been described, but are exceedingly rare. Occasionaily 

^.Wme of the cells of a sarcoma show a transverse striation, 

"opedally in the congenital sarcomata of the kidney. It is quite 

^possible that they represent muscle fibres, since these growths 




^*6 Ji— IVORV EXOSTO&IS GROWING FROM FrONTAL SiNUS, AND ENCROACH- 
rSC fiOTH OS THE OrBIT AND THE ChANUL CaVITV, (BLAJJD SUTTON.) 

{From specimen in [he College of Surgeona' Muaeum-) 

behind the peritoneum are closely associated with the layer of 
muscular substance which is known to occur there in infants, and 
"rf which the guberaaculum testis and muscle of Treita form 
parts. 

iTiaronu. — Tumours consisting essentially of nerve fibres are 
^ rare that they need no special mention here ; but several forms 
^ neoplasm are known to start from the sheath of a nerve, and 
We afe sometimes called Paendo-Neniom&tpA, The most common 
^ these consist of fibrous or myxomatous growths, which may 
other develop from the side of a nerve, or wlien large may cause 
U* Dcrve fibres to be separated and spread out over them (Fig. 36), 
They form well-defined and moveable tumours of varying density, 
and may give rise to considerable pain of a neuralgic type, 
^specially when compressed or irritated. They move more freely 
A a direction at right angles to the axis of the nerve than along 



ISO 



A MANUAL OF SURGERY 



its course. When multiple they may be associated, as aim 
mentioned, with the development of cutaneous fibromata (■ 
Itacum fibrasum) . 

A curious con dition» known as a Plexlfonu NdOroiDAT is 9fl 
times met with, due to a diffuse myvomalous change in I 
sheath. The nerves become thickened, tortuous, and vermifiM 
of soft consistency, and looking on section something like I 
structure of the umbiUcal cord. The condition is usually q 
genital^ and may attain to such a size as to cause defcnrmi 
Mahgnant disease of a myxo-sarcomatous type may also occ 
sionaily occur. 

The bulb formed upon the proximal end of a nerve after 1 





Fig. ifi. — I'sfiVDo - Nevhoma : 
Fibrous Tumoup npowisG 
FROM NtBvt Sheath, and 
CAUSir^G THE Fibres to b£ 

WltltLV STRtTCIIKU OVER IT 



Fig. j7. — Section of Cavernods 
Angioma. 



division is also sometimes described as a neuroma (TnnHl 
Jfeuroma]. ft consists of a mass of fibro-cicatricial tissue cont) 
ing spaces, coiled up within which are found prolongations <^ 1 
axis cylinders. They are practically always present in amputat 
stumps, and are not painful unless adherent to the periosteum 
the neighbouring bone, or to the cicatrix, when every movem 
of the nearest joint causes traction upon them* and may indi 
severe neuralgia. 

Treatment. — Neuromata, if painful, should be removed, C 
being taken, where possible, not to interfere with the continc 
of the nerve fibrillx. If this cannot be accomphshed, an attef 
must be made to unite the divided ends by immediate ne 
suture. When multiple^ total removal is well-nigh impossil 



TUMOURS AND CYSTS tfl 



ncflculonit Dctironu if Uiniicd In talent mny be t^isM^f^d oiit, 
tel il ttuWly diffii^d ihrou^houi a liiiih ii ni;iy occcKsftntc am- 

^T**™* — Sc^Tiral distinct v-aneliefs of Uimoiir^ conuitlmg of 
^hadi0B(rk occur in «tLr|pc3il prncEicv, bui Ebe t«rm angioma 
sofr ipplkd to ihriSD in which a new kttmixUitn oi bloodvi^s^U 

dptoflq^orj. 

Tkcc nuin vamliss of angiomA may he descrihed : {i} The 
sapit Dsvas; (a) tlic cavornoun nn^vus; (%) the picxifbrm 
lamu. 

TlrB!aifiU Vanu w rxtv-t^dinKl)' mmmon, »nd cr»nii<tt of a 
3M 4^ ifilttUMl CnipiliAncfs Ixnind lofj^etlier hy a ^m-iJl amount 
id ccnvctm linatuc. [t is often <:oii|*cniul, And iriiiiy mctui^c 
laFWljb UJX dutinz thr lirst U:v.- ikoiiI^i^ of life. It U lix^lcd 
^^^km, or may alH> involve the fiuhcuiancau^ tUsupi, but the 
Tdnijr form ol Ibc comiitucnt vc*ccls niwiiys perils, Ji nwy 
^^4 bngbl rcj colour. ^onsiMin^ mamly of .vtcrtolca^ or of a 
Mr tim if i\tc vcDules pnMloniin;ilc. Far a fulltr ^ccuuiit 

Tit (tovmiMu NsTut consi^» of chktvd ipac^^s. where the 

'^'uWlormof ihc coi&tJluent itbicls in lust, llic .trlcfic* usually 

ipaaig^irectty imoihin-u'^illril c^viiLFH liTiecl with endotlieliiitM 

"tiw<l tW imcrvcnt'-on of c^^pilbries tl'iR- 37)- ^^t* tumtjur* 

■nthu more o* les* erectile in nnturc. somewhat itacmlilinj^ the 

^Tftti UiTttniMini^ They iirr sonittimrs rnei -iviih tu tbr skin 

ud ubmuueouk itu^^^t. cofi^tiiutitig diffuse ur eh cun^ scribed 

'"OBUficrf tt Uuish colour, which tin hi* emptied on prptisure, 

^nfidly rtiill ^hen ^Lt:h is removed. PuUaiion is occasionally 

ICTvac. A snnihii tcmditiivn ^tl^»:iti^es in lfi«i viMci;i, eST>i;L.'lH]f^ 

^ htf- They are atwayit iicquiit^d. ;tnd it is not dimeuli in 

ubUicitn to demonatnuc this ihcv liav« been (oimcd l>y n 

Nation of !h<r c^iinllttiei l>elw«Q tiic Miulcs, ihc Vivtx sub- 

*mt meuitvhile di>up[)c;Liiii|j by a pioci.-ss of simple ;ttrophy- 

'^t^c^aooaUy a ciLvemous ancionia niay undprrgo i pnx^es; of 

■pvtuicous cure ai» tht rcauit of sotrtc inflammatory jilTcction 

aoiW ID U4tuic: to plilfbiils, a iioii-VASCular fibro^yhtlo tumour 

'iQuni«g. For tri-,itTncni of rirvi, rir., v^. p, joi , 

tJadtr tb« icrm pltzlfonn Aa^cma may be included the cirvold 

unjTvnn, or ancuiiBin by .irM^ioniosiSf the former term l>vini{ 

>^jfibc authors ti» uirnnurs tionsistiiig of l^iige vcv<cU. 

to a congeries of small vessels. It is most comnnjnly 

th« M^alp and face, as described in Chapter \K\. 

\h A (lULttei of considerable diflficulty. 




,^Tumouxs oHginatitig from ioinc abnormal conAl 
ihtt loclh Of tccih gcrmfi ore known aa 'odoatomM/ 



IS* A MANUAL OF SURGERY 

Bland Sutton^ in his book on tumours^^ has described sei 
different varieties, several of which are, however, rarely met 
in man. We can only deal here with the more important 
these, and must refer our readers to Chapter XXII. and txt] 
Sutton's original work for a fuller description, (i) BpttUUj 
Odontome. In this condition, formerly known as fibFo-cystkl 
disease of the jaw, the mandible is most commonly afifected- A 
tumour forms, consisting of spaces lined by epithelium, whic^j 
are developed as irregular outgrowths from the enamel orffUL 
They occur most frequently in young people, and may give riia 
to growths of an enormous size. (2) Follicular Odontomei, or, 
they are often termed, *dentigerous cj^ts,' are produced by 
development of a cavity around a misplaced or ill-developed tooth 
of the permanent set. which often lies horizontally, so that 
eruption is impossible (Fig- 231). (3) Flbrotu Odontomai art- 
the result of a thickening and condensation of the connectiw 
tissue around a tooth sac. They are most frequently observed 
in animals, hut are also said to occur in rickety childreiL 
(4) Badicular 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 resuh in serious septic inflammation of the 
surrounding Ixine. (5) CompoHite Odo&tonuita consist of a ctfi- 
giomeralion of the various forms of tissue entering into the 
formation of a tooth, and developing in the neighbourhood c£ 
the jaw. They may be very large, and probably some of Ibe 
bony tumours descrihed as osteomata of the antrum are of thi» 
nature. 

Lymphadenoma and Lymphvigloma'— The primary tumoun 
developed from lymphatic glands are described in Chapter XI ., 
a^ also the conditions arising from the dilatation of lymphatics- 

H TnmonrB derived from Epibl&Btlc or HypoblABtle B tn ic iniM . 

Such are either innocent or malignant in nature, the innocent 
tumours being the papillomata and adenomata, and the malignant, 
the carcinomata. 

PaplUomata consist in an outgrowth of the papilla? (^ the skin 
or mucous membrane, which may tie simple in nature, or compo- 
site from the development of lateral offshoots^ giving rise to i 
cauh flower- 1 ike luass ; they may be sessileor pedunculated. The 
connective tissue of the papillar, with its vessels, also extends intc» 
the growth, which is sometimes exceedingly vascular. There B 
no tendency, however, for the epithelium to dip down into the 
subcutaneous or submucous tissue, the growth being only centri- 
fugal in development, ami not at all centripetal, as in the caserf 
the epilheliomata. Not infrequently, however, a papilloma whicb 

' ULand Sution, ■ Tumours and C)si3.' Cusetl and Co, 



hsbecome imtatnl iray lake on iiiAlignini: »cliau. Citnicilfyn a 
npfioau ii diHtin^ii-JM-d hum At\ rpithdtoni.^ by xhv haxe hdng 
rc«lwiiii61tratiop. 

hptUcmaU of Ibe t4<m are met with in ilic form of bard 
oo pc cp oeo, sucb as warti or curns; Imi if growing from 
mMl part*- 14 froin the prifpuci*, they may In* fitjft nnd vA^Lilar — 
f^,,vtn«calwans. Oc>c*<ioiiAU}| war1«maygrowTo6iich.iiiL«}(te<it 
a* U comtitiite horTi'ldcc projcciioiu or cuuhf^owrr-l&e erowths. 

PipiBoniHU uf the iiiucuu^t meiiiEinkti^ mc UMially villniifi in 
cbcidflr. cooslitiitTrg long, ^mhtiaied tuftv. nsin^rpd with a thin 
^*f a^iomouG ^LlMiUiti, and conutnmif delicate bloodvc-^wls, 
TOci readily Ifivc «v-Ay,Ard mciy lead to con» icicmble hf Ennrrhage. 
TUy arc most cofninonly mrt uilh in the hUdder. Iiiil occiision* 
aUtris iti« p^\i«of ih<> kidney, on iht: intestiiut mutout m«ni> 
Insr.or inc r^ctum^ Tlt^y ul&o occur on the ttv<i \x^al corcb, 
mi irr tlics wnn-like. and h;trd in cuiisiMeiic^. Gtou-lli*i at a 
twy iJmibt Tvaiiirr. but Knm'Wh^t mere noWd in T^vrnr^^ are 
bud vithiD ihr ducts nr icini of ghndulv viboern, buch as (ho 
lens. Condylomnu nnd ntucoii^ tut<icles, A& fTi^^c ^Ariih m the 
come c^ lyph JIU. mc Bl«oof a pap tliumal oils uaturcr* 

Ililnntiati rnnriTT of new Rrowthi^ amm^ in conncmon wixh 
■cidiar i^ukU, and in stnictiiTc AimulAiinff w^tncivhnt clr^icly (he 
cearaDiODi which ilv-y Arlw. Tliry iJifTrr futm lb<m, hnwfive-r, 
bjreWfacu rbAl iht^yarc mripnMt* of prodnring the rhar^tctirriiitic 
otMwn, tlut they art devoid i>f doct^, ».nsi thnt tli<^ mim^rry 19 
ttcnplttc, since the alveoli *fc less perfectly developed, And may 
« touirly rxxupird l:^ i;rvirm1 lflyr?rs of rpithrli^l mils, Tlmrn 
ikhmv^-cr, no tendency for the epithelium to p»ts beyond ibe 
ti')iMiit memlKrune into the connective tissue, and honce they 
■bittcdi^iitiKuUhcd from uuicciouTt liimoitnt by the new Ionna> 
tai kin^ rentrifiig;!!, and nnt centripftal, in its urowlli. A 
*vi»M# annottQt of connccti\-<! tisauv it al>i'a)'* present, and may 
It 9erm^ in texture, or may manifc-'l v;irioua moiiihc a titans- 
A^aomata are Iraiuently cnc^i^Miletl, hciiLR mttply ujiiuecicd 
^ lb original glartd by a pe<Iicle. through wlitch rhe ve^sipk 
vto; or tbev may he of a diJluse nature. W hen i^rowiog from 
ttiKOua mcRiivHue^ ibcy iiire sotnetiiTiea pcduncutHtfrd, aa tn the 
i^<llkit po|ypu?( lecli- Tlie ^itsvuU m soiur; l^h;^ bctijLuc di«' 
I >ii«J with eEhision, giving rise to a cysto -adenoma or adcnfMrele. 
TWy 1/9 &b«olutf ly int Crom niAlij;noncv, except when, ar occa- 
ttQuly happetis, ibe connective tissue anderKoc» farcomAtoai 
Hbmi, When of lar^- vi/t^, tlicy nwy ^\vr. rise u> mtioih 
If KfilUlU by comprt^sdnn nf imporl»ni &iTuetiir<-s- Any gUndular 
«lw m*y become aflicctcd with adenoma, and wjvcr^il vnnelieM 
wWdckfibcd hereafter id the chapter* on the brea%I, thyrdd 
brfy, protitMtt, leMK ric, Th4f growih is iitimlly ^Inwi but it 
aecwoaally b^comet wry rapid. 



V»l 



A MANUAL OP SaSGERY 



<todlMBA^-Tlic' U)iU«nvit §antm of ct>lttir))A] new tn^wtU ns 
SmeniTly Vnown ns mnri^r^orcJirrinomMn, of which thr iciUaiL'Lnif 
van«^li«:K mt\y be d^^ciibed, vix,, f-piibclioiuiL, rixli?T>t ulnf, 
columnAi citrcinornAt mid ^luidulAr or adftoii^ c^nocr. Tke 
term ii^Lloid c^mcrr \f- al»o ijsed to indicate r dcftcncrativic clunc« 
occiirrinK in ^nit^ fnrrfift fif thin clnsft of titmonan;. 

The cfT^entla] chAfAClor oE A Cftnccrouf; fftowth conusts in ui 
imlimilcd multiptic.ilbn gf the cplthdb) elements of the orna 
mxjuletl^ 111 snrnp ni.v> this may rtniiU m the rtirmiiliun uf a 
9tip«r6da.l ourgmftih iif a papillomatou* type (Kip- 39), wtiile 
<l«ep pioc^f^ncn or columns of cells ailvtuice lato the tiASUM 
tHon^ the lymphniic ch^nneli, jiad even burM tlirtm^ti the b«Ae- 
mmi me]iihr:ine ai gbnrhihir alveoli. The iiriTalioii of ibift 
d^veloprnefit leads to an infiltration of ihv surrounding «1niciQttc 
with rouiifl cells, which .ire presvinubly inRaniinuloty in ori^. 
by llifl agcrity of ^Uitl: the nonnal tissues Ate (li»miWAled *od 
rrmovprf. and u fibro-olcatricin^l Mmni* of variahfr di*n«i1y 
developed Hfoimd thvepilhdiul out^frowlhs. H^ncfr.ill cancerous 
tiimours nmy be considcicd to con&isi of a f Wo cic*U(ici.il stroini 
(Fic* 4J) williiii the dlvroli of ytlnnU mc collections of cptthcM 
cclU, ftinirtiinrs arrsngcrt in fl mk^thivJir^il ruaiinrr, Uin man 
frequently inrgtilflrly pitckcd toccihci, .ind with no intetcellular 
suh:tlAncc l>rtwccn them. The nlvct^Ur ^pj^ccs ntc in reilily diUted 
lymphatics, -sml h^'^^t:v it \s msy ki undirr^l.ind ihjt ctrcinnnuta 
Ate di^flf^minalitd ty way of the lymphaiW ; Ih' r^nccr eelU Are 
nlwAyt^ cpttiiclmi in oricirtt iind of very vAnablc hitp and ^ope. 
Blc»odvcssds ramify ihrou^ch the growth in the Miona. and ue 
more nr Ws alnimlant arrnrding in ItK dni*iiy. SpeakinR gener* 
nlly. cancerous Iumc»;irG are Ufifi vasculAr 1b;in vircomata. 
aJtbouj^h there in a i^CAtcr amount t>f hyper^emia immeilialdr 
mound thi^m. A roimidnnihlr de^Mrec of pninn usually ui a 
neuralgic t>'pc. i» nftnn complained of, nwinx I" 'he implirjtioD 
oi ner^'c hLmienti: in (he Ktouih, and to their tub*e<iuent deunac- 
lion. 'J'he tumours arc, howc\'cr. not ncccssarilj' tender lo Ibe 
tcnti: li . 

jEtloloay. — A vi4t amount of work has l>ei?n rind^riak^n ^ih 
the object ol delerminin^ the cause of cunc^tr, »lUiough at prvMDt 
hut htllc advance \\n.s been mndi'. FoTmtTly (he d]M^aM: WASCOri' 
iiidered Eu lie uf conitttutionftl uiij^iu. ic^uliliiu: ftorn sotnc morbid 
condition of the bkiud. uud in fjLV'our of ihts faci ihe immmw 
difRcultv of cradicutici^ it y\;\^ cduced> as ttl«Lt its hcrodilaiy 
DAlurv in r n Any ca Adit On the wlii^le. hoiA^vf c. thU theory b^ 
htrn disciiideii in Tivour fif one whiih truiiiuins that it is 

tnanty local in origin, aiid probably the resi^lt of the isocula- 
I Mnd dcvelopmcn; of scnne apecific oreantsm. The cihief aifiU- 
n1^ ill favour of it» local origin Arc AS follows: (i) ThiU k ofbca 

urs in individviali who, uji to ihr time of \t% taaei, ba^-c booa 
perfect beftllh; [^) 1b:it Cachectic ijymploifi^ fsenerally oaly 





TUMOUJ^S AUD CYSTS 



>S 



t1:e \i%ti 



of the diMJi: 



then 



by «ii:(--ALie j>.u:i, tlic al»htJTptlcfli nl -STptii: ilia- 
b>ood, or pus^iiMy lh« toxic efTccf of seme 
nulri.il .ibflorbod from ihc |-rowth ; (3) that the ori^md nocj- 
pLtiu i> ^i4dy& sti3^)r. multiple lumourn hw^ tlir ftfrsuU of infct' 
iam; fruni ihc prlnurv i^rowih ; 14} Ihul -^ituw dfhfiitt fj.M:i:ft of 
IcoJ iniraiion nwy ftequenlly be irnci-d a*; The cins^ of the 
lunuur -f.f., the )rnuiion of the- lip ^> a ahoM <-lay pipe, the 

isg;^ IfTch (If st-phjlitir nflVriinrm, ptr. It tk slso inlrrrsimr In 
MPtbal cancer umjUy tnvnlvtrt^ tIi« intcfstinal canal in situ.tlidn^ 
itettbcrc ii> A siiuldcc chftni^e of ciilihrc, giving rise to inc:rca^() 
fnctUD ^Doti ihr pAMiAlfc of thr (x>]iic:nt>^ — f .^,, At ibc u^ipn iuiJ 
InPEt vntbof the n'^ophaRiw, thf pylonis. the ileo-ca-ail valve. 
ddv cpd of the sigmoid flexure, the lower end of the rectum xnd 
A* apB^ {$) Xlnrodvcr, if tin cviHy and thorough opcratico i£ 
JirifflJoen, tlie ^.-icrnih atn Iw rouiplrtiOy i^tiuHciilPi! finMi thi; 
i!«ff», whiUt even if it recur*, U tendft r-nthct to attack the 
:icitnt ia the ociffhliouniif; ^Lindfi, indicalinfc thai 1h^' remuval 
kj kcu iacompktc, 

QtlnbciiTc utiiFeof cunceriK^ttillsnfbyHifiVr. DVnaW evideiice 

ntus bft tikd&cate ttia; c^dcvt m-iv Iw triui^mjiied iram one person 

Uvctbtr,but it tt» fijuicwhai Mrimiv in uinuunt. Thu£,eiincorof 

ikccTTu ulcri biu been known Li>lie follciwcd l>y cplthtrlioma of 

itcprnis in t^e hu>LTKLncl. Again. 11 \tav Evmi vboi^n ti}- Sh;ttt[jc1< 

ibtiucvtuui houMsfcaUed by him -cancer house*") one *iei of 

•brilcra afier Another haa Ixxn attacked by Inis discaacH 

EMttimtitisI iesft4Kh, aa to the UanMuiMihiUly of lumlfj fioin one 

iQMdu&l 10 ;inother. k nec^so^niy unobiainiible, iilthough it hfm 

'vtt provtd xhM, in a perK>D aUeudy fi^jKvitn^ from cAncef, a 

pmmcf ihc j^iowtb Iran^pl&nted to a. diulart part of the body 

'Tllptw, mmI ir.id to the forniHilionof asiiiiili*! turnuiirat iK-sitc 

cl axuUtion. Attempts hav^ nisn beea m^de m transmit the 

<te»etoaRimal&, hwt with a very slight iioijr«e ol success, even 

b use* where the point of inucuIrtUon has been previously 

>tiut«d. Hence ihr view thai r^ncft is due to infection depemU 

ciaber on ibe adaIo^^ of the dUcftW to ether chronic infective dis- 

vdv« than od nny ncU ar.ccr1aincd facts, The relation of cancer 

ft> fWioipif alu has been nuich (li»cii»«d of rectum years, and by 

wv attthoriliPK ih<? c]]S(^;i.>(t la Rupj^ow^d tci licf duf? to these 

tflfvnuni. Thdr opioicnK are hixwd on the foMoAirif facts : 

^J Thid in the tiujoiity of cancerous growths certain ubnurrnwJ 

refieml>KnjE; ihe cot<:idia of p?^>(o^peIlll^ have Iweii dcnion^ 

nted wilbin the ^pitheLud crlli : but even if tht^se * cancer 

kdlM ' are of this nature, it ha:; yet to \ns proved thai th^y are 

oiaative. aitd not concurrent manifestations, whilst it is a)M> 

CBe that ncniiu bodies can be Tihowii tu exhi tn saECornat 

aod «\'e& syphilis, {h) In rabbits ^itlVering from irn- 





156 



A MASCAL OF SURGERY 



doubted psorospermosiSt outgrowths somewhal simikr in iiati* 
to epithelioma have been detected in the biliary ducts of the U^ 
and other viscera, and these growths have even been produced Ifl 
artificial inocvdation with the organisms, {c^ Cancer of the bM 
frequently follows Paget's disease of the nipple, in which liV 
disease psorosperms are almost always to be found. Mnd 
stronger evidence must, however, be produced before the thwi] 
can be accepted. 

Epitlieliomft (mn. ; Sanamons Epithelioma, Epithelial Ouieff).- 
By this term is meant a cancerous tumour growing from skin( 
mucous membrane. Formerly a variety known as column 

epithelioma was descritied. b 



this is really of glandular origi 
and will be dealt with later od. 
Epicheliomata are usually ni 
with in middle-aged or eldei 
individuals, although occasional 
they may l>e seen in younp adi 
life. Any portion of the skin m 
become the site of this tumour, 
also the mucous membrane oft 
mouth, pharynx, and itwphagi 
and that lining the genito-urina 
tract. It commonly results fit 
some long- continued irritalii 
AS in the lip or tongue, whi 
epithelioma of the penis isalwa 
associated with a long foresk 
Old scars, especially if tt 
breakdown and become ulcerat 
are likely to Iw invaded^ and i 
<lisease niay supervene on 
tractable lupus. 

Clinically, it may l>e looked 
a^ a mah^nant wart, which tei 
not only to grow outwards fr 
the surface, but also to bun 
deeply into adjacent lissu 
sooner or later ulceration folio 
Stiveral characteristic forms n 
be described: (a) It may oc 
as a nodular indurated mass, with hard everted edges and cen' 
ulceration, j-iving rise lo a Sijniewhat cr;iteriform ulcer (Fig, ; 
{b) The di,'Stniclive prociiss may extend etjually with the t 
formation, leading to the appearance of a depressed ulcer, fl 
sharply-cut edges, closely resembling a rodent ulcer, {c) Oi 
sionally the superficial cjutgrowth may be very excessive, and 




Flli ^S --Tvl'ICAlr EriTHKI.POMAT<U-S 
I'LCKIf, SIIOUIMi nKA?Elt-VJ» MaX- 
GISS AXll nUKI'CKNTRAl. (kaTKWI- 

FOKH [Excavation ydn.i.v.uv. oi- 



ruMoatts AHD cTsrs 



■w 



ttettmaiTe prooesat mipimal. gjring riHe ronpTcg'iH:tin|rcaultl!own'- 
SJtt nu£i (matigmMmt fxapUlowUi, ¥\g, 3^), {i) A diTonic cpi- 
tbtiJiDOtt » vornetiitm bcwd. in wliich tli« tibroufi stroma co^ilnictii 
Uhi ffinipiie»e» tbe cDlurni)!i uf epitliclial c^Wtt ; iIlc ^u^l4cc ih then 
iDduratFil mid wail-liku, with bul little ulcMiifion, \iJitUt flic lin*^ 
^\tr\ h:ktdi and tb« prog^res^ of th« ra<t<* nnicli ic^ r^pid tli:ui 
melbcf Jorma jKi*;- »7)' 
Tbt JivAM. as d rule, early iafcclj* neigMxjuini^ lymplidtic 
whic4i bcrnmo rbo srai of a similar growih, anrl lenrl 
or bter to irivoK'« Ihe skin ;iiid gtv« riw Eo charac- 
icr«tic alcc>AlioD< As the dis^^sc proi£rcMc», mort- dialAnt 
^i.upQ uf LiT'iiptialic trlAndii uiG AltdLkvdi iL lii uiiu^uaI to fiud 
tiia fom of cftikccr Afitrfntiiaifld through ih^ internal vifi<^<7ra. 
tml it do«6 occvf. Occastionalty ihe glands Iwcome cyi^c, 
opeoftlly io ibc r.ock, And on cuiluig into tliem a thin turbid 




Pit* r 39,— Pamllomaiuvs Trrs or EnTHtLJOHA^ 

iW like 9cru-f)u« may esi:iipQ. nitxed, pcrbapa, wilh iiiatws 
'jf qn[l>f1iAl il^firis ; frotti litiip in lirtip ^imiUr marcriAl i)t di^ 
chu*^ from ibv reii^iiUing Mnuefl^. ULcor^iicn into th« moio 
■Mub oE ihc itcck nu> alho follow, nnd load ti:i dcatli from h'vmor- 
fWt ; mLcrnklfc ihctti^ event UduciocAche^u and c^kliAUstJonn 
Knnfc|^dJ/j% au ppiiliclbma c^nidsis of chib-iih;iped roUimrK 
<' MbctuJ <«IU, ramifying in the i^uhcutaneoiis tisAiics, and 
^"^tfUrhn Ercdy with cncb oihcr, so na to produce an irre^ilnr 
Mvork. the itieshcK ol which aie occupied by a. tjbio -cellular 
ih (M^. 40). Thi* suprrtiL'bl cells in e|3ithehtnn:i an? usually 
t ID typoT t^ut in the deeper p^^rls prickle ce\H arc not 
Illy oboeTNW. whilvl the processes arc t>oiin<led by a 
\y defuiiitf byei uf Luliotdal epuhcliuni, lending; Ui btLtmio 
tDlamiut. Within (he proce^^e^ concentrically »rTAii[^ied collec^ 




>S8 



A MANUAL OF SURGEKY 



tions of squamous cells are frequently obseri'ed, known 
* epithelial nests ' (F^. 40, 1). The stioma in the neighbour^ 
of the advancing columns ts always infiltrated with an abunt 
exudalioiL of leucocytes. 

The characters and treatment of epithelioma as met with 
various regions of the body are dealt with under the appropn 
headings. \ 

Eodent TTlcer is generally admitted to be a cancerous turooorl 

an epitheliomatous type^ commencing probably in the sebaceo 
glands. It is usually met with in elderly patients, though oco 
sionally observed in those under fortyi and is seen with sped 




Fjrp 40 — SECttON OP EMTHtLlOMA. ^ZlBGLBR.) 

a. Epidermis : b. corium ; i. subculaneouR areolar (isRue ; d. sebaceous git) 
I. hair fohicle : /. cancerous inj^rowths from the epidermis \ g. deeply 
canceruus cell groups . /i. proliferaling fibrous [issue : 1 (above), cell 1 
or epidermic ^lobe , 1 (below), sweat glojid. 

frequency on the upper two-thirds of the face, the skin below 1 
inner and outer cantht beinp the chief seats of election (Fig. 4 
It commences as a papule or flat-topped nodule in the skin, 5 
rounded, perhaps, by an area of hypera?mia, which gradually a 
slowly progresses. The infiltration extends in all directions, I 
the ulceration usually keeps pace with the new growth, a 
indeed, frequently exceeds it. The nicer has a smooth 
somewhat depressed surface, is perhaps covered with gram 
tions, and bounded by a sliyhtly- raised, indurated, roHed-o 
edge. In the later stages one can often detect evidences 



7V.V0VRS ASD CVSTS 



IW 



thtMT IbrmalioQ bctieatb the skin beyond the edge. If kept 

4irfM, there in but little (liE^har^c, and impcrEcct nttcnipcs ftl 

u:^fLUttoa juc often observed, the sc^r, however, rpadilj brcak- 

njAnni oflAUi : biit u-here Ihc siirfufre i-; nlEoiied to ht*rome 

B^, it i» uton eo\«rcd with tLloughftT uttd an abundant of^cn^ivc 

fytbiiCgt iDAy rcsulL The condition is painless: neighbouring 

|)t:^lk^ arc nui cnUrKcd* -i>id the griicral hedth ducn doL 

wftt. rLcvpt in the Utcr Ktaf^rs. Tht progiess of the caa* i* 

llev.but continuou!:. Mid although il c^iids to spread superhcLilly 

alter Itim deeply. :iooncr or Mcr deeper sirwcturrs bocoine in- 

ttifird. ind mjthicti{ Imidcri^ tlie dt^sliuLtivT procc'^. even iht^ Lxmt^^ 

of l&* ^tiJ] being tl^mly eroded, ^nd the diira mater *^vposed,[^ / 

iitentt^ftMiiy, the Rrovtlh is very F^kmiUr lo jtn <iptthclio!i)a, 

fna iftbth, indeed, it u^ay be diffii:tdt to di^tiiij^LLiblj it. InUi- 

Kunf cnltifrinf^ uf epithv^ti.^l 

cdfi, iDl«np«T9ed Willi libro^ 

<tlhbr thsuo, BTU always evi- 

4ai; i& in ilir Uticr di»ca»c, 

M ^ chtfS diflerpinrr^ from 

ffitkdnBui causisl in ibe facti^ 

tilths the oonf4i1iicnt celUn 

ilAaach cpilhelb). are not 

qidmnic in rharaetcr, tieinj^ 

vialler, morr f^iobul.ir. never 

d Ibc -pocklc^ell ' type, and 

ttvfv fhowini; ^^^^ ^ kcFA- 

Eantm ; b«nftee 'ecU ne«t« ' 

V* aDcommon. althciiffh a 

lAdeocy tc thcif formation ia 

«aet£iB» ntHerveil: fii-) ih;^! 

CW dMp proce««ea are not 40 

Moct^ cotumnax or club- 

tkipol taxi 104; ill ^ut&id 

bwaAf bei>eaTh the UTid1Te<:led 

A nifaer than dvepi) ; more- 

enr»tiKu cj^^liinc ia more clc;Lrly defined, und (requcnlty fin^'uiar 

I HI nctioa ; (m.) ttial there lit Icm cell inrdtrallun niifund Lhs iteu 

' farnaiion. 

I A amifwhai fiimUar condition haei tieen describ«id l>3' Mr^ 
Hllutchi&wn tinder Ibc title tratcriform ulcer, ,ind probably con- 
Hlbts oi 3 cliiiuii<: epillielitiinj:). commencing in the sweat K^Andif. 
^k dnoelv re^emblet rodent uleer in its clinical fejituret;. and ]« 

Tbc ^iMtmeDt ol rodent ulcer consists in excision when 
|SMli»J4r, the defect being made ^ooA t>y gianuUtion and Nkin- 
p^kfti^. or by tome plastie operation. \Vhere sutli c^nnoT be 
mdattkca, tbe uker may 1>e thoTOiijj-h[y ^ntped, and lite ifiirra<^<* 
iToted *ilh ditric acid or some nimihu caiiatict 




— RODIUT L'LCBR OP Fac* 




i6e 



A MJSUAL Of SVUGBMY 




Oolomimr Oudsonuu— Thit afTcction, whacb was fonnerty 
tcniied 'cnlumiint cpilhciicmii/ ir> id the majority of CAM* A 
glandular cAiiccr. It in nici with mt^nl frequently in tne a!inwoi*ry 
dn.iln -arising fimn iiny poriinn nf ii in whidi tolumttu cpilhdmm 
occurs, and u^u.illy ori^'inrttind ax an o^■e^growth of Liebrr!rohn'« 
follicles {{'IK' 43)- These grow omwardi from t]i« naiiACt »a tb^ 
Kline way a» n papillmmi spring horn tbc fikin.but &\ao pcnct£«tc 
U(-eply inlo llur HulimucoLi^ iind rnui^t^tilaf coals, 'file <Wp pro- 




^p|iJ.|,^L.H f h -^). (ZllbUL*K I 

from tha muccMa, hu in^;kflod thv <ithar Inyvrv Snia]]««^laJ mifilmalA 




cesseii reiAin :tn iiTiperf^ct niveolnr orriuiKt^ment, the epitbelbt 
celU T\oi p«j:etrati;i|j tMryond the; LtiU^ment membrat^e, A ccnua 
unouDt of fibrotelLild^ ^liuriu is d»o ioxmil beti4eeii them, Asd 
upon its ;iitia(i]it the hardiness of lh« Euiiiuiir tfleperiEls. In ihc 
firmer lyptfH ihf stroma k ahunda.nl, :iii<1 Irhro cic^ilikuU ffl 
lUAlily, the Krou'lh of Ihtr tumour being «]ow; tn the vofler Ottd 
more TApidly -^Towing Tonus the stroiiiAi»leba .ilHintiu^t*asd more 
frf a MTnpl« tibm-oelluhr naniTr, On s<rnoi> rif fl limiterl portion 
of the growth, it would often Iwr imposKjhiv lo dutin^uisli it from 



TVMOUItS AtiD CYSTS 



lie 



\ 



I tbple iJkDoma of Lieberfcuhn't folUdes: hut if alarms sectioD, 
bcludia;; the whok 1hickre» of tbo IfTowth, is examined, the 
eitenoioQ of tSe f;Lind*i into accl between tKc muHcular Ea^culi 
•it wa iadicftCrs rhe nali^ani naiurtr of tTie vnse. L'IcpT;ition 
uRiAUyoccw« filling ri^ 1o a typical sore, bounded ia th« inor? 
cbfcnfe forms by ioJuntl^d and everted c<^e». NeiKhbourin^ 
l^iupb&tics arc implkjitcd, a^ in l}ic casc of a11 cancels. wliiUt 
Ijitrr ikn iti^ dt'^.iv <nri'-^<U lit rhr vLsr^iA, nni\ tmty hv g?rier»l1y 
itiwmjwiTtfri. A fiimtUr lypc of growih rx^irurs in the cervical 
ppffrtiijo of th« utcvus, ftiio (xt/isionflll)' ftTi-.c3 in tli<r ducts of 
xcfdory ^lajid«. such a« the iirc-LM^ ll I» »].%■> met witTi id IIjc 
vpmnr amxilla, nrigiiuiing in ihp ttilniUrginndHof rh^ miirniis 
mmlifHne Lirtm^; the aclrum. 

ffiutdoUr or AdBo^it Cancer, — CtLinduUr r-aiii:ct may 1>e looked 
iBu;i ni:ilii{n;ini Uani of adcnrjin^i. I>e-inrff the tanic! rpUiion tn 
ftuiloti; All (.pitbdioina to a bvrti^ papiD^nm. Thcr epithelium 
<ifiae cbDduior iAcini, from which it oric^inatcs. in not retained 
I? l!ie tttviticpt nemUrane, Imt tr;ivRU licryomi it hIiijii^ the 
tymphitict into tunounding p:kTls. ivhirh are trAn^fonnc-d h\ n 
^pfK/etA ilrtady descrilwd into tlii? lu'Tmur ^uLiHUince. 'lUc 
uuwuuf stroma varies ttmiiderably, and Hi;:turdiai; to whdher 
di^abumUnE or sriLilt in tjuanlrfy, (he lurtiour is briril of soft in 
ramsieocc, airi »low or rapiti m ^rfoivth. To ib^ former iypa 
1litl«rni Seininu aft applied ; to the bUcr, EncepbAlnd. A third 
'•tt}, kiHnvna!] Oollotd, i^ really due to de^ejieialivc c:hanges of 

SdnksA i« inct with mo-M fic^iuoTitly in the brcaAl, but also 
ocomiQ thr ;jEiAl;iIet (hiui.:rA5t ±uil pyloric coij of [\i*^ ^toitiuch. 
Tfce clinlot feJturo*^ of tht ditca*ie a5 wen in the breAc^r are 
ter^itd in the clinptcr on di f ^fc iet of thnt onfan. On rniked- 
(T* ^ximiiiatioci a Kinhou» tumour appears as h hard nodular 
>u& itic limits of which arc imperfectly deRned. Wiiun 
oil ACFOU, ii cfcttkn ttnder the knife, and presents n y*'llowT*h. 
*bik turiaCG, which rapidly 1>ccomes concave owinf^ to the 
cmEEiclKKi of the ftirou* ittromA. It has oflcn been compared 
iDlbe la^ciion of an iinn[te pirpU nr turnip. Ijoth rm ;iccount of the 
tp^t seiUAtkio imparted to the knife* and from Us a|]pearLince^ 
Ol KnqhDC the surface with the hbde of a kni^e, a typJical tiinccr 
fliccboliUjtinl, coDtaMin^ nf epitheli^il ccJU and debris. 

Ob nkimfopLcal oammiilion, iTie luiiioui is finind to corn^at 
of ifi «bund«nt and vtvll marked stroma [^'i^' 4J)i the acinT of 
«fcicb tfe ^Icd with cpithchal celU (Fi^. 44). In lliv centre hUy 
difCBerJttioa i» ufltn pECf^fL-iiC. Miidll cy^ls bein^ iXv-iMoririlly 
fnAitfd In thr* w;»y. Al the prTiphpry rhr growth may l>e «rrn 
tiUtaka^ m ail ihreciion^ ;ilon^ rbo lymphatics, whilst a round- 
Khhltnttioci of the surroundirk^ li]>9V]c» \i> alrio evident. 

It 




]«3 



A MANUAL OF SURGERY 



The relative amount of stroma and cells varies coQsida 
in different specimens. Where the former is very excessive 
cell elements, and, indeed, the whole tumour, may uu 
atrophy, constituting the variety kno\x"n as ' atrophic scin 
On ihe other hand, many cases occur in which Che epithelial 




Fig 4^ — STHo>rA Of ScirhhuSh from which the Cells have bee' 
Lahge Extent removed. 




pTf.. 4^, — Sectton of (iLAniiitlar Cancer, showing Alveoli ftlli 

Kl-JTHELIAL CtLLs. ANU A SOT VEhV ABUNDANT StRO«A. (TlLLM 

Such a growth would not be very haid. 

are much more abundant, and then it may l>e impossible 1 
10 which of Che a rCifici ally -constituted groups of glandular 
it l>elongs, 

EnceplLaloid or UediiUary Cancer is the term given to a 
of a similar naltn-e, in which ihe stroma is much less ab 



TUMOURS JSD CYSTS 



<«9 



p iWa th« «dl dcti«ccit«- It cwistil^iK'K a soft, rapidly irrovrit^ 
r [jjoiaui ibmidaatlv tui^plictJ ^itIi Liluixlxcuels. ;uul icijilitit^ \cty 
' ckI}- to sfipn nntjblxmrmK IvmrhAiir ifl^nds. The HkiD cn^r 
wk 1 tomnui U tlralchcd, wiih ojiMed blue vtitut ccursinjj over 
I. UWraiion occurs tArJy. And (tor) this surface a £uuL bleed- 
■(,fuD|CJliEiii[ mAs»i «p^ouI^ L:p,<;onslilulLii^ II11: condition for mrrly 
InitQ^s • funxtw ha^matodoa/ Knc^ ph.iloirt rartcor h a:ti vntt 
aibe br«ftiit, t«!£t)>s kidney, and a kw olhcr j^Undvlar orpi^ns. 

Un section it » f^Atnd to be composed af^^ R>fl wMtiali mass, 

«[irf*h*t trT«itiMinf{ lirain Mthvliun-K. h i* iNiially vrry vav^itbr, 

k p^bfM polsating, ;uid h;L-morrh;iHic: cxirnv;isaliaii into iu lii;6U«8 

BcM uncommon^ An .tlnind-int }uice ir. ntitmnod on sicrn^g 

■ i Under Cbe injaoicopc, it n seen lc> ttc cnmpix^i^ tif Ur^ 
Hcnv^ of SipberuAd^tl <r|^ilheli:il uvU'i, beld togf?ibcr hy a w^anty 

I CUMd Oftac«r rf^ull?) from a dri^'pntration uf (hr rpilhdial 
I icUof 4 fflAfidtiUr canc^. ]u most fr«qvieni vii^ iu ufiibin the 
I jfakmiftir cftviiy, in connecttoa with c^ncvrb ^&m(; inxm the 
I ii awaA, interline > cr omrnlUTn. 
H Tolhc iMLkcxI c^i; Ldloid LJiiLvi ptcrj^cnl:? dii ;lIvl'uUi nlf uclurCp 

■ Ari(i«fc« being nll«l with iranJticrnt ffcJaiinoos mattfrLnl of 
BivjiBf^ iknKily. Microscopically, the cpiincJial coJIs nit; rurcly 

■ ^n^-j^rhahkt being replaced bv a Mruciurclcsa cotblddl suh- 
lt«ia. Towarrfh the pfrfiphrry, Iio««ver, ifie cells may Iw *fMi 
Inptcrfs of dv^nnvraiion. globules of iVmnlem) foriTimg within 
Huoi ukd pcvsm^ ihc nudcus to one side- 

B Tbc TrtftUnMLt ttf Cuicar a1w;i)% consists in tK remoi'nJ by 

Bnpmtion vtiien pmclicAble- if such i« corducled in a thoroucb 

Btaoatt and at a mflicLcnily cnrly dale, n goixi result iiuiy be 

WtfKipited : tjul, owiny iti the tc-ndmc> of all c«tncers to spread 

B * W '^ lyinptialicft, it* entlicatiim 1* n mantr of rhe RTcatost 

Bncultv. Ki?cxim^nce is Ihciefore WTy liable lo ensue. 

I Jk id casea where removal cC the diM;n^ by the knife i* iin- 

■EV&ublci, uwiii^ lit i(H extent, ii may !«HiieliuLcs hr. [nhs«lilc 

■vmnc^f a portion of tb9 cli^tT.isi^, ili^ leinainder heiriR dc.ili with 

fcy«M1>CT, Of ihMO the mo^l ^lisfactory is chLcjnU^.* at nine, 

■*»ch biiAUAlly applied a* a pListt, a little opium boin^ ad<kd to 

i^r ptln. Ill otber €4L»e?i i1 bas Xnvn proprjsrfd Id slaive fhi« 

pcndi by tying the chi«f nmricnt artery, and lo diminish pain by 

v^vioQ A i^ntory ncrvta; sucb can, however, only give int most 

Xc^orvy relief. 

Of leccnt years oihct incl]icKl§ have \iecn su^cstcd for the 
lovniem of inopeialile mftli^ani lUsease— /^,, the imerKlilial 
Bpc6o^ Oi pyoktAoin or mcihvl >ioLetT or of various bu/:tunal 
Mhldx such a» Coley's fluid. S^iilit^tent evidence is not yet 
wbcDmavg tudete.cmhie the pnictical vnhieuf Lhti^e piuLe^'dtii^s 

11—3 




164 ^ MAffUAL OF SURGERY 

but there is no doubt that sarcomata are more readily iuRueixi 
than cancers. 

In hopeless cases, all that can be done is to keep any ulcecsl 
surface free from irnCation^ and if possible aseptic, whilst i 
general health is maintained by suitable diet and drugs, < 
excessi\'e pain is kept in check by the administration of ojriom 
morphia. 

OTBtfl. 

By a cyst is usually meant a more or less rounded cavil 
with a distinct lining membrane, distended with some fluid 
semi-solid material. The term is used somewhat loosely, bei 
applied to a variety of manifestations which it is extrera 
difficult to classify, owing to the fact that conditions which 
pathologically similar in origin are sometimes termed cysts in 
part of the body, and not so in another. For practical purpoaJ 
however, they may be grouped as follows : J 

h Cysts of embryonic origin, or arising in connection vid 
embryonic remains. I 

II, Cysts arising from the dishnsum of pre-existing spaeti (^M 
tension cysts). 

HI. Cysts of nfJi' formation. 

IV. Qysts of dfgfneratioH. 

I. OyetB of EmbiToiuc Origin, or ftriBinf In conn»ction wilk 
EmhTTonic Bemalni- 

1. The most important cysts to be considered under thisheadi^ 
are those known as Dflrmoida. These are characterized bv 4l 
existence in normal situations of cavities lined with epitheliuiQi 
from which may be developed any form of cutaneous appendap 
— e.g., hairs, nails, teeth, etc. ^whilst the space is usually occupJM 
by sebaceous or mucous contents. The structure of the liiiii| 
i\ all is very similar in nature to skin or mucous membrane, c<» 
sitting of stratified epithelium, from which a considerable growd 
of sebaceous glands and hair follicles often takes place. 

Several varieties of dermoids are described ; 

(a) SequeBtration Dennolda are cysts arising from the incotf 
plete disappearance of surface epithelium in situations when 
during embryonic life, fleshy segments coalesce. Thus, in almoi 
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 9C| 
nients. Similarly, they are not uncommon about the face an 
neck, occurring along the lines of the facial and branchial cleft 
Perhaps the most common position for them in this region istt 
upper portion of the orbito-nasal cleft, behind and to the ooti 
side of the eye (Fig. 45). It is not unusual to find the ski 
defective beneath them, and a pedicle extending from the do 
side, connecting them to the dura mater. Sequestration derniw 



TUMOURS AND CYSTS 



165 



pear as round, definitety limited tumours, over which the skin 
des freely, but are usually somewhat adherent to the deeper 
ns. They are iirm and elastic to the touch, and filled with 
laceous material, containing fatty debris, flattened epithelial 
Is, perhaps hairs, and occasionally teeth. As a rule, this form 
dermoid may be removed 
thout difficulty, but in those 
curring about the scalp, 
th the bone hollowed out 
bind them, it is perhaps ad- 
«ab]e to delay operation till 
nit life, unless the tumours 
ow any tendency to rapidly 
:rrease in size. The reason 
r this is thai the bone 
adually grows up around 
e deep pedicle, snd thus 
Dses the communication with 
e cranial cavity. In some 
.ses it may be difficult to 
move ihe whole of the lining 
embrane by dissection, and 
□der these circumstances 
le surgeon must attempt to 
tstroythe portion left behind 
ith the cautery or caustics, 
tberwise recurrence is almost 
ertain to follow, 
(ft) Dermoids may also arise 
1 connection with embryonic canals and passages, and have then 
«n called TnlmJo-DeniioidB. These are chiefly met with in con- 
■cction with the thyro-glossal duct (Chapter XXVI.) and the 
wa-aiial gut (Chapter XXIX.}. 

(c)pTariAii Dennoidfl are usually unilocular, and of large size, 
Vs a rule, they are lined with skin, from which an abundant 
le\'elopment of cutaneous appendages is often observed. Thus, 
he cavity may be more or less filled with hair, which is very 
unilar to that found on the surface of the body, and is stated to 
lecnne white with ace, or may even be shed at the same time as 
Ik scalp becomes bald. Large masses of teeth set in bony alveoli 
ire also seen in this situation, and even nipples and mammae 
bave been developed. 

^- CyvU occasionally arise in cmnectmt with the formation of ikt 
Uttk; such have been already alluded to under the terms follicular 
>nd epithelial odontomes (p. 152), the former being also known 
to <ientigerous cysts, the tatter as fibro-cystic disease of the jaw. 

3. Various cysts also develop in connection with ihe remains of 
fc WoiffioH My, as also from its ttiMes and duci. 




Fig. 45. — Dbrmoid Cyst, growing xr 
THE Outer Asgle of the Orbit, 
(Bland Sotton.) 



l66 



A MANUAL OF SURGERY 



Tn the male (Fig. 46), the Wolffian bcxly atrophies alnt 
pletely, being represented by a few blind tubules, sitiu 
to the epididymis, and known as the paradidymis, or 
Giraldes. Fibro-cystic disease of the testis (adenoma 
said to arise from this structure. The majority of the 
the Wolffian body form the vasa efferentia testis; a fi 
upper ones, however, contract no attachment to the testis, 
free ends (known as Kobelt's tubes) may become dilated, 
small cysts, situated close to the hydatid of Morgagni. 
sible that an encysted hydrocele of the epididymis sometil 
from one of these unobliterated tubules. The duct of the 
body forms the lower portion of the epididymis and vas ■ 



HydHtdDr 
HoTBifinJ. 



\1 Eti I ne p Ik r»\i 




Fic 46 —Diagram of Adl'lt Testicle, to show Relation of M 
AND ITS Ducts. (Bland Sutton.) 

In the female (Fig. 47), the remains of the Wolffian 
sometimes met with as a series of closed tubes in the i 
hood of the ovary (paroophoron). Cysts may arise in < 
^^nth this structure, and are chiefly characterized by t 
walls being the seat of proliferating papillomata. Thi 
tubules can almost always be recognised in the broad 
constituting the parovarium^or organ of RosenmilMer. ] 
OTBts formed from the distension of this structure a 
unilocular, and filled with a clear limpid serous fl' 
have no definite pedicle, and strip up the layers of 
ligament. The Wolffian duct generally atrophies, but ot 
runs down between the layers of the broad ligament cl 
yterus, to open in the vagina near the urethral orifice, I 
icnown as Gartner's duct. Cysts may arise in conne* 



TVUOVttS AND CYSrS 



■»r 



thfb vlTuctorc. p«ojc<tini- into the IntrmI Fornix oF the vn|>iRA : 
thry iw. however. e\lrcnic1y rare. 

(. Tbr pwitfmms MigaM/if, (Jt fxinicubr prorpw, it the tprirt 
i^^M '.o the protrusMO of peritoneum which precedes the testis 
iftiRBlbc tanicft vaj^iulifi, and whkb la the female ac!co^1patlie^ 
Aeitnod li^famcnt. Sorm-tlly it liccome^ Dblilcralrd. Init OC' 
tsBDilly pmtion« nf ll remuin n:ilen1, ami dtp c1:<<ttnc1«| ivilh 
I dear iira^'^colouKS^ fn^roat nuitii conMrtutin^ in the mule 
u imki hydtwtk «/ ikt t^rd, and in Ihe fenuile a kydrcceU of the 

pi- OrtU du« to the Dlstooslon of Fre-03d«tiD< Spikco*. 
(i^BndatioDCTtts-in:-^ ln>m ihcdir^eo^onofczivUiefi which are 
uapiu«^\J njtb cm:icJui> i]ut.l>, and iirt: fici|Liciit]y »f an JiilUm< 




(BLA)if» Si;tTo>.) 
^ OQ|ilnra*p<T Ovuwi llMucprtrpcr: Ii.pHr»6phi>tDii.or libue oilho hilum 



MlflfY nature- Such spaces mar be lined with ^pith^lium or 
cA^belioin. A* illusiration^ o( tfUkiiial cy*ls may bo mcn- 
Eiwd iltow whkh iuisK in tiumce^liun willi ihc ihyroid body, as 
»Atoc«ftd:t>oos due to 1h« dii^ten^ion of the c^^niral cntial of tlicr tier- 
vow syMcm(:i)-Ttagom>'cliA or ^yringo-m^ebcelcl, nod thoM?(ormFi 
of mvriaft cy^u u-blcti ari^r fiom diAtenaion of GraafUin follicles* 

Exodatbn <:yit* Hned by « M-uiuft or ntdothtliiU WiUl aie much 
■we Bumeroiu thai) the former, Enhr^inntntH -if l>in*.KP, 
httecete^ of the tunica va;;rTiali>, funiculnr proteHt-T fjr cana] of 
Xltk- and H-mitt fof tiis uF u^ii^tia, we of thi^ nalud:. Divcriicula 
fffcr- 'ii«ions of the synovia! mrmlEane also occur* and 

■ft k L'jkctf'l cyfrte. 



t6£ A MANUAL OF SURGERY 



A ElaTQUa Oyit is supposed to arise from the distension of I 

spaces, giving rise to uni- or multi-tocular cavities, lined 
■ndotheliunif and containing a limpid straw-coloured fluid- 
a growth when n^et with in chiJdren^ either in the neck or 
where, is usually called a cystic hygroma; a. somewhat 
condition is also found in the breast. 

(*) When a collection of blood forms in a pre-existing carity, 
sO'Called OTBt of BztraTaaation is produced- Such is met nilh 
the pelvis or tunica vaginalis (hematocele), and also occasi 
on the surface of the brain, constituting there the condition 
as an arachnoid cyst. 

(c) Betantion Oysts always arise from obstruction to the esain 
of some natural secretion from a gland duct or tubule, lit 
cavity thus formed is lined with epif helium, whilst, owing to tta 
irritation produced by the tension, a fibro-cicatricial wall of \-ariabli 
thickness is developed outside. There ts often a consideraUa 
tendency to the formation of intracystic growths, especially ii 
the breast, whilst the contents generally consist of the inspissated 
secretion, perhaps mixed \vith blood. ] 

Retention cysts may develop in connection with any ordinaiy' 
glandular tissue. The majority are described under the appropriate ■ 
headings, viz,. Mammary Cysts, Renal Cysts, RanuJa, Pancreatic 
Cyst, Here we need only refer to mucous and sebaceous cysts. 

Seb&ceouB Oyate occur on any part of the surface of the boih, 
but especially the scalp, and are due to obstruction of the duct ofa 
sebaceous gland. They present in the shape of rounded swcllii^ 
firm and elastic to the touch, moveable on the deeper stnicttuvSi 
and always attached al one spot to the skin. On careful exarniu^ 
tion, 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 lay<rt 
of epithelium, surrounded by dense fibrO'CJcatricial tissue, audil 
exposed to irritation or pressure, as when situated on the ba^ 
or shoulder, and rulibed by the braces, it may become very firmly 
adherent to the surrounding parts. The material contained within 
is of a cheesy, puUaceous consistency, yellowish -white in coloor, 
and under the microscope is seen to be composed of fatly and 
granular debris, epithelial cells, and cholesterine. Sometimes 1 
distinctly adenomatous element is present, so that the cyst waDi 
are thick and firm. Left to themselves, they may attain cod* 
siderable dimensions, the walls even becoming calcified. Oca- 
sionally the exudation oo/es through the duct, and dries on lbs 
surface ; layer after layer of this desiccated material collects, 
finally giving rise to wh^t is known as a Sebftceoua Horn- These 
become dark in colour from admixture with dirt, and always 
more or less fibrillated in texture, whilst the base is Infiltrated and 
hypereemic. Sebaceous cysls sometimes inflame and suppurate 
\Vhen the skin has given way over them, the contents arc only 




rVMOVRS AtiD CVSTS 



Ipinli diidMrs^d. and lb« r^fmainder un<leriOflft fnimiifClivfl 
dua^n. ^vmg n^c to a hurriUy- ciltMi^vc ulcermted turface. 
kHa niM[ rc^dilv t^*v mi^tnk?-ii fui F|itll)?-liotivi. <irid vfnaidv 
nptlljf, Tra« malij^A^rt dvi^aM of i^n irpilh«lioi]):ilOLts nature ih 

T>>p<ali — From n dtrmdd cyU il ia known by the fact th&t the 
Annnd ariw:* ciirl_^ in liiV, and Usomccim^con^riul* wJiikt il 
BinrdJ) c\vr dirccily att;4Cfaffd to lb« »Lkin. Troni a/d/f)' fr'Wf>jjr 
ici&reoof^icd by ibc Absence of lobulation, ind by iis more *oUd 
dimdcr, whiUi a lipi-inu i» softer And nioic movcablcr From 
aiAmk^Av/ii il is di^liTigiii^bcd tjy ihr- i^itiMrnrcof iJir riilfltfjd 
onfe*. by ill firmtr cootistcncj-, and by the IiiKlory. 

tNMmeDt.- A !wh«ccouscysl should be cniirdy nod completely 

-..■r,i ;f ,-iviji^ mc lo atjy iacunvemeHre or Ifmiblp, !n \\it. 
1 1 in Dtrfftkd i^ lo tr;»nsftx the tYim^iur, *(^i:rei!c fitit the 

-*-- "■* icAls, 4nd tlitn the cyst will c^n be readily removed 
I^OUpcAj* it nith tUtdcctinf; Jorccps and pulling ii away. In 
«kr alLAlMxiT* ihe tyii w;il! itiav nceil im Iw disM-tiol init ; but 
cua iWn it i^ ndvUibl^ to opeti it by ir;m^t^xion, :LQd If* deal with 
■IVMcran bslow rrkiM^rtJian b^jni abow. Homu and tun^utinK 
tk« UkouM b« €xci«d with lh« »urToundiQg akin- 

HlBva Qpvti nri^t? m i.oni]i7Ciloi> vhith the j^'Undulai follTdw 
ilud in oiMCOtM rn^nihrtin^s. much in th«? ft^me Wjiy a^ sobaceous 
^vorwiiute in the skin. They arc oift«Ti due to injury, and are 
*ydj<f ijrcAt size, ^c^isJMing t>f thin-wfillErd taviijes Uiiitended 
«iA ikcih; ihpj aiP t^bvtir to Uw lunch, and u!&ii:illy iTansliHPtit, 
ADivemovt oAen wen og the \ip^, bm^ath the toiif-vie, or *fom«' 
hoaton the Ub«A vulva^or 08 ulcri. All that is needed in the 
l^apv of tteatmmt \s to open and e\L:iM them. 

IJI. Oytlft tf N«w FormaUon sird fiucb as occur apart ^Tom 
-tqr imbryoQic condition or pte'CMi&itng cavity. Th«r following 
tmc>t« nuy he dcKtibed : 

^i An ImplantiHogi CyA i^ o^^ which ari&cs front ih«- ;icrid<rni^1 
smnkdi inia iHr cnbcuiJiiimiit or Mibmuroiis lUsueK of vpith^liAf 
f«JU vtueh retain Ihcir vitality, and nic enabled to develop a cytil 
"»J iuaiUr in nature to a dermoid ; in fact* Jl may be looked 
*ftAtac /Iffvr/nf or Trasimaiu- fUitnaid. Siirb an [xx-nrtnicc is 
>nB&> hrouffht about at tlie rvRilt of an injury, **pedally from 
F^ttciurod u-ourda; thu«, cy^l?^ of thij* nature have been met 
^Mb in the ftajECis oi pmhn of the Ii^ukI a^ a conNrqiicHKc of the 
jmtntlion uf umie slurp in^hiiuinrnt. whilM [htry -vre -A^x> <x:ca- 
acnQy teen in the anirriur t:hamber of tiie eye;, lultov^in^ ah 
^idKlofrn. H>cy are, [uorcovcr, ob^r~\'cd in the a>ili*i: of luIII«, 
^ a rt^tik %A goading them with tvunie nhaip Linpli^ninit. The 
t^ucal n^n^ and tf*'atnieTit aie strtiilar ro th<>s*^ of s dtimoid ry^r. 

t^) (^M somettme?. iuini aiennd foreigu bodies, whieh thu£ 
™* * cncapMiJed. They aie hntd oJtht-r by j;[ .tiiulation tissue 



I70 



A MANUAL OF SVBGERY 



or endothelium, surrounded by a variable amount of fibro-cicaliic 
tissue. 

(c) Blood OjBts are sometimes of doubtful origin. Some of tbi 
certainly arise from extravasation of blood, and in such en 
coagulated blood, or a thin serous fluid, is found within, the cavi 
being perhaps lined with laminated fibrin. In many cases a i 
called blood cyst really consists of a soft sarcoma, into wlu 
haemorrhage has occurred ; but m addirion to these, a few instano 
are on record in which a thin -walled cavt 
existed, occupied by blood, and readily rehUix 
after the cavity had been tapped. Such conditia 
have been most frequently observed in the an 
(see Chapter XXIXO- 

{d) Parasitic Oysts are produced by the irtil 
tion caused by the growth within the tissues 
certain living organisms. Thus, in the disea 
known as trichinosis, derived from eating ui 
sound pork, the Trichina spiraiis^ a small rom 
worm, develops in large numbers in the voluntai 
muscles, and becomes surrounded by a capsu 
which Ts subsequently calcified. 

The most important of these parasitic cysts 
that arising from the de\'elopment within ti 
body of the scolex stage of the Tania eckinococn 
Riving rise to what are known as Hydatid Cjil 
This disease is infinitely more common in Austral 
than in this country. The Tania ichin(Xoct 
(Fi^l- 4B) is a minute tapeworm, less than half i 
inch in length, which inhabits the intestinal cao 
of dogs ; it consists of four segments, the posteri 
one larger than the rest of the body, and conui 
inf; the Renital organs. When mature, this b 
segment becomes filled with ova, which are <t 
charged, and the^ve find their way into the hunu 
slnmach by the media of water or unaxiked veg 
tables, such as watercress, which have been co 
taminated with the dog*s excreta. The proce 
of digestion sets the embryo free, and I 
means of a crown of little hooks which it pc 
sesses, as well as four suckers, it is enabled 
bore its way through the walls of the stomac 
and thence travels by the bloodvessels, as a parasitic emboh 
either to the liver or to any other part of the body. As 
result of the irritation caused by its presence, a sac forms whi 
originall}' consists of three layers: externally, a fibro-cicatrici 
layer, then an intermediate lamellated layer of chiiinous mateii 
and finally the cy^it is lined by a protoplasmic germinal layer, frc 
which solitary la:'nia heads or scolices, also provided with fo 



Fig. 46 — T^tNlA 

ECHINOCOCCUS 

(x ABOUT ao). 



rauovRs asd cysts 



rr^ 



a circle! of bi>aki±, mAy br dcvclr^pcdt wHilfit »omp> 
of tbcm, kmiun ;i^ brood'Cdp^ulcs, nuiy HiiSf^ in lli<" 
■ig- 50), nfliisbtPi-cj-sU are nor unfro*]urrUy foTmod 



«3iy 




ItoaftCARvuu cjDOtnKc vv>M TMi Wall*. (ArrvR UtAnn Surrow.} 




Pro 50,— DUAUKMAIli: >l:<.[L 



Wa^l ok CvTir 



<i|v, or «otocyvi: r, brood CApwIn o?\c1i>{>(ni: fivin tbc proiopluniic 
ti|w, cir«fiilocytt; ^.mc^i. or KpunU hcu^. onlATfed , 

itli«ccoliciM,an4lli«yi^ i)ic[t lum m&)r pass ihTou^h ihctuimc 
thbou^ mb a Tult llir^y irc bftrren. Occasionally even 



173 ^ MANUAL OF SURGERY 

the main cyst may he sterile (acephalocyst), and in such caautbe 
walls become very deJinitely laminated. The fluid contaJned v 
the cyst varies much in amount, but is always of low specifit 
gravity, not more than 1007 ; it is colourless, but slightly opalfw 
cent, limpid, and contains but a trace of albumin, although a con- 
^derable amount of chloride of sodium is present. On examininj 
the fluid microscopically, the characteristic booklets are obserwi 
The organs usually affected by hydatid disease are the lively 
kidneys, and brain, but any part of the body may be attacked. 
Occasionallyin the bver, and usually in bone, multiple cysts devekip 
quite distinct from each other, and with no enveloping cyst-walL 

For the diagnosis and treatment of hydatid cyst of the liver, see 
Chapter XXX, 

In other regions, if the tumour cannot be removed by d»- 
section, reliance must be placed on aspiration, where the ^tw 
tion of the growth renders this practicable. 

IV. CTats of Dftgenonttlon arise in connection with tumomSi 
especially those where the blood-supply is not very abundut 
Thus, mucoid degeneration is not uncommon in fibromata, fibn)- 
myomata, chondromata, and even in the harder forms of cancfl* 
Occasionally cysts form in the sarcomata from this cause, W 
more frequently as a result of haemorrhage. 



CHAPTER VU. 



WOUKDA. 



A mxvo hAs been lieliiied !i% the forcible solution of contiauiiy 
jdujrofllic liTsuc^of ;ltc Ui:ly ; but the Lcrrii i% amm ciimmnrtly 
fartied (o injtiries of the *oh p:ins. invalvins the skin or mucou« 
iKAtciQ^, Lesic«i5 in whicfa the Mn tlocr* nut parlicipalu. find 
vohich the deeper sIructurcK* vucli zis bones, lifi-icncnt^. ctCi,aro 
axDTulinl. ate nunc frt«iijf?iitly ip*jken uf ai* tunlusionjt 

^ OPttWlOll i^ nny 4.ubout:inef>ii4 \votind or Injury due to the 
ifScyof^tCTDaL violence, caiiiiinL; I icorrttion of the ceil utir tissue. 
thstf oeccsftttrilj involviue Hut:n ^Jcepcr siructuies as muscle>i 
ISBdcdf, npTves or hones. If, however, these are injured, special 
bnjmnay be added to the condition be>ond iho&e of z con- 
<<■«. The signs of Ihia Jatter It^ion uiv uauiJIy v^T^y oljvicma. 
*^.Viiit.brDiAinf. ordiaojW^liunuf tilt jKirt. mid awalliag- TheM 
€1 iM^iitv ^^pl,i(n*»i hy t^e ii;ji;rj' inflicte-l on th? i^jbcutaneou* 
liauK, ur&kh in the v/oret cases muy be c^ntireiy Ji^or^unizeJ 
^ tqiAraicd fri>m ihe skin. The ;immjnt of bruiMn^ vark:) with 
btpwiinjureildud ihc severity of the Icsioit : thus, in tlicr i^ycljdb, 
*EiTiCEn, &n<l \iilv3, wheri> th** ti^'Vur*; are \hk, the ^cchymoftis will 
^wy exicittivc n/id of a black colour ; on the ficitlp thtro i», on 
bt oibcr hanJr but little swdtin^, if ihc injury docs not include 
tfaofiotf bcucaiU ihc aponeurosis tjf the occiuilo-froiitalJ*. A(i."iin, 
l^aiidiHcin of the pAtlenf f^ general health mmicnceic the aitiouoi of 
Uoodclhised; ivt a ritrong man ini^orx! trainmic, but Lttlc bTUiTHnfi; 
<>otT atfgTi> wtiilM in thoK of j LuifiLiid temperament >-ind relaxed 
toaiei. the ?ila>thIe^c injury often wiffii:e^ lo prcjdiicc n vciy toU' 
HKMiE cechymocis^ Blebs and biiUf may form o\tT the injtiTed 
W m \nd case*. The changes that occur in n briuic aro wtll 
Wikn.the colour panoiag from u Ij lock j^h-pui pie llirmii^h vaiiuus 
4udn of blown and (^revn to .1 yellowy which ^radu^dly f^ilrrs^iml 
^^uppnra; thif ts due to the dibirUe^nLiion of the ted corpicscle^. 
ud ttMaine of the tissues hy the ha.-iiio^lobin thus ^t free, or 
^ thf products fornird dm ing its leuioval. When hicmorrha^o 
bto ukra phc^ into ihe deeper pans or iindf-r drutr f^iKci't^. il la 
tAfn Mint days b«fore the bmhe ' comes out/ and this mnyo^cur 
nttvedbust >po(, ^^., in the eyelids after a blow on the scalps 



174 fi MANUAL OF SURGERY 

or, again, after a fracture of the neck of the humerus, theblo(4j 
may travel along the muscular and fascial planes, and the 
first appear about the elbow. 

As a rule, in a bruise or ecchymosis, the tissues are 
infiltrated with blood, but occasionally the extravasation is 
localized, collecting in a cavity formed by the laceration of 
tissues, and remaining as a fiuid swelling, or Hnm&tomA' 
somewhat resembles an abscess to the touch, but differs froni it i ^ 
its history, having supervened immediately after an injury, aJ' 
having appeared without any heat or other signs of inflammation; 
moreover, though at first fluid and soft, it soon tends to becan»j 
harder, whereas an abscess is preceded by a stage of brawny ii 
tration, and the softening comes later. The subsequent historyi 
a hematoma varies somewhat according to circumstances, (a) A] 
deposit of fibrin may occur peripherally, leaving for a time a flu 
centre, which gradually disappears, and the whole is 
absorbed. This is well exemplified in a sub- pericranial 
ha^matoma, where the contrast between the fibrinous deport 
out and the fluid centre is sometimes so accentuated as to gtn 
the impression of a depressed fracture, (b) The fluid portion 
the blood may be absorbed almost entirely, and the solid fibrinoai 
residuum may remain and become organized into a firm fiUoid 
tumour which persists indefinitely; the mass ts more or kfl 
laminated, and not unfrequently pigmented, {c) The fibrin mff 
be entirely absorbed, and a slightly pigmented fibrous capsw 
formed containing serous fluid, and constituting a definite cysL 
Such is best seen in connection with the cerebral tunics, tnait 
there known as an arachnoid cyst, (d) Infection from withil 
or from without may occur, leading to suppuration. 

in forming an opinion as to the gravity of a subcutancooi 
injury, one must be guided by the part injured, the extent rf 
tissue involved, the amount of blood extravasated, and the a^ 
and vitality of the individual. In the less severe cases, thougti 
there may he much manifestation of bruising, recovery will easatt 
but under less favourable conditions sloughing and death of tb^ 
injured tissues may result- 

The Treatment of a bruise consists, as a rale, m the applicaliff 
of cold or evaporating lotions in order to check the bleeding, bnl 
such must be used with care in old weakly individuals or wheM 
much laceration of the tissues has taken place, for fear of the 
injured parts dying. The skin should never' be incised excq* 
under special circumstances, such as the rupture of a targe artWT* 
or when some definite advantage is to be gained by dealing al 
once with the injured structures ; for though under careful anti- 
sepsis the dread of opening recent collections of blood no longtf 
exists, yet it should not he lightly undertaken. At the same tiiiKi 
when a tense and painful hematoma exists, as under the &isca 
lata of the thigh, recovery can be hastened and pain relieved bj 



UfQt/SDS 



« 



fiMptx puncture, followed l)y careful compression. In nf^neml 

bwoc <xf t^c hody from a (all or extensive injury, pair axn cjltcn 
blenbcncd br appl^-ing hat fomcntatioiu or by n boE bntb. Any 
Ljafav^npnl inflairnutory ph?m>ttin^:i mii^it b«- freaErd in ;tci:oriJ- 
lAiKevith f^enertil sui^icaI principles, Thcru is often j> ceiiain 
hnmiiL ui fever and cociatitutica^al dittlurUonce for a few days, 

trti \hfK mu&l be dcali K^ith by puqfuli^cA jtntl u ftukab]<! limilJ' 

imtJiliet. 

OlMll WoozKb. 

\a cpcn wound may ]w dchncd *t?i o w>!ution of coniiimity of 
J07wper6cufll jmt *jf thr lioUy, iriclutlinf: >km (»r niucims (ucm- 
fannt- VatfiMti kinJa of v^ounda arc de^cribe^t fiuch #r< the 
■B^. Uoer«tc<U conlu^cd, puncturt^cl. puisoncd* and gunshot ; 
hft,cf course, the mo^t i[LiA>rU^t tliatinUiou lo draw i& helwwn 

I. IMud WouiLdA^^An incised wou:id is on« m:Kle by any 
^AorpcblliAC; m&liuiucut. such as a knife or aworj, Init occasion- 
aUt^^imciu boi i;foO^Lt^ in ihU inajuici iiuy be clitu^it-toJ^vd 
t7^«ikirApfw.ir:tnriis ; /-if., fh^ slitn of th*i kne^ oi' elbow may 
trdeanly tplil on^n from f^llm^ on )t with the iimh no;ced, nnd 
occuKoollyA policcmur& Iniiicbcon will lny open tbc ^cnlp ari 
f«Tt)]F £1 if ,& kfiift li^d I>'t;ii rmployed, alihoiii,'^ tfici^dtirs oi ihc 
lomdnua of rec*wity he hniised. 

Tteipocul f<^Jlur<:s of an incised wound ore; Jtft toUows : 
L The kririorrl^^c: i^ fice, from llie f^Lt thfit the vessels art 
cabIi t^vidnL Th*,Tmfiunr, of ronr*ii*» depi-ndtion ihr*. tivr tif 'he 
f iwij involved, And ihiv vaM:tj]:iriIy of Ili4> pu\i ; iu conunii.Lncv, 
i^MMltedeauly of the slructurcs, ftllo^inf or noi of contrnclion 
ttd pdiactioo of the »veTcd rnii?i. A[i indsiun lluouk^lt cori- 
|at«da kt6Ained paru i^^ Ukoly :o bleed irtxich more rhnn u«imI. 

?- StptrMvon of the hpt ot the wour^d ,-klEo occurs, bul ihc 
>«nM(3lKAp]Qj;dcpcnii>upon the cJaslicity stndchAractcr of ihc 
fubb^^ved. 

> &ua!»iDgort}ii^niar|>insof Eh^inriftion wahftcnt, Kotlutundtr 
MMry arcunts-Eancrs rapid hcnliiif; (by tir« intention) r-hould 
•♦•un. Tbe surface*, to bcKin with, are lined t>y a microscopic 
^erof dunu^ed tbiMte. stuttie of wliicrh ituiy fw ncCuully df^iul: 
W tf«iirjLbI« precautions :iTe rikcrr. ihln i« d) abiorbeiit ^^d will 
n D*vay ial«norc wiiIi sntisbclory union. 

IMaoiBt of iQcUftd Woundji* — Seven c^wiilJats must lie 
'prided lo if pf jirj^iiy lnMllni; is (o I* obtained, vi/, : 

{K\ Th» AfTMt or ftU BJ«mUii0. - If ih^ie i^ ^'^n^trAl oozint;. 
<M<ihve to th<; Air is '.*fuii ^uiti: ^utlkicnt ; or somelimcs it may 
W Wyp l a ft cwtcd by prcMui^ fui d. f«w minuter with An ascplk 
*pV^ Art«!TW<i Jtnd vrin* will need a licf^tLirf, bnr if siiu-it^^d 
u3« 10 the «kinf itMiy may oft^n 1^ 40curad by patsing the needle 
*^kr iDfecrtinjf the auturc undct the blocdiuit e^pot. 



176 A MANUAL OF SURGERY 

(ii.) Tli« tumoral of Foreign BodlM, utd ClftMuiiig of the Wi 
ftnd its StUTOtmdlngi. — Dirt, splinteis of wood or glass, 

of cloth, etc^i must all be most carefully taken away, and it 
be necessary to anesthetize the patient add enlarge the 
for this purpose. Irrigation with a i id 40 carbolic lotion is 
sufficient in many cases to render it aseptic; strong antisepll 
often do more harm than good by irritating the tissues audi 
creasio g e x udat i on . 

(iii.) The coaptation of tlie oppowd nirfkcH by means 
sntares may now be attended to, when there is a dty u 
presumably aseptic wound. Many substances have been, andui 
employed for this purpose, but amongst the best are fine al 
wire, silk, horsehair, silkworm gut and catgut. In casualty wq4 
and for parts of the body where but little scar is subsequendj 
desirable, as in the face, horsehair and silkworm gut, being do» 
absorbent, are perhaps the best materials to employ; but 
ordinary operative work, which will be more certainly ascp6^ 
and where the after-treatment is more efficient, fine catgut ordk 
may be used. There are three chief varieties of sutures, vii, 
the buried, the deep, and the superficial. 

Buritd sutures are employed a good deal in the present di 
since there is no danger associated with inserting a foreign bo 
into the tissues, if both it and the wound are aseptic. Catgut or 
silk are the agents made use of, and ner\'es, tendons, musclesor 
fascia' are the structures mainly dealt with. In deep wounds ilii 
always moHl desirable Co effect union in this way of all the parti 
divided (that is, to build the part up again), and not merelylD 
unite the skin over them. 

D(fp stiiihfs, or suturts of reiaxaiion, are required in cases when 
there is some difficulty m bringing the edges of the wound tfr 
gf^ther, in order to transfer the tension from the healing margin t> 
tissues further away, the edges being thereby relaxed. Forllul 

fjurpose thick silver wire may be employed, inserted i or ijindwi 
rom the margins, and tied directly, or lead buttons may be intB^ 
posed next to the skin, and the ends of the wire fastened roood 
the projecting edges, thus diffusing the pressure over a gre*W 
space. 

Superficial stitcfirSj or sutures of coaptati&n, must be so insertrf 
as to bring the edges of the wound into contact without uudoe 
pressure, and without any folding in of the skin. Various metbodl 
are employed in the apphcation of these, viz. : i. The inttrti^ 
suturf{¥\g, 51, A), in which each stitch is separately finishedoftdi 
knot lying well to one side of the incision. This is very frequcOT 
employed, and is ujiually most satisfactory, especially in wow" 
which are of irregular shape or in which there is Aity tensor 
2. The glovir's stikh {Fig. 51, B) is a continuous one, in iriri* 
the thread is carried on from point lo point, and only fasteoedit 
the ends; it is not a form to l>e recommended for general i» 



WOUNDS 



m 



Tb« Unkft or iiM^iAolt ttilch (Fig. 51, C) \s a form of god- 

avousnilujc vhich ha» been ndoptcd for fcvcfftl ycar^, ftE»d is 

cA the bcKl whkJi cAik br cmpfeiyci^ for rxicnsivc wmiQdK or 

In it tlje nr?cdl«t nftcr tr;»vcmn^ the ]ip!i of the wonnd, 

OEMkr tbc «Uck of the? thrc-id. no that ih? loop of each 

it 15 ti^titened, U mniniAincd At ti^ht an^ks to tbc cd^x 

I, wbiliGt tbc inlermrdialc porlinn lies pfu^illcl to it. 

it o^, lite Dcedic ii; pAitscd in the opposite direction 

ibe edges of tbo iacisioop wilb the free ctid long cnoit^h 




PlA Ji -VAKlCrth FtikHt OF SuiVHK 

*aiiBiv: II. «4nDniiDUB lutufe; C. blonLet ftit^h Ai the lownr 
twviHc hax >ii*( been poAUi^, tnd ihn uny m u'hich It rAichd W 

'^vQ lit . tiw iiDcil]« u|n^Kli in tlw oppo*h<? iirKlU'ii i" -ill, ibc ullwr 
■IkdiM. Ae frw end bcanj: left ioit^^ >o iu cu cUiutih it co bo tied intT? ■ 
ki>ai«tih|fat4Mbl*lbrc«d which lhcn»dlcbq>cArTJ'^i ihrougJi 

,|rwenl rl coraine through, «nd 10 t-nahle il lo Iw lied to the 
"** portion carrying the ii*«dle. i. Th^ ^miV^/./ »«i"r^ '*m"°^ 
\tmphfvA^ It j?onfiiat« in tyiriK the ^titchci ronml ;* ijudl or 
of CAthclcr ot; dlhcr wJc of the woiind. w that the docp 
r»j 1* majuiaired in .inpt^Mliou. whiUt the cupflnjcinl 
in kft c\w for adrimonal sutures. Prubrtbly the only 
under irhidi it i» now Li«:d ar* in lh<- civr-iaUoh^ Jof 
p«lttWwii,or for cxttavvc p<^int-^l o^ ur<-tbfTil I^Mul^, 
or jigmn^-n mture is cKCiibk«iaUy x«;»tlc u« (>1 ior 



178 A MANUAL OF SURGERY 

harelip or scalp wounds^ but it has many disadvantages. A 
or needle is passed through the sides of the wound* which 
brought into apposition with the fingers, and Tnaintatned 
twisting silk around either end of the needle in a ti 
fashion. 

Plasters are sometimes used instead of sutures, but ihe 
mu^t he very small and insignificant which only require 
treatment. A fine aseptic suture is in most cases preferable. 

(iv.) DTftiluv« must, if necessary, be provided for, in ordff 
guard against the irritation and tension of retained blood 
exudations. There is stiU much difference of opinion as to 
need of drainage-tubes, and individual proclivities must dedde 
to the practice to be adopted in particular cases. In wounds w! 
there is any doubt as to the completeness of the hsemostaas, 
where there has been much tearing or laceration of theti 
it is wise to insert a tube foe twenty-four to forty-eight hours, 
order to allow effused blood to escape ; but if the wound ia 
and aseptic, and efficient pressure can be exerted by the d 
it may be advantageously dispensed with. An aseptic 
inserted Iwtween the layers of the dressing will form a soft, 
and yei firm pad for exerting such pressure. 

When, however, drainage is thought necessary, the indi 
tube introduced by Chassaignac will be found to answer well 
should be cut off fiush with the surface, and stitched to the 
of the wound so as to prevent it shpping in or out, and 
obviating the loop of silk usually attached to it. D 
Ixjne lul>es ha\e been substituted for the above, but with no 
tinct advantage. For small wounds, a strand of horsehair 
strip of gauze or protective will generally be all the 
requisite. 

(V.) All fresh eonrcea of irritation and infection of the 
must be excluded by some form of antiseptic or aseptic 
these will be described later (p. 201). 

(vi.) Eest to the injured part must be secured by such 
arrangement of splints, clings, or bandages, as may be necessvji 

{vii.) The general health of the patient is a most imporW 
item to attend to. In an operation case the bowels are alwaji *> 
be previously opened, and the patient's diet carefully regulated; 
in casually w^ork a good purge should be administered as sooai* 
convenient, and the food and drink limited. 

The conditions which prnait healing of an incised wound bf 
first intention are essentially the reverse of the seven requislli 
mentioned alwve, and may be epitomized thus: (i.) Non-arrealrf 
the bleeding, causing separation of the lips or deeper portioBsrf 
the wound ; (ii,) the presence of foreign Ixwlies, often impurtj * 
other septic material ; (iii.) the edges not being brought itf> 
contact; (iv.) imperfect drainage leading to tension upon ^ 
stitches ; (v-) subsequent infection of the wound owing to a i>^ 



mSUNDS 



>79 



ttc, ; {vi.) Uck of »et lo th« pan ; .^nd (vii,) comtitu 
ftondJtions, such a» dcfidcni cencraJ vitality frum dLsc^sQ or 
uuscs rcsuIliBj; hi w^til iif ri<liMij i[> tlu- wiudkI. 
SVjuM lay ^^^'^ o( in^umtnauna nhow ihomw^v^^ inxa incised 
vnad. cIm ^bAbilUy la ihAl they ate ^cplic in ori^n, find wiU 
bfaccoRiFftnicd by *onic amount of fever. Union by 6rM intco- 
bra tfl rfticly occur uDttEtr sucli (iicLinmUnccs ^ml, inilci.'^il* il is 
Ivrteito Ukc out vomc or ;all of ihc EiJtchcs ai once, and ihua 
tclm lay Tcmion which may be prcrcnl. Uccjifiinnally an 
:ioo of IJood or icrum may octur in ibc tlee|*rf piirts 
II! ttliiUl Ihi? 'iiii)e(fid;d p,u[* ;itp healing. nefrsNitaling 
M of leniboa by n punial opening of the incislonH and Chc! 
of a gauctf drain* 

II- lAOCntad or OostuBed Wounda.^Stich iDJuries aie cnusfid 
bf UxK intitrumt^il^, by niji-hcnc^ry^ mii^t^ilTj^H tbv wheels of a 
itMft,tfc., whkb Icid lo l>ioi5int; or ciiiahing of tbc. tissues, 
Th^jrr diai^^ti^ri^LiI Yiy the foltuuin^ aij^nn: 

I. Thr BmaoTThase H, as a rulr. biw si ijjhi, since r he vessels are 
tn icfots irre^Urty, ^nd not cut clf^nly ; Ih^ inidile and inner 
«tiicb ^ivo vTAr last, aic curled up witbtn Hic contorted 
I, fonTiing a birri^r ^^tifficivni ic prevent los-s of bhxjd- 
ln, moTCiftver, being elastic, may ne pulled oiit of their 
and Boajr sometimes be seen putsaiin^ upon tbe surface 
tb&vnMtid. 

1*^ K'^P'' ^4*^^ than in ur tnchcd wound, ami are 
torn, and hniiMd^ Layers or portions of dead ti«8ne 
vhich luvcto be disposed of before repaii can (al*c place. 
aothU £o(m of wound usx^ally Iic^b b> gr^culalioii, or, aa U 
to tir intmrei, by wicnnd imcnTion. When a limli is torn 
ovplctdy off, the leiuLons are often left long> and the mu<flCuUir 
project pcomintrntJy from their fascial sheaths, a« flabby 
mai^if^; the hkin, inoreijvcr, gives way at a UiKbtrr point 

ftofrt ai of tbe ca«c deptnds Urgely upon tJic queAtion 
ihe wound is or is not n^icptic. 

Aaoptio IdiccrateE] wtniiid U may he fxjvilbfe la brtii^ the 
tber by *ijiurtf ur oibtrw^w, anil, even thoirgli they 
t bruKM, htfatin^; by a ^lii^htly delayed iirst iiitenlion 
ife. if drainatit ts provided. If tbc w^^oiid rcittama open, 
KMA of ihsvv wtI] pn>l>AMy i>t ithst-itbed, jinN-ss krac 
t, and ihii& an aseptic: graniilatirg i^iLrfarr will rriiutl. 
maybe a bttic aimpl« traumatic fever fir a d.-vy or two. 
It will be of ttit]?consei]ueBcc, or of ro long duraunn. 
tht wound is Septic, hm%'rvj*r, it wtti niTi ;l inoie maiki^d 
Ooim»e> rcftulling I'lnnUy in a i^raniilatinR nurface. Three 
say be described in tbc course ot ihu caiw, vis* ; 
The tlAKc of injury* rcsuliiDg in «hock. 



e8o a manual of surgery 



[h) The stage of inflainiiiation and filoughing, with 

traumatic fever. 
{c) The stage of repair by granulation, or prolonged suppa 
tion, with exhaustion and hectic fever in the wor^ 
The inRammatory period lasts a week, ten days, or more, a 
ing to circumstances. The chief dangers to which the patient 
exposed are shock, various forms of septic trouble, ind 
secondary hemorrhage, toxemia, pyemia, etc, and traumi 
gangrene. 

The Tieatmeilt of contused and lacerated wounds varies 
their character, and no absolute rule of practice can be laid 
to suit all cases. The following plan of treatment is that 
adopted : 

{a] Immediate Treatment, — The great de^deratum in all^ 
cases is to render the wound aseptic. To accomplish this, if 
desirable in severe injuries to anesthetize the patient, and tl 
to scrub the wound and its surroundings with soap and carbc 
lotion (i in 20} by means of a sterilised naiKbnish- All ford 
bodies must be removed, and dead or doubtful tissues cut r 
if unimportant, whilst bleeding vessels are secured by liga' 
Ample provision must always be made for drainage, ^ce 
carbolic irrigation will of itself cause much exudation ; 
ally it may be desirable to make a counter- opening for this 
pose. The wound is then drawn together by sutures, and it 
advisable to remote ragged and torn fragments of skin vdt\i 
scissors or knife, if there is sufficient tissue around ; an anti 
dressing of the usual type is then applied. If, however, theskiti 
is scanty and asepsis not assured, it is better to leave the woobJ 
open, or, at any rate, only to partially close it, and then to dustt 
over with sterilised iodoform and pack it carefully with aseptic gaua 
(b) BalifleQuent Treatment depends on whether or not ibt 
measures adopted to obtain asepsi.s have been successful. If tin 
wound remains free from infection, nothing special is called fa 
beyond careful dressing ; if the edges are in contact, healing bf 
first intention will ensue ; if not, the wound will close by grannh- 
lion or organization o£ hlo<id-clol. If it becomes septic, andlhi 
surface is co\'ered with sloughs, these must be removed by naluni 
or artificial means liefore liealinR can occur ; the use of antiscpOC 
poultices will expedite matters considerably, but it must be re- 
membered thai secondary haemorrhage may break out when the 
dead tissues are finally detached. During this period inflam" 
matory fever continue<i, and the patient's general health nuat 
be closely watched. When once a clean granulating surges i" 
obtained, it is treated in the same way as any healing wound, skii- 
grafting possibly being called for in the more extensive cases. 

The question of Amputation will sometimes be raised in dealiDg 
\sith the graver foims t)f lacerated wounds, and allhongh man] 



WOUNDS 



i»l 



Intoart QOW saved wlucb would icievitably in fonner day^ Itave 
Ard «3crWired, ^t *.Xl\\ occa^ionntEy no other iteaiment i^ possible. 
lUitiAad^si ruJefeciDiW b« laid tlown us 1o wlieii 1l> ampuUtc 
U fltKn not to do so; CHch cas(» most be Ircalcd on its uwii 
kwili> Ap«1 fioni ihir locdl legion, thi.- follmvinj; ikmeUs will 
piveto bt carefully conMdermt : (j) The ags and rttalii? of lh« 
pftMi, Aft old periM>Q hsis mvich loss recupcTHlivo power th^n & 
jmif OTLC.^nd hence a damAjfcd limb may <ntc:Q be left in a youtJL 
riudi onr ttvnild rrrt^ainly it-mfivt: In «n r\<icr\y prtKon. Th^ 
vtan^of the individual U porlup« even inorcL important than 
Lh ip, tor stxnti men al MXty nic in a much more hcnlthy And 
RxiAiat slAtc thati others at forty. 1 he babiiSt a^ Xq tenLpcr^ncc, 
ieu,vinu a!«c hi? i.ikcn icio onn«tderation« and the ^xistcncr cif 
gMPi d[»ca»cv such ^v diabetec or -ilbuminuria might induce one 
hnavt to iwlical rather tliAn conservative measures. \h) Tho 
linfty of the flxlnmitr injured. A Le^ has to he sacrificed much 
ntf* fin)iient]y th^a dui uiDl, since the vitality and ri?p:irniive 
poacr of th« Utter ^xre ttO mtacli ^tater. (r) The eeptidtj or not 
d lb& mxiud is of tbe ^catcat si^nifcance, ^ince, if icfcctioa can 
hpirftukd, ilic chaoco uf mew^iviii^ tbe liml> 4ic niucJi iin- 
pmrd^and on« ivotild tb«a oft^n dehiy opfrT^lion, \vhervd« sepsis 
vcdJtuni tbo »caIc m favour of radical Lnt«rf<ircnce. 

A) In the IocaI coiidtiloiis ulilch may ^m^gcat or determine the 
ftxknmnce oj an ampLiUiion, one may conveniently divide tbcin 
Mo m> croup«, viz., vfher« amputation is eMeixtiaIr or wtwre i1 

^ ABfvUtloa tb icitaiiily cadlcd for — 

t. 7n irim up ihe stump of a lirnb torn off by mnchiupry, or 
ocetf by ihe p^ivsaijo of a railway train over i1» or cjtniod aw^y 

^ICUMD-bftib 

1> Wbcti ibc whole limb or ono complete f<e^ment of it haii 
hiQ totiU^ diftorgiiiix44l, or cniittied lo pulp, though still retain' 
■If ibcoan^ctioti i^-ith the body. 

3. la cascf where ffftnj^rciic i» immircnt or has £upcT^'cced, 
CTpBcadiy if it n of ibe »|i[e^dii^ typ<^- 

I- Wka severe tcptic lymptomt, /-^,, osleo-myebtis or 
«nhitti»t or tboKc of ijiicipicnt pyaemia, or sometimes tboac of 
ltl>*i», arc mamfeMcd in a case where an attempt t^ bem^ made 
la«tt Ibc lifnb: or when cxhaiuttiLia %upervcneii from piuloii^ed 
«9pv>tioa> 

y la scvKtv compound contu^one ol the foot involving tho 
wtt ttd ^jm^ opep the common synovial cavity. Here the 
hetie pUn 10 adopt, as a rule, is to amputate, sinci:^ >pcptic 
tnhhtit «id d«:ith of the bones h very apt lo rn^uc. Tba 
^^itm« ol the foot from ibc centre of the circulniion incrsatias 
<W likdiboixl of i;<jii^re[]e, csinrcLDy in old people. 

li AmpttMtMi W donbtfiil in rhe fnllowiTig ronditiims ; 

U Compo%in(l commu^uivd Er^ctur^t in parts oth^ than the 



iS3 A MANUAL OF SURGERY 



foot do not Per se require amputation, even if neigbbouriag 
have been implicated. By careful attention (o antisepsis, 
drainage, the removal of detached fragments of bone and 
bodies, which should usually be accomplished under an an?! 
limbs formerly condemned to amputation can not only be 
served^ but also restored to a considerable degree of 
usefulness. The final decision will mainly depend on the 
condition, and previous habits of the individual. 

2. When the soft parts have borne the brunt of the injury^ 
have been extensively stripped from the booes, amputation 
no means an essential, provided that they can be restored to 
original position, that there is a reasonable probability of 
vitality being maintained, and that the utility of the limb 
not be hopelessly impaired after the wound has healed, 
surgeon has here to carefully balance the risk run by the 
if an attempt is made to save his limb, and the value ttat 
limb if saved will be to him subsequently. For instance, 
the muscles of the forearm have been extensively torn up 
machine accident, he has to satisfy himself, even if the vas 
supply is satisfactory, whethei' it is worth while exposing 
patient to the risk of grave sepsis, when it is probable that 
the l>est circumstances the hmb will be of little practical use- 

3. Laceration of the main artery of a limb need not in it» 
determine amputation ; but if in addition to this the bones, vaml 
or nerves, ate injured, and especially in the lower extremities of oU ' 
and feeble folk, amputation should be undertaken without delay. 

As to the Period \s'hen a limb should be removed after an un- 
dent, there is no doubt that, as a general rule, the sooner amputfr 
tion is performed, the better : the longer it is delayed, the greittf 
the risk of septic infection and absorption. Moreover, experieDce 
tells us that, if the limb is removed before reaction from the 
initial shock is fully established, the impression upon the systai 
is often less severe than if the operation isdeferred until traunutic 
fever has set in. On the other hand, the shock in some casa 
may be so profound that it is better policy to delay intederenct 
until reaction is established ; this is especially the case in sei'tn 
crushes close to the hip-joint. primary amputation in this locakitj 
being \'ery frequently fatal, .Vt the same time, if in the opiniA 
of the sxtrgeon shock is l>eing perpetuated hy the presence of ■ 
crushed limb, it should l>e immediately removed. When, howevtf. 
septic fever is present, and it seems desirable to remove the limK 
there is no need to w^h until defer\escence has occutred, as used 
to be taught ; as soon as the septic part is taken away, the fertf 
and concurrent ph(;nomena will also cease^ provided thai ^ 
amputation wound is maintained aseptic, 

III. Fnnctnred WoiindB and Staba. — These may be brou^ 
about by any form of penetrating instrument, from a pin or neeW 



woutrns 



-«* 



to I IV ord' thrust or bayon«t wound. The extcTiiAl openinj- mny 
k fi its^ innicnifiiCAEit : bkit the grcii imnicdi'ile d^ngr^r i& the 
dnn^ tlui m^y tie dniK? to <IeRp stnir.tiires, ]>loadvp$sels or 
■eno beiDf; dix-ided, and serous c;ivitics or \nscera opeaed. Tbe 
lasn/i symptcms do^od uJmost entirdy upon the f]iicstkr>a 
'ic ioEcGtion, nincc if it occurs there is ^Iw^ys cnnsidcr^ibTe 
Ijr in edtciMilly diuinin^ thr? itf?plh*( iif n lonfC xnil n.:trrow 
ubiM any :U1«inpt to doic it would Ur most injudiciou*. 
|C«U»cluni oi pu> readily form and bunon- in nil dircclior!i, 

WouMb rr^MiltiDi; horn ihf? moilf^in nwordlHiToaQt. thciugh wry 
^MMiif fponi Ihi-ir w/r^ anr.l dtpth. are not v.^ ttift'icult to hftil iii* 
tbft bflKi«d by thu oM trmn;,'ul:ir l.dud?, 1 h«y ^ticuld he 
tevsuftaly syrtD^cd out with vt^nti carbolic lotion (i in zol. well 
UdU, aatl thp fiiiiii u^eiiin^ uol allocked to dust uiilil ^ill di^- 

<kvfD h>K cpis4Ht- if nw^fwii/y, a count*T-openJng should be 
Bttdt at .1 rlc]>«ndcn1 spot. Serious ha^mtxrhaifti cr pJLr:iivsis 
oto^n; thfkt imporlAnt ^<^^-rIs or ntivcH bi\t been diviacd. 
oSb foi ininjiriJUle n[H-ninj^' iip tif (htr wound, so as to *\pos(r the 
ii|uml stturium, vrhirh ^ati ihpn hi» trebled ufundnn arlnn- 

Tbe commonest form of punctured t^ourdn rrtct with in civil 
|0(lke ntc thofic produced by iiMdlw, whkb hcv fptqucntly 
irobea off thprm in ibr bntiy. Thev nsiiiilly nnnur ahaM ilm 
luuA^ Im. ki>oCR. or na1rt> nnd m;iy It'Ad to ftubsoqucot trouble. 
lf««nflOQii ailct the injury, ft i:^ Htd\i'-«^>Hc 1<^ undcTlnkc tboir 
<inciiite rc<tK)%>d. a prnct;cdiii£ -^jmrEiniKN e\c:cxrdu]K']\ Miiiple, 
ha tfwionally n*cc»*iuf]tif; a rWp and diilicub dis^i-rrifin- 
9mld tbe ne^lte not be removed, it frcmicntly (rav^lf; abcjut 
lWhady«Sonjc the mii^oilar ^nd fascbl phDC5« and there ir; no 
IttNiu^ where it mjiy ItwI^e or t-iiriM' lu ihr %urfiife. or htiW 
idif « may retnaio in the Inwly. It may oceans) anally ftnd it* w:iy 
**> tia p«l\is ol the kidney, and constitute the- nucleus oJ a renal 
okiki*. or po!i«ibly. tf ic enters the t^iillblndder, it m.-iy c^um: 
ddecyattiis. ;indi;i\e rise Um f"nn;ttkmtjfK4ll'SiimeM,4!ioc(;uErod 
■ «ca»^ reoently tra^Ated by oTic^of us. 

FcM the dtti'ctbon of poni'tratinK forcii^n tKK]it.<s oi a metallic 
utare. or of ^plintera of uU^ oi Mone. the newly iliscovered X 
T'^^cf RAot^rn *rc exceedingly valuable. They Jirt- piodnted by 
;u^unj^ a powerful etectrxc current tbtough a tnodiiied Crookes 
'"*^ or, ttS it i* now termed, u * fociis luiWi' This consists of a 
ibiagb^ tube sh^iprd somcAhaE TIktr an iucandoccnt Ump, into 
*hkhjuefiiird rwn (rnn inn 1 v— on (> rhf ncg.itive, cunaive. ;ind Ihc 
«Air, oc pontive pole, > platmum phle ^ei ^t an ^ngle fio as to 
'Ad Ihc rmy3 Kcnemicd at the negative end lo the convuxily of 
tubolb. A very h\\^\i \Miiuin miiM l>r present in the lube. If 
no* ibr limb ivith the ^n[>pnsed fcireipn tvidy within it is placed 
aw a duk «bde cowlaininK --. sensitive dr>' plai«, ;md the tulw 
pu ih^vc It, n> tb--it the convex poriicn on which the rays impinpc 
i* Aoutti Uk bmb. a »kin|n"am is* producptl wIiilL, oo develop- 



Ik 



rt4 



A MANUAL OF SURGERY 



ment, shows the osseous tissues, the outline of the Jirab, i 
the foreign body, if it exist. Figs, 52 and 53 represent K 
appearances, the needles being clearly seen, '. 




Fig. 52. — ShIAIJKAM 0¥ NEIZULb EMBEDDED IN Tki:UB. 




^■''< 5i- -Skiac.kam of Needle embedded in Thumb. 

The nwdle was in rhis ca^ found quite iintixpectedJy. the thumb having t 
e^amine(^ fur some other condiiion, 

A modification of this process has led to the production of 
Cryptoscope, This consists of a cardboard screen coated y 
platino-cyanitle of potassium or lungslale of soda, and if emplo 
instead of a sensitive plate on thefurthersideof thehmbtothetu 



H'ot;sx>s 



Ibe ippouance^ produced can be seen by the naJicd eye, Since il 
;ti|toa)GJible in ihU rjuu? lo mow the limli from *idt-. lo Mclr, or 1o 
icwt it, a batter id^ c^ti) Iw obtained of the pontion of the 
bn^e bochr ; by simpJe sJcjAgraphy, ii i« oltcn imposr^ble 10 tell 
foviick aide of a boncchc forci^^ substance lies. 

IV. tauhot Wonnda,— It will be tmpoABibJe in a work fiucb tu; 
i\aU> fo minuulv lhio ibc mbjcci of ifU'^'^i^ vroimd% hut il in 
GBCDtJAl to iiidjcalr iftbut UK tlicif moot impottAnt fcalutc^ and 
Eb 1^ ie<tpect ibey differ ittnrt other form* of injury :ilre*dy 

Tbc character of a guD^hot wound vAncs accoidini; 10 thu 

Imm (jf tlw piojtxtik-. tbe ;liui empkijrJ. ihe ^'el'jLily uf lUe 

~S the dvMAr^^ from ih* IxkIv ni xfcWrh the Tire*n» tvas 

rd, th« pan of the body i^tr'uck, and ttie direL't^on of the 

lerable cJianec^ hnve tJil&en plai:c iq ihc ^tTuuure 

[lob of ibe RUDf. and of me projecliles u^-iJ in modern dny^. The 

)i;Arriu1 bullet having been discnid^d for the* conical, greater 

ifQitnAiEi; pow«r and velocity bi^ioR tbc fetult, whiltl Ihe lolft- 

[tiB<i ibc bullet derived front a rilled barreJ increa»c5 tbc Iniiiry. 

VftiB the angle of inridenrn is mnrr nr Iru anitc. cvm The 

buUet has a tendency to be diverted itotn a cETai^hl line 

nuicuUf or fucial plnnc^ or dcn^c! iiKniTicnts, t^o ht^. m ,'u>me 

lo nialce a con^lete ciKuil of the body. The ^^ound» Are 

itl^ more deanly eti:, and i^w L-urrale'd than formerly, though 

■ Itulitt s4tii«s a bone or n lohd viscuiE the deaitrtictive 

m*y be gremer. Dangerous wound* may be infiictcd by 

thet. av. iai iJiM^ncr, wltei^ one tjif tlic pellets cntcis the 

M. BhiCst lb« it-ad« or oiber portions of the cutrtdge may alu> 

RQJTird inio tbc body. A blank cartriflffc. if cliw:]iarf:cd at 

Tt disLaiicc. ukfiv produoe a fcvcrc vtound, and undc; mch 

^^^icrs (be ^in amnnd is bkely to l^e bmiaei] and 

'T>rvL leaving a |>ennanent bluish-black tatluoinf^ of the 

[ jcaturcs <^ Kuri'^hot ^ounda niay lie enumeMted as 

^ i.j^ The unknown exieni of ihe Injury, unce, although 

1^ only a small external opening, the subjAceat itasutfS 

-v^tely lacerated, or lar^e cavities la^d open; {!>) tho 

^wmaiiiju* tire ^^xatt ti^ik of the niia^ilei (i) ihc 

'nianiin.^fion. wJiirh, how^v^r, nii^es rmhrr frorn 

Tig "Ahi'h may have been driven in, or from lack 

La tl;c l^'ound, thiii^ froi^) the Indict ii^lf. It i& a 

inlf'-icT^tin^ fact lh;il luillet wounds ptr ae are not 

-^«tpt>c» the misvile, f-n) vrheu lodRrd in the hotly. 

. ^ nw to no suppuialion, and hE?cr:<mini{ cncao^uled. 

' ic n always A coowacFAblc amount rjf I irui^n^ and laccnt' 

ibe Ruieins of tho wonndk to thai, Lf >e:|>%is supervenes* 

i^cslougtau^ may follow. [*) Tho depressed mental com- 



iSfi A MANUAL OF SURGERY 

dition of patients who have attempted suicide by this zneaias 
tends to increase the difRculties oi treatment. 

In the old days great stress was laid on the diflcring 
ances presented by the apertures of entry ai^d exit of the 
the former being small and depressed, the latter large, 
irregular, and lacerated. This distinction, however, only 
good where the velocity of the huUet is not great ; in the 
day there may be but Uttle difference between the two. 

The Olinlcal History of a gunshot wound is very similar to 
already described for lacerated wounds. As an immediate 
of the accident, pain is experienced by the individual, as . 
certain amount of shock, the degree of these phenomena, 
ever, varying with the situation of the lesion, and the mental 
occupation of the patient. The amount of bleeding 
depends on the vascularity of the part, and whether or not 
vessels are involved. In the course o{ a day or two, 
strict precautions are adopted, septic inflammation is likdy 
develop, giving rise possibly to suppuration along the m 
and fascial planes, or to acute inflammation of the bones 
joints if such l>e injured. Constitutional disturbance of a 
type is associated with thes« local phenomena, even am' 
to pyaemia or septicaemia, and dependent largely on the 
track through which alone the inflammatory products cafl 
discharged. Secondary haemorrhage may also arise during 
period. Abscesses may form and burrow in all directions, gi 
rise to sinuses discharging an abundant secretion of puSf 
causmpr convalescence To be much delayed. 

The Treatment of gunshot wounds must necessarily be 
ducted in accordance with the general surgical principles al 
detailed. When the limbs are involved, the rules of treatraei* 
laid down on p. \^, etc., should be followed, although da 
surgeon's practice is liable to Iw considerabiy modified hy6» 
patients environment. Conservative measures are often ibk 
ptactioahle aftor a battle if the number of wounded is large. 

In the less serious cases, where amputation is apparently UD* 
necessary, the tirst requisite is to control the hsmorrhage, ud 
to apply a temporary antiseptic dressing or application, suchlij 
filling rhe wound with an antiseptic cream or emulsion. As soot j 
as possible, the wound is thoroughly examined and cleaBSsd, : 
foreign bodies removed, and bleeding points secured. If ll< 
bullet can be readily reached, it should be extracted, a comrter- 
opening being made if necessary ; t>ut when placed deeply, 't 
may often be left with advantage for a time. If no importai* 
structures are divided, a drainnge-tube is inserted, and the wound 
dressed antiseptically. Under no circumstances should an atleiop' 
be made to entirely close the external wound. 

If, howe\'er, vessels, nerves or hones have been injured, tbB 
wound should be freely laid open so as to enable the surgeon to 



WQVttOS 



i8r 



cKtuT Ut«du9< points, or, if posinbk, tE> e^turc divided nerves* 
tfbarnnotiefra^taeatAoripicutcsof lH>nc. Whco «ptic infl.tni- 

^ rfideiTit dr>iina^c eMiiMiihef]. Should ittnoui iriUiiimalory 
ifsplectt ahsvt or li cvhi^ustion from prolonged »uppurution 
Ulein,xccodai)-aniputatJi]ii may be i:4LWd Tor- 
la daililig with A bullrc u/hlch h:is UkIj;^ dcMrply. various 
ippfiuMCft luw bttOD iDtToduced in ordt'i' lo locuie it» «\aci EatiiA- 
tra S)cb OS ihc pofccUtrt'cndixi probe of NcUlon, or sijnn: of 
1^ Qcn: complkAlcd clcctrkttl LuiihUdULt;^, by Ltii.Mii*i of rthjcli 
iW watt? of ■ compact U Hr^ried u'h^n [hi* hulln U i^nrhpil 
Stiip^by hu ajfio > l.xr^e M6 of uKeftilness l>«foro it in thi« 

Guu^l wQundK of ihff chf^^Ht And nhif^inir^r^ will be rcfetrcd to 
|lmdiw(Cfcuijxcr*XXVII.and XX\,}. 

V. ?aboii«d Woondi. — Thr ffTCAt nujority of poi%c:aicd wouads 
vt dot tu iHiiJc drtinili? mirrn-tirKflniiirn, and we have diuni^Mxl 
ttnr mtir« aivt cbaricteHvlicb citowhcrc. -\ few only rcimiia to 
hdeah ui(h bfrrc. 

Mill of Insects, aucb a» bcc^ and wa»p*. may be exceedingly 
SfifJfcig and p^ijnful. Um :(rr not jts n nile itiii>*ffTous, unle^ 
SVw lond complic:itioii. vucli :is erysipvla^^, -^viperveDtfif. or ih* 
*np ut vtry ruinvcroujL, «<( when a iwflrcn nl anfiry ln^c-i settk-a 
«il pn^d. or tht part involved is wich n?* to l«id lo «ctows 
>*Ai^. a in the pharynx or lon^'uc. a.-dvn]:i of Uir glo1Tt>i 
pQ«il4)' an^nf; uodcr such circiimnt-in^renH All th^t is u^vi:ilEv 
■Mdei tA th« Jipphcation of an alkaline loticn, vucEi as weak 
Imt Jinwuiii^tr. Catre mutl nlMJ Ite c]lelti^fd lu stv ihdl ihtf 
in^ind poison tt4: aie not left in ll]« bodv- 

Shm vftrictias of fltcst and spidcra tat aiao exttYraicly vrrtilertt, 
tfrf is b p09sitk llut aclii4l di^uM can be transmitted by the 
mm. Tbiis, if a ^y bilev a person ?tftcr feeding on putrid 
'.inuL fionss iovm of M[nic inllamoiation may hr firiginatrd ; or, 
ipa, uithmx rnay bo spread in tbis way> M<>«tiuitocE« too, 
pBT Jn diiporlJim i6\c in tuu ui^wUi ^Jd development of liUrije. 

Hks-bltSfl Tf^mtv bill I!:r1r^nf)iirr hm%;)«i th^^y^irr exrririltnffly 
oit n !h:"i countij', th* t-ommon ftddcr (P^^.ii fervirij bein^ tlie 
«lf ivcKrrvius on<! froiiicnily mci vnth, nnd even with this the 
fniB- i% aiX tufBcicnily \intU-Eil li) do aiLich liann unlc^n the 
adnidml atlaclced it a child or ^ pi^rson in ;i vtry li;id s[i*te of 
^Mhh. The poison is convcyrd to th© wound from i he glands 
«d pHson *ac situated tin either *ide of the upper jiiw throtl^J!l 
kit uaali id the tpcciali/cil Iceth, which upen at llinr rtpicch, 
iiri Ib^v t«th are *o delicate in some ST>aVes that it may lie 
tfcult i'3 nnd the wounds so produced- Tht^ffsctfJ of an adder'* 
l«i Uc not, as a ride, noticed iinmediatpiy, Inil come on in the 
'■vni nf an bout or so ; extreme prustratiou supervene, with u 



IBS A MANUAL OF SURGERY 

weak pulse, cold clammy perspiration, dilatation of the pupils, 
perhaps delirium in bad cases, merging into coma. 

The TT«&tm«nt consists in preventing the absorption of 
virus by tying a tight ligature above the wound, which 

then be laid open so as to allow of free bleeding, and the 
excised or cauterized. The collapse resulting from absorptka 
the poison is best remedied by the admmistration of stimulants 
the hypodermic injection of strychnine. 

In India and other countries many varietiesof poisonous 
are met with, and wounds are frequently fatal ; indeed, in Indii 
is stated that 12,000 individuals are yearly destroyed in this 
The symptoms come on rapidly, and are extremely severe, alt' 
they are, modified according to the variety of snake. The 
ment must necessarily be more energetic ; probably the in 
tion of Fraser's antivenine will be the means of saving many i 

The Anatomical Tubercle, or Bntcher'8 Wart, con^sts in 
papillomatous development usually on the knuckles of those 
are exposed to wounds either in the dead or slaughter 
It is in all probability a manifestation of tubercular infi 
and, indeed, resembles somewhat closely the appearance of I 
when it develops on the hands. Treatment consists in 
application of a powerful caustic, whilst in bad cases it is 
sary to scrape the surface before cauterizing. 

DUaectlon or Post- mortem Woundi have obtained an uneo 
notoriety ^is being fertile in the production of serious inftammat' 
disturbance, and although the graver forms are less common iK* 
than formerly, yet they are still met with occasionally. It il 
well known that bodies are most virulent within a few hounii 
death, and honce the post-mortem room is more frequently re^W*" 
sible for thuse affections than the dissecting room ; moreover, iht 
care which is expended upon the preparation of subjects by in- 
jecting them with antiseptics still further reduces the daoigea 
which mi^ht arise from the latter source. 

Inflammatory disturbances may arise under these condici[«i| 
from several distinct causes: ■ 

1. The mere presence of strong antiseptics, such as arsoic,, 
often suffices to irritate any small abrasions, and also to caiaii 
tenderness and ^1 little congestion of the matrices of the mill- 
This, howe\er, is ^)f little importance, 

2. The orq^anisms occurring in actual putrid material have BO 
power of attacking living tissues, although considerable irritatio 
may be cati*ied by them if small sores or abrasions are present. 

3. Pathogenic organisms are frequently found in bodies soM 
after death, and are especially virulent when developing in tfcjB 
exudations from serous membranes. Thus, the effusion in septK 
peritonitis is intensely noxious, and hence the surgeon wt» 
operates on the living subject, and the pathologist who examioff 
the body after death, are alike exposed to the greatest risk either 



WOUtiUS 




MiT^; it is^tlso possible for infection to orcur tlitough the hair 
Mkksof aa ttnbroktfn akin. 
I 7W kaoos ori^oated by any of thcso oicati& vary m tljar 
alme whb ih« ni<?thod of inoruUlionp i\\^ virolvnee tif fb« 

^^H^ cases all tluU ot^^uos h a Lmitod irriiaiion nf soint; obtusion 
pWnkh, which litpldly disAppcars on ihe AppllcacUjn of mjjtjq 
viblnr- or aniiwpiir Inlifin, SitppuMlivp fnlliniliiU^ nr flven 
^tdk tnee from infection of lh« hiii follidcs, :u)d in vromc coam 
ruieua forrn^ of omychU. pitrcioychLi, or difhiv ccllutitia, 
Of without nuppumtjoii in the nearest ]>inpbittic K^'^nd^. 
■ice toicTfn^c *)"mptomH u«t)aJly aiminpany rhe hitler con- 
ind «\'cii acutfr !;eptic;fnnu mny he de\-cJoped, The 
it« ircalmrtit iodicatwl for a di&ncction wuimd i» to lie 
Gt ti|;ht haDdlcctchicf aiuund the ti;ur of the k^xjuodcd 
ii^, 10 a« 10 «iKX3urag^ bWdm^ ^nd pn-^^nt tli^ :ibsoTpTi<jn of 
Vox nai^ruilb; |h« pavt is Ih^n welJ Wii^hed LirLder ^ tap of 
. cdd «4(tfi unriicrdcd in ad orittifcptic ttolutionL ^»d sticlftd for 
■ntaumic^; an uiifii>e*plit dicy^iijt^ iiiyat tht^j tit^ ;ipp]ieOH 
^Bby bduntnaikm which ari^^^ Mtht^>]iivnTly nia»i lie Treated 
^fe»di( to the i^tral rules of surgery. 

At cxc»<1(n^ty rtirmnon result uf poisoned wtiunds, wliaicver 

ihtirurifia, is mnamrnation of the n.iil nutriit [onychtA]^ or of cbe 

cf cbc finfircfN con^tLlutinif a whitlow (/htin-nvr^bt) ; and it 

be cuavtrQJcnt to dt-bLfJlK; llicw i:ondltion^ dX ibi^ plicc. 

Cj^vUi U Jilmoid ;iKi^»yfi dur in rh^ inferlinn wiTh pyn^nir or 

' •^gafticin^ of the malrix, Ktarting nt the i^ido or Wkp of 1h« 

vadco* the acmihinar foM. Scvcrnl v:irietief^ are dcricrihi^d : 

r OflfAlft Pomlaota {Ptfi-o^iythk, ot f/n£i(aJ H'Aii^ca') i.s ah 

ifeitfa of tbi! matrix commonly *ptfa in nurse* and Kuifceon*. 

9 tfud) fuppuiatkiR occur* beneath tht; nail, which iH tht^reby 

kamed. The condxlion umally *Eart» on one nidc* and f^radtially 

dlodsi nnind thr wrnilunir fold jnd beneath the nail and the 

Wi vtitl the whole iniktnx ni-iy b<? :ilTw:tvd When llie loo<;ened 

3aii*cul n way, the dilated ptirtjon ot the rnaiiix iti iound to 

fce CMTTfled into rranuUtion tiMUc- The prottHs i» cxtrL-mcly 

ftttful Ajid !ujincwij:Ll It^dious. Tiie uiily LopL- of iheiJiiJiit; its 

hea in rcmoviu^ with fine seizors, pot.iibly nndcT an 

, all tbe looscr)ud ponion of tho niiil, nnd iben touching 

'A ^anulaitoQit wjib nJtTdite of silver, ivhilM the mo»t 

tog attilLcatioiks arc utThoiU dotibi linyred-im^Ll |h>ullkc*» 

y fittdt with hot carbolic Imir^n ( t in ^o). jnd frrf|tK-ntly re- 

?on*^> At the Mine time the e^ncrnl health must be attfaidcd to. 

'- Oojdila Hfl%nfr is ibc tcim applied to a MjmeiAliAt similar 

mditijo trvt viih in h^dly naurtKhed chikli^p. Tlir wholt 




i9> 



A MANUAL OF SURGERY 



matrix is affected and transformed into granulation tissue, 
the digit becomes swollen and club'Shaped- Treatment 
in avulsion of the nail from its bed, and the application of 
septic fomentations or poultices, tc^ether with lodoform- 

3^ OnycMa 8yplillltic& is a condition met with usually n 
secondary stage of the disease, and may arise from injuries 
during this period- Considerable dusky inflammatory hype 
appears at the base and along the sides of the nail, whilit 
matrix is converted into somewhat prominent grauulation 
and a good deal of offensive pus escapes from the sides. 
nail becomes discoloured and shrivelled, and fioally 
perhaps peeling off in layers. Subsequently irregular 
new nail substance are produced, but it may be long before 
nail is at all serviceable, or it may remain rough and 
for life. Treatment consists in removing the nail comp 
early as possible, touching the matrix with solid nitrate of 
and dressing it with rodoform or black wash. Suitable cgq 
tional measures must also be instituted. 

A Whitlow {Paronychia or Panaritium) is also due to the 
cause, viz,, septic infection. Four kinds of whitlow are describe 
of which one is a true celluhtis, another a tenosynovitis, a tin 
is a locahzed inffammation of the skin, and the fourth involii 
the bone of the terminal phalanx. 




{ii) TheSnboQtloiilu whitlow consists merely ma. development of pna 
the cuiicle which separates it from ihe cutis vera. It is very painhlp 

otherwise is of little importance- A banc 

poultice, combined with tbe removal of (ht li 

cuticle, is all that is needed in its treaimdiL' 

(^) The SalMntuimu whitlow \% a true ai^ 

pK w% III / ff I litis, commendng in the pulp of a finpr. M 

\\ II ill /if often spreading upwards lo involve ibe palnL I 

^» II I II I i\ is attended with great beat, pain, red[iEM,a4 

^VkllL l^/f sweMing. which latter is at fiTBthardandbiMl 

^ **^ ■ ■ ' ■ but later on becomes more bo«gy. moA it ■• 

elated with much icdenia of vSt ubole fiirt 

and even of the dorsum oF the hu^- UisoW 

difficuh. from the tension of Ihe parts, tn M 

certain of the existence of matter. Caudtl 

tional symptoms are not* as a rule, very «Jiat 

though the intensitv of the pain may uhatat iii 

patient The band should be elevated, ftndlti 

finder poulticed. A free incision should beMdj 

adopted, and this may he accomplished hr^^ 

Ihe patient's hand under one's own ten tftt 

and cuttinfif in the middle line lo^aida tbefiBOV 

tip. Occasionally the pua forma at one or (W 

Pir. 1^4 -DjArpBAM OK SvNC' ^ide of the finger, and the incisions muit IN 

VIAL Sheaths of Flekor be suitahly modified. The wounds sbootd bi 

TKNhnNsuKHANii (AvTtk dressed antisej>lically after snch inci^ou. >rf 

KEtN Asii White) no longer poulticed. 

{r) ThcThAoal form of whitlow b re^llja^ 
puraiive teno-AvnoviiJs of the flexor sheaths The signs are much tbe tf* 
a3 in the former varieiy» only more severe, because the process is often id" 



WOUSDS 



191 



HittHii It it impivi&ai l*f n^etaitei ih*E the fL^ww «hc/i[b> txitrinimiitaLe 
I mA ik canAoA HlDkOr aticalb ftl«ra\ft io the cave of the ihirmU, iiiLttllr in 
|Hv tab tnfvr, bat eci, u a ruU, in th* indtfiL, midillc^ and rine tiniEcn 

3 b tb« IcHpt caw, ch4v. mppiiraticia omhs al iho J««v1 of Ihr 
thr neamnul br^a. bur nc<rn4iaii:Llly tt oventep* (hli hmir, mvI 
Avihsibe ptUm Ic the xune wjiy ai m the ibumb &m] jfiilc fn^^ct Km 
«k aff)t laniOQ ouil be niju}c (o antLvipai^ iikich riiici-jii<?n. niH\ nL»o to 
hfltt « v M pWAlbl* lb« kdhiaiori^ %t'hif1i the ir-n^cnt ni-o Imblr in rnnimcl. 
w K pn^rvM UiMn tloiiahina it^nt ihp artu^n*** of ibc inflawimai"*^ lr» 
ft^akitmmihp piu may hiiTT'""v tn tti« 4or«iiiii "# Th( imti^rt, D«pviithUiiiK 
iiwui injiirtmi. 01 Lhr? p«ni4[runi nuy he arTcMiEivl. Ijiiainf i<> lUi^vf 
0f liaub «l ilic |ih*l*jigct . it»^ 'Litli3|jlulMn|:rHl i^Liirs m^y alv 1>f iJivt- 
rKpMMit II die pftlm ui3><,ihvl> care mitif; ho t«licii in tneitinji iho abfrota 
MlviiMAd ilu MpvriWial palmar uch or ilt di^ia] tirnnchn Th* ImJfD 
^miOB akng th* ovnimof (be mMAcarpal bonn. and not bLj^htritiaii Ihc 
dddh d [h« palm . bvt an incitinn may ali^o br caHhI for ^ir^? bri The l«ve| 
^ ^lEn^-toan. uid lliit m4>- br ni^tlc jii thr niiilJlb^ bne uEiIkjul iJjuiKr'T 

*H7^l«iocc*iKin*JU ii iinna A^otn iv:'H< n?crc4i& of (hi> lermin^ r^alaAh, 
aMif iKtisr icii^-ipKhmlly mr u a rrcutJ of uibciion from ibc niUJ ntMrii 
Tb ladifniiutioD ma) be fmiitd tr>lbc«nd o| ibfr bng^»of ni:ty ttprml (■:■ Ihc 
sub rrwfeidilaH. vnd tlht nnovAlpf tb« hnnrt^ ildiOiiH muvr in lurb rjurii 
CMOttiE Aw Ijcatiaviii tviwioJ, 

Knpnlr of Woundx, 

Ufanner day^ five (lillt^rt^it nietrtuils uf rep^tir were ([escril;«(1. 
Wfl bcr«u«d koou'l^dge ^nd iiiriher r«»«3trcb wnrrurt m ia 
tolxif tfc« $iat«meDl tbal ihcrc is but one method of repair. 
•Uci, hov-ever. b modified attordii]^' lo tho L\inJitioas uf ihc 
*o«»i, vkd tbat Ibi* j:roces.s U the *nine wbaTevvr tissue i.if the 
hdf « involved, tw il bone, nui^cle, tc-rdmi, or ^ubcuiuneiJUb 

Tbe Btttnl fibcU u lo Uia prvcess uf rap^r iti<iy be aijL«d u^ 
Ucvih : Thp mar^ns of tb^ woitnd atP alvistya hi>uTkcM hy an 
^VB M usjom: in » btAtc of io^^cr<rd viulity, f-vcn if no bruising or 
i^ of fhc piirT» Is piGMnt. A ccrtnm amouni of h^nvor- 
bftt oi;cnrT«d. :in4L the divMetl vesf^Uarcin Ji cnnilition of 
IkmhrKii; nt. far sk the nem parent bnnches, which in their 
taa U« fLlif{btly dilated, partly as a result of this obstriictton and 
Piflly &oin the tcdcx irni-^tioLi of ihc injury \yi^. 55 ^-ind 3^), 
Tbi uabci? of ihc woiiiifl is ^cnmlly covrrr:! whh ^ film of 
'jBTh or blooddo<, i.rbiUt i»ny spaces left in tbt inUriiliccs of 
tW cusucft Are siinilariy fi]M wub clot 

i<t llic 6r»l ftlai^ in ibe pti^csb coamin m an abund>int 
nttUlUB cf fiRiall n^und ctTK, pTriumiiMy leucocylr^, whowr 
Incticn k 10 tetaove slU di^id or daTiiat'ed tiuue. ah well as co 
li«ik tip. dT9tnto^taK-, Ufid hii:dJy ut>sorI>, uny bloodclol whicb 
tu? U pfc^iit. Tht-<te ^<'IU arc piobiMy derived from ibr 
^unmdidi^ vms^U^ inci me ^ummpaoi^d hv n rpriain Amoiim of 
■Bnwooaingk so thai w* bave herw the earfy m. 1 ni foetal ion t of a 
4i|[hi mfUniiRatory reaction, which, if it doc?i n^i extend beyond 
■n«iB lipiita, ts d btacAciJEd piotccdln^. Should iti however, 



^itat 



193 



A MAt^UAL OF SURGERY 



become evcessive, as when sepsis is present* injurious results: 
follow. Much discussion has arisen amon^ pathologists u 
whether this stage of repair is to be considered iaflammaCocyi 
not in origin, and well-known authorities are ranged on 
side ; the phenomena are, however, so exactly similar to 
occurring in the earliest stages of inflammation that it ts ■ 
possible to draw any accurate line of distinction between theriL 

(t) The exudation of leucocytes is soon followed by the aj 
ance of a number of larger cells with more distinct nucid, audi 
which cell division is always accompanied by karyokinesis ; 
are termed ^brobiash, and are supposed to be the active agcnttl 
the reparative process. There is some difference of opinion as' 
the origin of these cells ; formerly, in accordance with the 
helm dogma, they were supposed to be migrated leucocytes, 




-««)S, 






*■'"' 55 — ^'-AMLV SlAGt:* Of HeaLING BV FiRST l^JTENTIOS OF A Cl^4N CVt 

Wound. (After Billroth.) 

Thd surfaces arc in clu^ apposition; the divided capillaries an filled wi 
tlirombi, as also the inrcrsrices of the ti»ues, AhiUi the capiUarks ji 
Jx-yond thti Thrombosed area aie somewhat dilated, 

luore recently the rcstarchfis of Thiersch, Ziegler, Tillmanns, md 
others, indicjite lh:it tliey are derived from the muttiplicatiaa rf 
fi\ed connective tissue corpuscles or of the endothelial calls liiiii| 
llie neij^hbourinf^ capilhiries. Whatever their origin, they sooi 
form a layer of cellular tissue which lies upon or between tbi 
Mirf;icet* or lips of the wound, whilst the previously effused lencfr 
cyte^ dissippcar, stime finding their way back into the circulatioi^ 
and others serving; as pahuhun for the nutrition of the fibroUutt* 
[r) The vasiiditrization of this cellular layer forms the txA 
sta^^^e in the process. This is brought about by the oatgrowtfc 
from the walls of the nearest capillaries of soHd rods of [tfolfr? 
pL'isin (Fi^' 57h '0' ^vhich appear first as minute buds, but rapito 
increase in k'n^'lh. and may ]>e single or doul>Ie. They soon beoa 
o\er to vmiie with similar threads growing out from olbtf 



ii^O£rAri>s 



w 



opObm, orwith ii*e wall of another vessel (Fig. 57, *),orocd- 
uenHj they wntl* wtlh (be vesi*) tbey sUirtcd from. The 
civectn^ taouc ccJla niaj niao become bpiu die shaped, And Mm] 
w; bfaiuching prjL^ssvfS to onur x^irti iht* nrKhiior^i from thr 
iCHd vjjb. After a tifn« tliosf^ protoplasmic thr(.<adH beC'jmra 
Otti^and bolkiu- (Fii;, 57. f), and a communiuiUon in caUb- 
:bkd betw«CD Ibem jukI the mother vcaa^, ho tliut btoud paruc?. 
bto ibtfn Tb^ fvw EVipilUrv w;i]1, Ai fir^t hnTtRh^rri'^'Ui^. ^uon 
btCMM llMd with doAnit* cTidothclia! ccLlv, %ncl ^trvn^l^«iiv(l by 
'61 coaooctn'C tiAStM uhidi i'^rma around il. Uy il)i» iticani a 
«fa W&cubif UbbUc is proJ\icc>d, hitoi^n a^ t^rn'iiiUiu^'^ iittut^ cuti^ 
wrinc nf loops <d C7tp\\]ai\es. fiupptinnl by a numhi^r af l;irge 




??s^l 



■-r-3: ^" 



fK |fr— L^tta Staom of Hkalix* tn Fjiut IffiaMTHjx (Avtbs 



vr «iMatin|[. (i/r«fltuiin4[ gntJiulftildn riixiir. ivhiSt ihe epiihdlum ha& 

;k«lnl TnuT)ili%h (fIU wilh u v;iiying ammint i>f inter eel lulut 
tdm^Mct alM> pr*i*nt, which, xi first bomo^cjicou», toon tiecome* 
finUdtcd iQ tcxturv tKif;< 56). 

f/i The ir^msfcrmttitm of this granulation tiMuG inio ^6»- 
a;tf;iiE»/ fusH i>i next piuci-nleil \wiili. Foittieily lE vi»i Mip< 
pc»i ikit tlw crils of llie ui^nuktlon tissue weT« tbemselve^^ 
tottlonned into the hbttA of which vcat ttsbuo i^ developed, but 
ftn idea i» Duw aLaiiduurd bi fftwui of one which mainUins that 
dv tthtillf air iKti^ed as jin InitfrcelltilHi vxiii.htiioii from the 
itobfautfl. By the contraction of those fibres the cells Ij€COiii« 
^hUctd out Aod comprcAAed, and 1h« ii«^^ly -formed vessels con- 
ttictcd.Mj that iLsIinicpiji^sr^llic w:-*i lisMicbL-cuniesles-sand le** 
(4X3^1, arul OL>nii(-iu,'iiEK' Ttrmrr nnrt dt*nsti, n^ well iLs smaller. 

'3 



"94 



A MANUAL OP SURGERY 



(f) Whilst this last stage is in progress, the surface of 
wound is covered over with cuticle, which spreads inwards ' 
healthy epithelium in the neighbourhood of the wound, and 
cially from the deeper layers of the rete Malpighii. 

As already staled, the gjeneral process of repair sketched «1 
is moditied slightly according to the character and condition a(1 
wound. Four chief modi neat ions are met with in pi 
surgery : 

J. Healing by Firatlntoutlon or FrimAi7irtlio&occurs in cl 
cut wounds where the lips are unbruised and brought tt^ether,i 
that no collection of blood or discharge between them is 




Tig. 57 — Ntw Vessel Foruat^on. (Aftek Telluanns.) 

41, A small bad-like projection from the wall of a capillary; b. the unica 
such buds fine wilh another, ur with ihe branching pmcesscs o( 
tive li&sue ceils . t. the canahzalioQ of Ihesc procesaes. 

whilst asepsis is also maintained- There is but a iniGroscapi 
iine of damaged tissue, which is easily absorbed, and the proGM 
runs a typical course as sketched out above, union beiQg-eflecbl 
in about a week- (See Fi^^s. 55 and 56.) 

2- Healing by Granolation, or second intention, as it used tob 
termed, is met with in cases where there has been definite tcsstf 
substance, so th^t the lips of the wound are not, or cannot be^ 
proximatedf when ihe surface of the wound is bruised or damtfd 
so that portions of tissue have to separate by sloughing, or wM 
the advent of sepsis has prevented the occurrence of piimtfj 
union. 



\tkfl m snuU amount of ftSttptic d»<l Iirgu* is pTM«!Dt, it » 

Inmrcd » prc^-iously »lAt«d (p. 65) by on [nva»on of Iciicocytci^ 

'fron ihe siiTTtiumiinf: vcv4*U. t^hkU <li^n1ciriAlc And K^tul^mlly 

ttad^ ia^ ThcM' arc followed liy the fibrohlntis, \vhich form a 

b5«r *)i i^ntDuUtico liutie on ihi; iturf^cc o£ ihi: wounds If 

attt'a mvcb slo<xi|;b to ))c tlcAh with, tbc vitnlity of the Kranu);i- 

•taa bsAue aintiQt \k nuinuincd bcynitd a certain dUiaiioc from 

m> ftjuftc of QuTri-TCiiiH ^nd «o by a pfocc» of limplc anvmic 

jltaaboo the unjbuirbcd d«fld portion ift cat^ ofl^ and ti ^r:uiu- 

mH&c« rcmaim. If the ^lotich i.i Kptic. tikcrative In' 

tian ocxiir> in Ibriidj^trnr living tiuucp which ItringKaliuut 

[« ^iaidtr rt^ull, thou|<li af^ompLuiied hv «uppunition and sqitit 

[(prtf- When. howtwTt th^iiv ta a &impltj lo9» of ti«BU«. with no 

or duaotfo to tho ti8S>u» (Fltf, jtj), tbc course of rveuta 

llows: Toe Wood'Stream In the superficial CApltlHries 




^ V-C4«Li ST4ut3 or A WucAiii Aim AcTt'AL LoM or SiJi»r«?<aL 
■ni m StrrvanciAL CAnttAJiiti mnoMMnM^ a»d tkk Dtu» 

hem armtod, »dJAcertt on«4 hecoitie dUntvd. and fiuin 
ID cftudaXMB of pUemji And l«ttcocyt?s rcKulK. Thi^ pksm^ 
Ulcs on the s^irfdCc and tanxxA a k>'cr of fibrir, cnt^xnglcd 
tbe Euc^jca uf nbkh arc a number uf whiCc cotpu^iEi^s. m> 
tlw wound bocomrii covrcpd with a film nf whili^iijcllow 
) tcsowa ai; lyrarb. Thi^ incrc^ficii f^mdiuiliy in jitinimt 
tel tiiid&ttcss hy h hirtW fgrmnEion of tit>roblnt:tr., :Liid 1^ ^lsoii 
■kxruluucd fiooi licit iw intu grAniLUtioii liasuc, the pioc«Sfi 
■xnip|iQg Erom four ro *e\en d^yit {1'i|C. 59)^ 

TW iieatiiig of a bnJihy (^^uiuktin^ wound U brought alioui 
bj the cop%'«f»ion of the deeper laycr?i into fibrocicAiticiAl n«ue, 
jai ]^ lJi« rairiiGe betQjiuii^ co^eTtd with tuliclc- The coo- 
tmtila Icodencj inJtertnt in ail cicairictal lis*nfi brini;s ihfiul two 
FouiU ircfn tU prewnce hi (he ba»u of iho wound l>MiKitli iho 
npcr£d4l Uycr ol i^nmubitions : iL] The surfaoc »Jea <» "10 



196 



A MANUAL OF SURGERY 



wound is diminished in all directions, a most important el 
in the healing process, since if the base is adherent to some 
resisting structure repair is slow and difRcult, and the 
may remain open as a so-called chronic ulcer. When the 
lating surface is very extensive, contraction may proceed to 
an extent as to obliterate many of the vascular channels, and 
thus depriving the superficial tissues of their adequate nutrit 
the healing process may be indefinitely prolonged, (ii.) 
depth of the wound is diminished, partly by the continuous 
of granulation tissue from below upwards, but also by the 
tractile base lifting the deeper structures to the surface. If 
base of the wound cannot be raised, the cicatrix is usually 
pressed and adherent to ihe underlying parts. 




!"■<■ 59 ~ L^TEK Htagi^s op Healing by Gkamllatton. (After BiLLROtaJJ 

During' the process of repair the wound takes on the appa>| 
a lice already descnl)ed as characteristic of a healing uktfj 

3, Heftllng under a Scab is a proceeding that can only be p^; 
milted in very small wounds^ such as superficial grazes Afld 
abr:isiiins, and is practically identical with the granulating p^ocf*^i 
except that, instead of an artificial dressing applied by tb*] 
sur^ifon. the lesion is covered liy a scab which consists of aoOfd. 
blood or dried exudation. Such healing is only possible wha', 
asepsis exists : otherwise pus is likely to accumulate beooA 
the scab and give trouhle, 

^. Healing by Organization of Blood-clot is only observed iftl 
slnctly aseptic wounds ^vhere there is definite loss of substance. ^ 
as in the di^ep channels made in the treatment of bones thickCDed 
by chronic osteitis, lllood is allowed to collect and coagulate W 
as to till the cavity, and the surface is covered with protective 10 
prei'ent irritation from the dressings- The dark coagulum showi 



WOVSDS 



IW 



Fe^tnoc of diuvo for some Mj^ but cnOnally tht pctiphcinl 
ponLooA bcccBiw enauuldi aiA jrelluuiah-Aljiic] in luIuue : lht«« 
ti» turn tipcofno vafciiUfia^d and iransforcied into grnLrulaCioii 
|laB9r, ^h'lvich in time eprcAcli^ ov«t tho whoJd burfu,cu fruni 
|Mplb(fy CO ccnCTC, Aod thcr hcallne occuts as clcKnbed alx^vc. 
Ilbecloi Uabwlutrly p^tssivif in rhiit procf^s, Winj^ iiililujitt^d by 
wncjtet ftnd r«nu>vAl by dnpcratfft, And thu^ m^rply R«rves ;i« ;i 
WW of mpport or scnflbldm^ for the ^ildjii£ up of the i^rfinula- 
Itntiaaiue whkh replaces it. 

I \lairlsA mis* of fibroid i\^w\^ covv^rwl by epithelium, which 

!tu b«ea formed by nuiure in ilie r^pAtr of a u'ound. It lu at 

farii >sKuUr. And comain» cdU of the connective tiwiuc type ; 

l'bi:J[rf a tnne.as contraction conimucs. thc<«-lt v1eTnvrisl>ecorTi& 

6i3n*doui, r«w«r in oumber :tn(i le^^ obvious, the intercellular 

finct insu* more abundint, find Ihe vessels cons1rict«di go that 

I balri Kat lwcoii^<.-6 Hrll-iiit^h bloodies* Supc-rrKiall^ h» coluui 

rdutiKfrncn rrrl to whirr, i^txtX if of smqll «t7c it mny filmoKt din- 

I ifpAt, but nvv^t nlKoluitrly, iinlete tho (iihc\ilanooiii; liKsnc hns 

BBC been opei>C(l into. AVbco ihc i^ns around hccomc injected 

It iftj CAvi^. suclj .w sliftjp OiclJoii. the -inamic ^Jir tissue 

tKrawtaf^in rvidffni by cnnirast. Lymphfltict, nervts, hairs^ 

Mi cutaueouK ^LtndR arc all absent, esccept pcrtiipi^ at the 

icipicfy, aiid the (pjthcliat covering ilftclf is merely n iinlform 

Wwiibout f«iH!?ii% 

T\t PatkolOfiteal Ptmnomoiui connected with hcuxm are a« 

L SlceMlTI CootTACtiOB- ^v'bich may lead to cicat dcforniily, 
'npecnUy irhrn thr umtind \\a^ <>ocvirred in tlit llcrxmc of any 
i' rir ^ointfi. A wetvlike mx&% of fibroid tiisuc then form«, 
i«ftae mo^^mcnii^ And rcquirini; operative inirrEcrcnce. A 
•tooidy burned h^uid ina>' by cttiAtri^ial cuntnLttiua be filled 
«1L JO mi!d|flit]y ma^A. i:;jlleU a cbib hLtntl, of lirile um^ : jtnd^ 
■=iiiiJy, tbtt chin may be drawn do*-n :tnd pisiciicilJy lixed to 
'■■ I'^rmtfo, and t!ic lower bp everted, as Ibu result of u barn 
■ hvoX ul iTie nn:ti. Tlie Trtalwent o( tliia cuiidltiun couaiiitM 
Timt-jling the cicatiw, iuid thus freeing the puri^. during which 
ptCMtt 4 most be remembered ihot deeper structuroi^ of import- 
sttdi AB the mam vc^acIs nnd ncrsca. nxny be ndhcrcni to 
ttdn KVface. and thus be emliin^rrfd. Wiieii oirci: tbr scar 
bwff dnideiJ, llwre is *b ^ nil*>, n<^ ditlienlty in restoring the 
to ll»dr normal po^lioj^t, alihoiigh where the contraction 
existed iot any IcfiL'tb of time it may be advisable to do IhiTi 
■betj, e^Tii by teradU'il extrrisii.iii wilh ii weight and pulley, s^c a^ 
1««Tmd any nisk of Ucoraimg the deeper sirutturet, which ;iTe 
vv3}y 00Qtr9Ctcd wccndarily- The row surface formed by the 
Wiin^ out of tbc comr-tcicd pait h^t* novr Xo be covered with 
tfilhrinnp by laame 6nrm of ^in-Krartirig or by a plabtic opetd- 




198 ^ MANUAL OF SURGERY 



tion ; the majority of cases can be dealt with very efTicacious^ 
Thiersch's method. ] 

2. Orogrowtli of tho acax tU«ue is sometimes met with,i 

stitutitig what is known as the false or Allbflrfs Keloid. 1 
most frequently occurs in the scars of bums^ but may arise ( 
any cicatrix, presenting itself as a fibroid indurated masij 
dusk^ red colour, with perhaps a number of dilated vti 
coursing over it, which occupies the region of the old xarA 
may possibly send claw-like processes into neighbouring hnl 
structures. It consists merely of a hyperplasia of the scar ^ 
but as to its etiology we know nothing. With the evctf^ 
of somewhat severe pruritus or itching, ils presence entajfa 
inconvenience, although if it occurs on exposed parts il m^ 
very disfiguring. Removal is useless, since it almost ihl 
recurs m the new cicatrix. It is therefore better to leave it ak 
although the pruritus may be combated by large doses of Bf 
potassse. After a longer or shorter interval it often disappi 
spontaneously. 

3. Ulceration of Bean, usually the result of defective nutfiB 
is frequently a very troublesome condition to deal with, as rq 
is extremely slow. 

4. FainAil ScAXfl arise from either the implication of a d| 
terminal in the cicatrix, or the pressure of a contracting i 
upon the bulbous end of a divided nerve, as in ampuW 
stumps. In each case further operation is necessary; in 
former Ihe cicatrix^ or at any rate the painful portion of il 
excised, whilst in the latter the stump must be opened up, 
the enlarged end of the affected nerve removed. 

5. Malignant Disease of Scan takes on an epitheiiomatous t] 
and produces a hard, indurated tumour with everted edge* 
a chickened base, with usually a good deal of fcetid discha 
The progress of the case is very slow, since the vascularity ol 
tissue is slight- It is painless from the absence of nerves, 
as long as the disease is limited to the scar, no lymphatic id 
cation win he noted. As soon, however, as the malignant gro 
invades healthy tissues, all the usual phenomena will show tb 
selves. The disease may be freely dissected out, having regu 
subjacent structures, and the wound closed by some plastic meti 

Mellioda of Treating Wennds- 

II is quite unnecessary in a work such as this to occupy ^ 
in describing the many different plans which were adoptee 
surgeons in pre -anti septic days in their treatment of wounds; 
ahhou^h even now there are practitioners who scoff at the te 
in^s of Lister, and maintain that merely cleanliness is nec 
yet the majority of enlightened men make some profession 
using: either the antiseptic or aseptic plan of treatment. Ui 
tunately, failure in carrying out all the necessary prw^auJ 



— vrovfn^s 



TW 



bub au( urirxiiTimorly id wicj^niTatkm, -inJ «k-p cannat emph*aa« -, 
lea itroogly the urKeot Dccc^^fity of Altentii^n lo the mirtutcst 
debit) if »acc««» i» to b? attained, cApcciaU^ since so innity of 
^opcfalioa^ now uiidcrUkco iice wily justifublc unilet such 

Tbt JUMMptlo pirm of irenting woun<js. ori^^nally introduced 
bj Lord Lnter, is an uuttonie of tht germ theory of putre- 
liaitm. Ic bas Cor if^ objt^d xhv prfwaihni of 1>;iLte[ial de- 
v«l3fniF-iE in (hft wournl by ihe u*iw of diemic.il a^<*L-it4» c^pahli? 
<if ikctrovtnCf pre\'eoCru^', or inhibiting ihctt pjrowlli, lnnum(*f- 
4U; mdanda of appl>ln^ this tre.^tnimt h^\e hceii adoplej, ^id 
indli£iTrni]^ anti«rprir wpnis h.ivr li^^rn n^t^A^ pmniinrnt itTvinng 
AoEi lieutg carbolic Acid, corrotivo suhliniAte, iodine, iodofnmk, 
nlKylic »cid, iTOttc jicid, vtc. Whil&t the prsciicc ciifici* ui 
wiouv KiripGAl schijoU as w the dnli«;plk-'f employed And ihc 
dietiki »f thpir applicilirm, yei ihc principle in unme form tir ofh/^r 
11 >o» generally adopicd. We Eh:ill hetc morcJy sketch out the 

wmH routine fc>llott-rd at Kii^g*^ College FEcispiial in undcrtakinjc 

iopvntxii], oc in the trcatmcut of ^ wcjun^i, 

L TW lioia od lb# vfir^nn mum he nnil*Hv1 pnrip by waihma ihf^m 
IkflMi^lf iridi luip aod vaicr, tlu? lutti mufi be <:ui, if n«(l be, and 

■hfltt kcpllc rviAtantU ]k *:r qpt fu cullci:! f?r fhJ^ {>urpi»c t> purified 
■■I^Fwh AUy Iw «TDplr>>^ With nJ%-nnti£« Tliir h.iarlH !xtk rfairn imni4irH*d 
'kieiADUf Winn (prpfrrmbtr 1 tn r-^l, urhirh pp^nHrv-i thf ^liin, snr! :irn 
fKR «ftd<Mly Tttan a iisMimnfr ^'-^lirttnn It t:iiiv tv t^lmrly rinrlFMiootl 
AiiafaKl>gtie c«i]ity b fwrt enKnUj^l. ilnmtih \cty duijaUe. lintv II hfti breo 
JiBMiUMcd that lit niUiy « wurul iImi lical* hv iii^t inlcnli^ii ^tni* arc 
[fntmL Ibeiigb ibovt tin^ not, ua rulr, c-f n jMTliti^dic nmiirr 
i k AU iftitn«Mtoarv«tfiUztdi]i ihirh of cirbnlic loiion |i in ji>f, wtLicb.iE 
ttoit Iv r«meinlw<ed, [Jili4ft in acipn^ciablL- tiFn^Ti'««f<^rroy mk(:rr>tm. and ihew- 
fcn^ditfic^ 00 Dpsraflan a InLh IniiniTn^ni ^k lurlclrnlyuUrri for, v^h^fh Km 
■ot tan PKviuuMy puri&id. lE iont^^t tfrntutU jmt in itiumi-iEi'iiilvicEircirrtciEin 
4c ■!«(£[«. bni i( ^oold bt first plKoJ in li^ui-ficd txrholk acid ^ a ftw 
utd (be« rinwd vtiroiiE^h the i Ln vo rajlviion Sppcinl 44ne mut W 
ftimd tonin}* Tk* l4«rc«pt ii>McihAi Iht recih Bud i^rrAfioni irv fr«« frnm 
4M hltfv|'fl0« nod offaer dirt, u lUbla (a aHiitnuLatr th^rv 5>linMlil an 
ti iMl\ na IIiR Hiiir duritii; i\^ ri|irrA]l[iEi. it miiHi, of ccHiMr. (kol be 
Wua until tiHXviiKtib ir-purilioil T&^ltni; iUn tn^iniincnin ritlicr ia cir- 
loUonur ia * 'At^i loluijcn <ti Mufbon&lo nf fcxln (i |>ar cnni ) t> alhi:j i 
fdMM QtftSft dri rcAdcrLfit; tb«iii 4Kp|ic 

■■ IpOigMT UOlaU I'rify eirrlitUy iitsaeO. urt i lerElk aouncc rjf MpLlctilEtfC- 
«a. ihi^cMW tv ihnH'ti^My puVifiM In vtntitf eirbDlk lotion before 00*. 
«) 4naf out ofa I ia 40 wlmiun ilumiK tVc uiJor«ciun. tTu1?» iho^uniton 
caWklojlvirlT cerl-kLii of ilu nucM, n b bcticr lon>co&lf aUrnitad numbtr 
tiipaM*— w IH*> And iat the uiitiani lo ckoiMv thom in » U>w! of ImTinn 
fMilut ilILlLiIi [iiiilliiin t'^rtii^nflol ^nrLcajniifHrimi'' i>r ifmrcuakHJ 
■ nrMic«4 laHiniiit* lotion uv lulvAtitft^Hnily emp1rkyr<1 vh»ii tiLsrviftWiV 
**!< tt « the U«diiiAlt«i of Ihf- •iprirjff* It lit kdvl^lik (* l«rp >P^iic» 
"*! tc lubefcnlv duckte or rectal ojwtalinn^ ftp«fAlc ffum Ihwo umpioj*r| 
» dHile woafldt : and ic t> Ultcf lo employ nwool ni^Aba 'or »ny enmtltion* 

Im fW«mc apnnim aMtr am fi(i«nil lOTi, the frrtlowinu pniceiivittt ™*^/U 
i^piiri They *rp ft™ thimn^hlT i*THi;g Pt» ot coW vtiicr. *nd [iwn piMM 



«o A UAftUAt OF suBcsnr ■ 

u> Kuk toTvymc hourv in ■ fiirly sironj* nludon of wulrinc tciU- Thefiii 
ihea atntJtn well rrnvd In critJ i>r bi>l WAter. uju id ivmovvBll ibrvodt.M' 
AnoiZy imriicihol \n a ^qlutivti vf outUjIic uiJ {i iu Mjt* is wfaicb Ibcy Mpk|l 

llZl rccuin-.J 

En t 11^ 3r>cafbohcT~>n'~>Ff r^'r^re utr Sillt r?<|rtim v/ r^ rtinrmiffh ^■JJJmlM- 
Ifi order Eo ptci'car TTifr hiHcTi Mi|H>*i^T^ori ^^ cammciiiiy wen, n liMdriAUf M 
ixn.\ )l ElUJ/im^'^Iy Tur sumr iLnw Wforv- iilncint: LI m ULitHnlk *cd ^ ll ibottf 
br in Iiujk cc>iU» iillcj nMou !i Tfrl.iLi [lic^ii i>n|v ilif i^iImkIc Kr ^ndk ATb fMcU 
Caltfut, on th« oihcT hand, mun ooi twlxiileS or in imofil in carlxjlk kNkiiltf 
too ToniE. u II u ipi lo bfooma roUon, ami bvoali ^hvn nttd 

(- Thd ilrLb of tlifl {wtlant Mhuuld b* Uiavh] prinr To openrinn kt the |wiil 
i[ idl lihjry iuiil Tlim r^Lirrrm^ht) w.ihhad wUO *Out> himI Wftlci. and Onvd 
vtUli LUi jimi^iirptJc ixiinpmH for notuc buun V/htn iht |«ticB< i» oa ibc Utk 
*n[] ana:flhFi^i«d.a finjLl c!e«nMnc b undortAken. Tfar pan i» Amt ^fvll r^M 
«ith lurpcniini^ ur nhcr. to rnm&ve «!! CiLtnful enur. anj ihtn w4ik«oftBq: 
hnttly. II lA flij*ih<hJ cvflT wilh ■trooLL orlMjlU tctiofi. or M^n icnibbBl witt i 
nAl]-bni*ih Q^rrmi;-* •GiiNitnaf^ tft wtmrnni^H iikr<1 iiiiA#JLd nf outy^Add.ln: 
i« m>L iHj w[mfiicirir>-, tincr li is unnbleici ji^nrTr^iv ilir Ain Ui ilis wnceHctt 
h must not be fofirotlCQ tlvt n very eTMsr*cllc u-< of cjuloht aM wBI br ^ 
1ow«| hv Ioc*l irrujitfoni u i«ll nn l»v il* Abmii^UoB laio ihe blooJtlWM", 
■rtwCLA-lly In protmcEfil opiinittonK. <^KniQ. nul or\Zy doM Um ^u«lliy ol «■ 
ftkin V4ry in cliMnrvnt mrlividual* (cu m^y h* i]lniim«d tiy oontraulu^ ilul di 
coal'funvvr. who pmUihls' baEh« ornrp a yoir. uilh thjtl <if 4 bbl>. iflhkfa^ 
soft, clenn. wxl ddlciltr hi" ir aim rtlffe™ !n varloui reirlotii of ihe bodj. «ri 
hence ibe proccv uT nufiruKtigii mukt lie niulLficd ncoordiiiK to ibc thtrrt— 
of the Iniegumonl. Anv >4rt wbor* dirt in«y ii«umaUted«niAnd*>crap«ldBt 
ftTlsniicm, r^., th« umHlicut. cittrnal for, tovt, or conaa glaiulb in psrvda 
wiTh Inng fi'ifFttlM 

V\'htfn ihc opcmilpn hnt brcn crxnpleted. ihtt ikin Aiouiid ihmkl tv uala 
i^lb-uival wliEk Wiirni ^.-^rUtlii: Imlun, niter a piece of drrvLnf bo bee* pkoolik 
4 I^Hiictiiuii tr^ct [Im- vkvutit] Tbiv cWnvanjc ulioukl nlwayn be nccoaipli^Md 
hy wiping [Niriphcrnllv a'^iky From tho conm, sued any tpon^to or ««b wteb 
hAt ^<-<<n iiiilijrvii for ihu purpono ihouJd out beallowad to touch ifae v«u>d 
urmi repiirlficid 

v1, tW ftnft of tl* npiT&tUn nr ^iiiiinil ifviuld tv ^urrauodnt wfib Hittic 
ttf*l», »tiO Ibne tcvrtnl liy tcMvli wninc oai of hoL cubutlc loikra. Thr 
latter Mv firK Kuihcd in a »oIu(ioil uf i in lo. and |h«a ihruns out «f the kt 
I in 40 toliiliori. And Upi ^varin mitil fci^ulrtd DurtnE tho opa%l^am iha 
wound ni«y tw occ^idtinAUt- imyittocl wjlli 1 1 In ^o ciLfbolic totutioB. or inth 
CoTronrvti )»ub]imnr«i (1 in fVoi : hm tiirh ii iut( r1w4>^ lulvlulilfi. m H l«Dlh 
10 tncivtiav <biT flmniini of iiiitiviiiii?nt cn/mi;, nnd it iv«l1y unoDCF^ar^ If oiv 
i» OTtiain u to ttie jiKpiic condiiUui of cierytbiiiK «iii|ikj>oJ. Who* dMln 
with ihe pcrUunvil u\itv vr Ihc intvrior {>r n iolm. tbc Irsa one empkm Htt- 
Mptki Ihff betlAr. km« ihey dm ^IwnvfL inur« or tew irritoling, and Mad l> 
d^UftinVb-m n( ihe ■ndr>lhflial Irnmfj, uhirti it r>i tn imiwrlani to ^^i"****" 
fntKci In bci.tb«rulp rf prurtii^c which ^*r :irr rndfUVDnirjiw now rAcaoHifa 
islboiiricieil 3iitlvtHL-i for the cmernal pirt* but lucpsli lor the SnierM «( 
iht ^gund , one ouuhjE tlvfxy* \n: cciutiun huAv^'^L. iUai Ihj* idoaJ hu bflcn 
aiuinedn and then nntttrptic JiricfttioD ra«r I'* rourtcd In 

vU Btlurv clodnif ihi* <vouivJ. lh« mur£*o>n munt ua* *vny •ndMrtxar to 
wcura K^iliiii* h;rm(4ra«it [t muit be uril ciMnMd with & dry igHMt 
wniniE out j>f hot c^tioUc lotion, and rvat. [f nn:mury. IrflOBvl : h mftf Pt 
ulim^e. npcci^Slv in larj^e wi^iinds uf vujcular p«ru. to inacn a aailiUl 
dfAiiiftfCc-lulie nnd niitth it Aiiah witb tha BUifKC. but tn muiv t/uat it i* 
potuhle ic> diiHnw with tuch The indoion ii tb«n doivrd. U'siindvoon- 
mimifxiing wiin vptic cavilJci. lach u th« mouth or rtclum. should lwpuni«d 
wlfhi v»lution ofcntorktflof ttnd (^oonink to 1 <r|incej i.nd<honp^vden<l«tifa 
iodufoiETi and vUhrr lofl E>]Hin itr liijlLlly |)!iEgtfn1 . vrplLi? eunfjuniaaduo Uby 





WOUVDS^- 



tw— >i dsbijWt am/A rr«n whea ti dott oecnr. tt may be kFp4 under ooftttol 

'#. Pmlif. A K^rvlull) 4JTJUi|?vu &ii(iBC|i[k dnMins i^ Jii'i>liixl, tn^ thv fmi 
■ad' 



put CB ft q:lini oc in ■ slinjE, a\ mA^ lic-ii vuii Ehr rc^EiiicnacnU 



U UK^nUBnt.— ]lao4r%1nAgis(iilirhutw*Ti«inf»ln>'r!rl.amlrhrc1rR«tniE 
iBDtiCMiad lluoivli. It duv W Uft uiitE/ifilml inr n^tm in ri^Vi L!4>"t, itt the 
frfliniWf of nrliicn MliwlLt IB rc^o^cil, i1l( Mi1<:Jin l.drJi oi>l. ami in all 
MDfaiiniif the «f«und iii:! be comptclcls' tulr<l When a dniimfe-iubc has 
WiHvned. n. la mftlly poiuUc lo tflVe it *ii nl tha tod ol f-^orytour of 
knr«Vkt boun : ibit« Ia tio iidvMflfuv, »i % nUv. in kMptnu il iri iov^fr . 
« h «drr tv^nml fior th« rvRKivAl of tA« «v]>- w n >Wnpiijw<iiii fliiiil iaHicH 
ntdawvv tbe Am twrfny-ftpur or ihiny-^ii hovn. Should ihr ih^cliuTk:?! 

I K imt tL ibem and rnlroft linrins (he 6n( i»«nlv tmr b*iur>; all ihftt nhtJuM 

^M tidttnpACk nn virivi dkitp i^atifp at urinl rhiv mJV>' i^vrn. if iii^'r*«ur^'. fv 

^r Ai BO Ihe different fonriFi o( Uravslnf ^-liich aro employed ni Ibo 

pwal d*y, mudi mi^hi W niiui-n, Ui! v,t muM cootont ovir- 

xhowiUi A few norm js To tho*j arclinarily tniplfiycd- Lord 

L«t«r pcriDtccI out «ome y<^Ar« hack Ihat ihc mnin ctiuiiiiiaL;; 

if s ftiod dfOssTDf; con^i<Icd in iU cont-tinmc ^ixnc ihoroLiKhly 

truikorthy jtntiKpiic ingrcdirnl i in chiNm.itcrial Ixri^ig vi s;oiied 

i^tkAC it canniJi l» divupfltprf l^pftiri* ilic n<?Kt drf^wioK ; in ht 

fcror Mtirely umrnuting - »^tl '"^ <^* c;ip*city to readily abfrarh 

»f mood or scrum tlui may ooz« from the woimd. All the 

vnpiftl •tnliMrplic itri^vii|£v viz,, ihr c-irliolic and c^uuil^plUk 

psm^Aiul ewn tTir ilrmbnith ^tixr and ^vaol> bilrd to fulfil 

CD* tf more (if thci« rcq\iircnuiiii«;; htii in the double cyaftido 

ncfcuiy and rinc eini«r, wc have ft niatcriAl whicJi i? to al) 

Is and purpi:i9f> |>rtfiTi- All thiit i% U'i[u\Tvt\ U to mmstfti 

Et «^h ckrtmlic loCioQ (i in ^o). nnd it mny then 1>e applic^d over 

cW ikcajod wiihool fotvr. <.Xct thin trer>b portions lakcn from fhc? 

' 'A supply (which in A\<AAy\ kept Id x m.^ckiiiioibh covering 

«iiri Innj* ^ptitll(te4S vritb irar|h>1i€ Jntiori, t h\ 70) nit placed* 

«d 6n»lly over all a Itbural covunnfi of Kt(;nh»d or antiseptic 
*»L «o 09 to difluM the prcMurc, which U applied |i>' me.nni 

•( urcfuJ bandngii*;. The IjcM material fox li;tndnge:i i» Iruttcp 

<hk.9nc» it lA tf|;hl anil od^pu itself eai^ly lo the uiubiiff of 

'hf part- 
(Mm «ln;Mtnf>:9, such a* boric lint, iodobmi c^ukc, etc-, nrc 

«t4>iottaly coyJoywi. but ihry^ue noi so saiLifiu.lur> for gencnd 

«v «s Ihr ryanvV gnufe. 
O* Ui^ y<ari m^itv Coalinettul and Amoricftn surgeon* hAv* 

b<n itkiTiplini; to cllnninjiic th^ iTfitatirt; prnpcniea of chcmicftl 

■UbsqUics by ihc Hilo|Kior> of whm is rwlh-d Aseptic Burtorr» In 

ibi, ■■•pdft i* obtniitwl hy nut^nw of heat, the most pi>ttetful 
t*faiCMuic <Mr poMciiaon; the inttrunicntE. lij^aLuro^. «uluies, 
*nJ tessinifft Are »1<:rili«d by placiiie them for *n hour or so in 



Ml A MANUAL OF SURGERY 

a hot -air chamber, raised to such a temperature as to destni 
germs, or by boiling them. Such a plan has been empM 
with much success, but requires infinitely more attentifli 
details than does the antiseptic method. Where our a^ 
are constantly changing, as in a large teaching hosptil, 
where many hands are engaged in the work, there is I 
greater risk of failure. Most elaborate precautions are alsot 
as to the dress both of the surgeon and his assistants, or d 
onlookers; whilst operating theatres, tables, etc., are all ( 
fected in a most careful manner. Resting, however, ad 
accredited fact that the great proportion of the organisms 
tained in the air are harmless, and also knowing by expd 
that the precautions as to antisepsis sketched out above an 
sufficient in order to obtain the most perfect results, we ha' 
hesitation in maintaining that for all ordinary purposes 
especially in large city hospitals, the antiseptic method 
preferable to the so-called aseptic plan. 

Qeneral Gondltlons cannectod with Woimdfl. 

I. Sliock. — By the term 'shock' is meant a general dep 
condition of the nervous system, resulting from some en« 
stimulus, which is either transmitted to the vital centres 
medulla from the peripheral sensory or sympathetic nerves 
injured pari, or may descend to them from a disturbance 
emotional centres through the nerves of special sense. 

Much confu&ion in the minda of students having arisen as lo the 
meaning xo 1>e attached m the terms abook and oolIapM, v<e propose 
hmit the JatLer title to one Form of shock, in which the Bymptoms! 
marked and usnallv prolun^eil, arising either from a protracted Open 
a£ the evidence of approaching diasoUition at the termination of a 
illness . in short, co1lap»f ii practically the same as what we desf nb« a 
shock 

The degree of shock experienced in any particular case 
sarlly varies immtnstlyH from a transient giddiness to pn 
insensibility, and although it is impossible to foretell the 
effect to be produced by a given injury in any particular ca 
there are certain conditions which in measure regulate tbf 
produced. The amount of shock may be said to depend Uf 
four foUowinjj; factors : 

(a) The scveniy ttnd extent of the injury. This may be cak 
in two directions, riz,. by the numlier of sensory nerve ter 
affected, i.e., the superficial extent of the lesion, or by the 
to which the injury extends- Speaking generally, the amc 
shock varies directly with the depth of the wound, sin 
deeper forms are due to a preatt-r amount of violence; 
some cases extensive suptrficial wounds produce a much | 
effect than more limited deep ones, owing to the larger nun 
nerves involved, alons which stimuli can be carried 






: tbuK, 3 gcmcraltKed xM k mtm lilwTy to prndiice fiitat 
than tbc complete indneratioii of tui extremity. 
The sdie of Ihc injury. Tlie more ct^Mntml the crRan 
c^mol aDd the more cluvcly It is coonnctcd 'A'illi the chief 
ijiii|i(ttEKttc centres, the f*ie;il«r will lie the shock; t^ia%, a smull 
of the inttraline, itotruch, of iiiy of the W!:©^!^, is much 
Mfious than on extcri!n\'o accident to one of the Umba. 
nil bet is smiclinieft of the greiitea practical va,lue in the 
4MffnAiUition of ihe vm^X nature of ^tlxlomirat injiiri^r^. When 
mvtn shock vrilh abdominal pain laitti fur lutrntyfour hour^ 
dbiT a accident, the stir^eon may be nlmo?tt cerui^ that aoinc 
ncni) DISCUS hii^ \>xn M-iifjuisly ilitniAj^tiJ, Jiid shuulJ uX oucv 
anfidir lb« advieabitity of p#i('>iTninj^ lapimtomy. An f^Kploni- 
Dkyiaeioon iA much lo«s hkcly to do hatni in s^ich a case thon 
hfttitv ii hJooc- 

U) The ■rrftnu iniffpiihiiiiy of ihp |»ilienl i^ * most imp(jrtatil 
fmntt, fcir there can be no doubt that the mftre highly otgxihed 
4enennoiAS tvstcm, the K^cdter will be ihe nmount c^ lihock e\ 
pencDCieil. Prisoct sunsoon^ will bc4r this out. iinv amcnirsl the 
ccffutoiid bft^inr types of crimimik o[inTatTon*i mnv Ik? \ictimniei} 
rebate «o An;nibetic in a «urprisin^ manner: nmorifT«E ne^rcufSi 
ud MDe other tropical racc:i pain is liomc with lortitude, and 
*pcr«bgtt» are AttrntW ulth \eir >tJKlu Kenevj] eiTectin 

{ij Tbt tjpttU^iifM Of Krt of the tnjnry. \\'hf"n ihe whole nervous 
Ij^Mb if maintained in n iit9iGo£tennan>nn>^ioiisly expecting- the 
rwwpt of socne painful impression, ihc eHect produced ^vlll be 
cuncumHiily incrti-rfJ: whiUt if tht aiieiititni w (Ii\tile<I, and 
■04fe«| acti^«ly armi^ted in slhrr rhmj^s, tht- iihock jlI ihe time 14 
nwdi dintimshed* though iti ellects may be SAib^etjuently ^ieut«r. 
Thui. o] the keen excitement and nervous tension oi \ battle 




iilihn> lijvr ufien Iteen uuiinded ^vecely. ^iiiil yet nul known it 
*' ler: whdat Ihe pain cf ih* niosi trillitig cut may pfod;K^ 
^iioek Ahou the patient ia in a stjte of ner\'Oufi dicid 
■olexcilcmcnt. 

Two main ^'aiiMies of sIkxIc ma/ he described, which differ 
(^e^ io th«ir origin nud m«thnd of prodiiction, the fiymplomK 
ttidjc v«*rv *iimihir' 

.*' IcUre SLock vitli Beflei OardtAC luhJbllloa.— It is a wcIJ- 
LiKnti phy^^oln^irnl fart iJwt, if a frog's jtxinmen i* laid open 
Uid the »xpc««l intestine shatply ftruck, the h(\iTt will stop m u 
tndition of diastole* exactly similar to that produced by exciting,' 
thi CNnEo-mhibitory appaialuv: whiUt if the vu^'i aic divided 
tfiot Io Ihe bloiKi' no pfTect it proilucecL A Mtdden i.Tiish of x\\^ 
■•c*»itfc a heavy hammer hai. a similar eff^-c;- I hat which cjn 
i lie experimci^uUy produced in a froi; is an illusuaimn of 
'- fXjLuxn- tn Ih? hutiun Mibjoit hi tlie bbuck futluTviiii; f^tidden 
L^^kfs. Thi; mtdnUary ttnlie* Ar* excited by ihy affptent 
*ii»ndt, inJ inhib«L<jn of the beorfs action through the va^ is 



»M A MANUAL OF SURGERY 



tht> result- The abdominal contents are very closely assod 
with the cardio- inhibitory apparatus, so that not only mpW 
the viscera^ but even a simple blow on the epigastrium, Cff d 
ing a glass of cold water when heated, may prove fotaL S( 
from any part of the body, as from a severe injury to th 
tremities, may have a similar effect. Impressions reaclun 
medulla from the emotional centres, as by the recwpt * 
expected news, or from the visual centres by seeing soia 
revolting or objectionable, may similarly react upon the hci 
produce the phenomena of shock. 

The Symptoms vary with the injury inflicted, from a 
momentary giddiness and faintness (known ordinarily as an 
of syncope or a fainting fit) to complete prostration, ii 
bility, and even death. The pulse is at first small, sIot 
weak, but soon becomes extremely rapid, and often impcro 
or irregular ; the countenance is pallid and shrunken, a 
brow covered with a cold sweat ; the respirations are sk 
shallow, and the temperature usually depressed tw^o oi 
degrees. These symptoms are mainly due to a condil 
cerebral anemia (i.f., syncope), and will be followed 
tumultuous and rapid action of the heart, and by a tendi 
vomit, w^hen reaction is established, arising from the posi-a 
hypera^mia of the brain. 

2. Torpid Shock from EzlLATtstion of the Nerroiu Oonbti 
name given to the condition of collapse which supervene 
more prolonged suffering and injuries, such as after protract 
eical operations, even in spite of the administration of anfcsl 
The condition here manifested is much the same as the 
except that the pulse is alji/ays rapid and weak; the meni 
muscular powers are similarly diminished, and reaction is 1 
associated with vomiting. When a considerable loss oi 
accompanies the injury, the more severe manifestations 
form of shock are seen, the patient lying absolutely uncoi 
and apathetic, and perhap*; covered with a cold, clammy 
the pulse is scarcely discernible, the features shrunken an* 
the respirations so feeble and unfrequent as to suggest tbi 
one will ]>e the last. 

A third form has been described as HretbiBtic Shock, but 
merely a condition in which a depressed slate of the mei 
centres is present, whilst the mental or muscular systei 
more or less active from other causes. Thus, a patient su 
from shock may be restless from the excessive pain of the i 
as is often seen in se%ere burns and scalds; or, again, he r 
intensely restless after great loss of blood; or, lastly, shoe 
be accompanied by traumatic delirium, a condition of the ^ 
import. None of these states, however, call for special nc 
this place. 

(Occasionally the evidences of shock are delayed In tht 



WOVSl>S 



MS 



I 



I 



MTiftcc fnr sonu? Itmc after the iniuty, and come on gradunlly. 
£89ccuilj t> Ibi-'t t>ic CAK After r^iilivay accidcni^ when a<^ ^vcnX 
i^lljr lu« lipcm PXperipn-.-ral ; for ;i lime the nnxirly and cxdte- 
«« iff« Eoch thAt no dvprc^ion Lt noticed, but us tlic mej:t:tl 
potnrhition pAsaea off, the mdi^'idu^il (;3Lp«Mc^cc^ tiyinptom* 
(TJir tmtihr 1o tbc abo^-e, tut pcuUtbly liithcj uF tlic natun; of 
mofthnib Ehnn of r«'i1 ^hock («V« Chapter XVII.). 

rbe Port^mortttm E^viUtrDca^ ar« not v«ty cSiirnctariutc. t>ut 
IJMj di point lo A loss of control of tlur ncr%-ous ^yattni over t)ie 
YATuki, reuiltiu;; in ao<t:iijid u( ihfr hjdjn diid Aitptiiji.lAl p.ii t> uf 
twhidy, ADd enormoits engorg^^ipnt of ih^ sMominal viwera, 
bin 4Dd ereat v«noLi^ iTunk«; ih« hean coi>uiii^ pracirc^illy 
tobbcd, A]ILoui|;h it is prubjiMc tli&t the tjglil side is mucli dis- 
tcBCcdftl th« lime i>f de^dh, i:>pfcially v^hcn due \o relive shorli. 
«iht«p«ni]y ampiyin^ it«elf hv po^i'monem contraf lion, Thecw 
pliMnm tm suppoxd io l^c explained by a goncml loi^s of 
tMcof the vascular sysEcni from a rrHtx ci^hAuMion a[id pAFAlyMS 
tf lh»t«tt)- molar cenEic, allnuiriR rhr* hioorl to -irrnmLd-i:*? in th** 
vton finable portiii viz,, the lungK ;ind porL-i] ^^y^tctn : i1 isi 
(oaiWcy however, ibal (hey atv due in Urge mc^&titc to a tpccml 
Mttni* mccluLnlMn A-^^ocMlcd \^~ilh ihe ' deptc^^ii ' br.inrh of the 
ia^ which ^v^mt ilie ^lanchnic ajta. 

nipBnii.— I, From the Frencral resolU of h^mcrrhaqf. K»t' 
hmmisd thirst arc then prominent signs, together with a scnw 
li djapixTA, CAUMOK rapid rriipiidLory efforts: \\\^ mental cox\- 
diM, moTMiver* U less affected, and Jhe p.ilitnt is Rtn<?rally 
^■HJble; the ^nth^x in exces^vcly Nanched. and the pubr^ may 
toft k mjuked ha:moTThagic wave, i. In f^/FoiuwH o/ Mf irdiM 
6cTO ue mjieiadfkd tr> the syinptiims of iJiock IIkjsc icKue |i4r- 
tntiarly conn^rted with tht? region afTected, iv., the tn|e1le<:tua] 
(iCMna, 3o tlut tiDCon»ciou!tiie7>3 13 the uredominaiH fculure, 
> Whoa vomiting 'vs> -tppruachm^ undtr ibt; uitluczuLcr of an ^viaillutic. 
lar pilientS piUMf uMially becornen we;ik nnd r^tpid, ;ind ihe 
ff*wnnmc< pai^. Thid condrtion clf>sely vmuUies fchock, and 
b oh« ooly disiingui»hcd by the pro^dss of the caec. Und«r 
mb <iiut£u£Li[it:es. if to[nitiij^ Is pljtiuly iiujiiLncnl, it is vui^e to 
iamsu^ ibcftmottm of .*nsP5ihetic, as the paiient is n^ualty not 
fdlr und«r its inilLODco* 

IiwIaMQt^ln slight coks s-cvy Utile i?i needed beyond reeling 
<|Giet]y finff a few iiunuicSi or the frihibiliDo of scixwii 'Axiit\\n\\<i 
uicmduit lo the nottrili;, Mich at Ammnnl.t or sm^-^Uin^'Wdi^. In 
eta noro MVOfO cams Ibo pnlicnt in laid recuml^eot, with tlii? 
lAd kiw; bol bottles well pTotcclcd and blanket* are applied 
to the tiunk aim] rxtrrmilin^ Lo maintain and ijic:reav? the 
Mly teiBp«Tature^ If able lo iiW^Uov>% a Utile AiiTm te:* or 
^'ititm may be admLninitered ; LnjI it unconsciouSf ;i brandy 
••CTo, or h hypoderrmc injection of ether or liquor Wrychnia, 
BMceury. U mum \x bornt! in ntind that the patient hat. in 




^5 A MANUAL OP SUHGERY 



most cases, only to be tided over a certain period of dep 
before reaction naturally follows, so that it is all-important 
economize vital power, and not to waste it by over-stimula ' 
which is also apt to cause excessive reaction later on. 

The intravenous infusion of hot saline fluid {i drachm of ch 
of sodium to 1 pint of water) has also been employed with 
siderable success of recent years. The modus operandi is descn 
at p. 2 1 3 ; the ^uid should be introduced at a temperature 
105' and no' F, Several pints may be injected to begin 
the exact amount being governed by the reaction of the pati 
If after a few hours symptoms of depression again supe 
the infusion should be repeated. 

An important question is often raised as to the advisatality 
performing an operation during shock. As a general ruJe, it 
be stated Chat operation should be deferred until reactiod 
come on, unless the presence of the injured organ, &ucb u 
badly crushed limb, is evidently prolonging the condition- Undv> 
such circumstances it should be at once removed, and it will 
often found that, as the patient comes under the influence of 
anesthetic, his pulse improves^ and the state of shodc dJK 
appears, the anesthetic shielding the medullary centres from 
painful a^erent stimuli- Again^ it may often be possible to 
with urgent cases without delay by the use of a saline injectios 
into the venous system prior to operation. Prolonged sbotk 
after an accident is always a serious symptom, and often indicative 
of internal injuries ; the importance of such must be carefully 
considered liefore deciding on the treatment. 

Shock may be pm'ented during operation to a large extent faf 
a careful attention to such details as keeping the patient wca 
covered up and as warm as possible, by minimizing h£emordia|[e 
through bloodless methods of operating or the use of fona- 1 
pressure forceps, and by rapidity of execution, A bypodemnc 1 
injection of strychnine given just before the operation will also be j 
useful; and it must lie remembered that incomplete anjESthesb ' 
tends to increase the shock rather than to prevent its occuneoct. j 
It may l>e advisable, in cases where the pulse is very weak,ti> , 
use ether rather than chioroform. -, 

11. Tnmmatlc Fever. — Traumatic fever is that which occun 
after the receipt of some injur}', simple or compound, 01 after U 
operation. Two main varieties may be described : 

[a) Simple Traumatic FoTer occurs after subcutaneous injuries^ 
such as sprains, contusions* fractures, etc., and after aseptic 
operation wounds or compound injuries. It is thus found in coO' 
ditions where micro-organisms are al>sent, or, if present, are ii 
such a state as to l>e practically impotent. The generally acknov-- 
ledged cause is the absorption from the blood clot or inflammatory 
exudation of some chemical substance (possibly, the tibrin fer- 



Ill fibkb hu a pyroscnons eiTcct iic>ofi the mcdulhrv centres. 
pr.JjJilv lb* fpvrr fnlUswinR ;l^ppH^ oppraiiont i^ larRnly clr- 
by the atac of imtaiinic anti«.*ptic«» ivbich incrc.iKC the 
Lion.And lead to con«d«rnblc damngc oi the tissuci ; il mild 
arr aIooc ui^il lo itri^-itc upt^n ^tscptic wouaJ>, nr ptc- 
if no irti^niiun t« (*mp]oy{?d ii ;itl. Ehis^Q-calM * TPiuitrtyTi'.iry 
vill be iib«c7ic. uq)c«k other elements, such as retained 
idbcluriEc or accumulation of blood, arc present, Uccanion' 
|illf lever ts <i4ideiv^ it) c^m?h wlii^ir wc bni^e no j^iuuuElh fur 
thut absutpiion of fibrin fvtmeni is taking place: il 
Ite due to sctni? p^nphcral irniation, /.^., a bu(ll> titling 
iSot.anil diuppeaj^ tmnjcdiLiCdy on ihu rcm-oviU oi tlic cuu^. 
Tfvf^mpromH Af t thow iif slight fi^ver, reftcbing loo' oi loT F. 
wiihia tu«Bty-£uuj or fony^igbt tnuT^ of the injiiry, tviUi coated 
latewi kirrt of appclite, etc-, ^froMJxially pft^bij; olf in three or 
iru 4ij9. If Uiub liniJlcJ, i1 lb of no pro(pioslic importance- 

\hj BfnptomAtlc Tr«uiniitle Fever i^ ifiAi c^ii^rd bv ihi^ afKnip' 
tiB«d4rof tb« prc^ucu of puircfaccicti, re^uttin^ fr^m the vital 
xtrntT of Don > peihoKCf^ic orK:Lnifimn in dischnr^cs, blood-clott 
GTtkMlL^AUF ', Of fcom ttie Atkforplion ot ihe toxiocs connected 
vitb A (ip\r1r^nirm oi nathojfr-nic: nri^ni^mK in the wound or it<> 
stfiMidictf)^; or from the supervention of ftorne Reneml irfcctiN'c 
dafiricr. All tfac^c diHcrenl ntnXc* have been dcuilt »nth else* 
vtoc^fid rcqiiirr nn fnnhcr nwtir*^. 

ILL TnnmAtic Delliinm. — AUIiough ddliiuni b» meiely a 
Tfnpom whicli is tuperidde<l to others In certain CAfte^, it U 
occMMnoilj of M> proncjunced a character as to ddinand special 
itraion* Three form^ arv met with : 

M The Active DelUhtnu wliJcli m:L;jnipdnie« severe iujviiie!). 
IvdmUrly in pleihori* , 3tnd often in previon»ily he;*Uhy indi- 
rWuib, vbocie envir^ianiDnt has t>oon suddenly changed ^om cbaE 
dercfjtlay life to 4 aick-bcd in a hospital ward. Septic con- 
miMSkn of lite wound is vistLilly pref«n[, ^nd tbe dcliiiot)^ state 
HMvsdaied a^ttA run« a |>.)r»lk] coutac with the traumatic fnver. 
'^ilc it ti ikoC of a %iotcnt typc^ nhhou^h the patient may hn 
ral And icfttlcst; be :no^c« the injured part vhithout any 
tiKkaiappn^ciarkHiof tbepain which, if cmnMriou-s. Im nuwt MifTcr, 
hoi fe it eafiUy re«trained by the c-xhibition of Jinnne» .ti^d tact 
** tW port of the attcadanl. The '^ympttyma are mo»t marked at 
■fhu aftd commence ai the end of forty 'CJ^lit hour«. laMing, aft & 
nit, lev two or three day*, Thtie ti a di&iasie for food, which. 
h»n*r, can be overcome by gentle persuasion. 

ttHAMBt -i'aticnte ta tfiiri condition must never be left ; ihc 
to >hoiild l>c li^ht, but Eiuunfibiiii^ ; the bowels must be 
(kctsi^h^y opefle<I, iin<l an Iceh.ig xn the head m;iy tip UKeftiL 
^ iKUid Abould I* freed fr<>ni :my s«plic accumulation. 

tDBiirlBWOf ftL^w Hutteriac t7P« i»met ^vittl m individuals 




of low vilality, exhjtu&ied b^ dissipfltioc, drink, dif^au, or luliv 
hyp^cnk surrouadingTi. It is commonly a^ssocialcd nith fcifrot 
an asthenic lype, such a^ \^ ^eii loijx.^ritf^ ihc end of acplk <r 
infective diseases. The paiient visually lies an his bar!k« curing 
^-ucanTly upwards, a incohc^rcnt* tnlccv no notice of uiucfan^i 
objcscts, and i» observed to pick at the Licdclothea ^ti6 roulicr to 
himself umutcUigiUy- There i;( oflen, in addilinti, ah invijIuaUiy 
f-stvipp of urine or ttces. Tbe riouih is ijpneraJiy opm, th* 
Coii^u« dry, btown and cracked, atnd vt&cid mucus coUccti^bout 

tllL- ICClh (jW«), 

The rreaUaealJ^houMlwdii reeled tuc^teruluuEMiig andCecdkn^ 
av l>y That mean* al*in*' <:in llie p-ilienl be 4i(v«d- 

(^) NfliTOuB Tr&UtDAtlc PoUrluxa ik ob^^rvud afl a rule m inJi- 
vidiiala -shu. prL'\iuu^ly i-^f iiitttnticiiitt.' hfiblt^. \ia\x ^utTefciJ miud 
serious injury, such A9^ i:Dni|)ouiid lrac:ture. Eii ^mU llie ^i.ijmt 
sympioms do rot show ibemseke& till About the ihirJ d*y, hut 
ariT ui^^i.illy preceded by sorudamouDlof »]c«plc«H)ti«sjLnd WiXiuin' 
ma .11 uitibl, or the pAtjdJt may hd\r shon ttOAiKht:^ of fdccp, 
firmi U'hirh he 3w;ikes ^ini-dHirioti^, This gradually incfBtvi,. 
j^nd is Tollowed by violent delirium of the woT«t tvp^ (idaitm 
irfMtrHs), in which the patient i* haunted liy Icrriiyine visaoof 
of rcptdcK, bL~irrib1c ii^secls, itnd the like, EnMii wbuli he trie* 
m vain to escape. During thi* sta^ of e^citemeni he U with 
difficulty rectramed from jumpirt^f out of bed ; in tnany insUuoc* 
th«sc patients arc nemarkably cunning, and, m^Tu^n^ to dude 
the vigilance of their ;iUen(laitts, vlII succeed in c^CAping horn 
thti room Iw the door or Vp^ndow, and «o inflict tcriouE, vid wen 
fntal, injuries upon themselves or others. There i* olivays a 
tremulous amdilion of the e^lremilies and of the lonffue, which 
is while Jiid conipd, whilst the ImjwcIs nre nbslinately cnnliacd- 
The pulit ard temperature vary consideralily, and Ibe Ma is 
often moist and cUmmyn The violent st.iRc is 4dwnys followed 
by profuLiMd exhau&timi. in %vbicl:i the p^Uicnt may sr^LluaUy sicdi 
ii>To a <i[!1tf^ of cnma and die. In A chwt of fiadured leg, the 
«tTU£^^]^« of the paLtt^nt will cause considerable displacement of 
the linib, and nccc^itaic constant attention to pic^^enl farther 
mischiff. The llnjb shjulj never be fixed to ibe beOt but Uus^ 
in a S:(Iir>r's swing. 

Traatmeat. — In c^ses where an aitaclc of debrium tremetw il 
conr^idercd imminent, cither Irom the previous hiBiory of tbc pntkai, 
the trrninluus stale of his h^mds and tongue, or bi« slfie|)1rs6ness« 
the h<'.^l ttEiiment to adopt H to support the iirengtb by suiiabAt 
food nnd a medium do^e of slimulnnt, combined with froo purgicg 
and, if need be, soporifics (chloiaK bromide, paraldehyde, or 
lucirphiii) ; imder such a rp^imen the symptoiiis usunUy snon 
diuoppe^r. [n the acute muniacal attacks the paliont mod 
be fully controlled and f^ardvd. but with as little ouunifcsU- 
tion of restraint as possible. Good nourUhing food (possibly of 




WOUNDS ao9 



a fluid type), with a ceitaia amount of stimulant, should be ad- 
TDiDistered during the quiet intervals^ and sleep obtained by the 
eihitution of drugs, especially morphia hypodermically ; a hatf- 
grain should be given at first, and more if necessary. Hyoscine 
(j^ j^in) has been occasionally given with advantage* but it 
must be remembered that it is a powerful cardiac depressant, 
and has possibly been responsible for some fata! results. Free 
purging is of course essential. 



14 



CHAPTER Vin. 

H£MOBEHAOR 

Bv the term ha-marrhagf is meant any loss of blood, whether 
significant and immediately arrested by natural means, or n 
excessive and requiring treatment to prevent its continuance, 
may arise from {a) trauma, either in the form of an open 
sulicutaneous laceration, or internal rupture, the vessels of 
part being divided, torn, or punctured; {b) such discasesasl 
to weaken the coats of the vessels so that they are unable lo 
the intravascular pressure, e.g., cerebral haemorrhage, the bar 
ing of aneurisms or varicose veins, and some forms of secondj 
hsemorrha^e ; (r) the extension of ulceration laying opeo v 
of varying size, both external and internal, as in epithelJomi 
gastric ulcer, etc ; {d) inherited constitutional idiosyncrasy,** 
ha?mophiha, or diseases, such as scurvy and purpura ; and {e) 
conditions of maintained congestion or hyperemia, which lend 
produce h.tniorrhage where the blood- pressure is sufRciot 
uvercome the reJiistance of the vessel walls. 

The character of the bleeding differs according to the vo 
from whici) the l^lood escapes. Artenal Hsmoirlu^ cods 
in a dow of hri;;ht scarlet blood, which escapes at first 
salti/i'i. i.t., in jets synchronous with the hearths beatt and mi 
be derived, nut only from the proximal, but also from the disti 
end of the divided vessel, if the collateral circulation is sd^ 
ciently abundanl- VenouB HnmorrliAsa differs from this in Al 
fact that the flow is usually continuous, and the blood of a dtfl 
red or almost black colour. If. however, a large vein is wounded 
such as the internal ju^^ular, the blood may escape with a vet! 
definite spurt, owin^ to respiratory or other influences. OlipOU 
Hsmotrhaffe is marked by general oozing from a raw sui^ 
iht blood iricklini- down into the wound, and filling it frv 
below upwards. ]^y EitraTasation of Blood is meant the pounn 
[lul of hisxid from a wounded vessel or vessels into the lax areoli 
planes immediarely adjacenr, which l)ecome swollen and hogg} 
The usual constitutional signs will be manifested as a resulti 
such extravasation, and, indeed, fatal htemorrhage may occur i 



!NOnftUAGB 



fft 



WIT virhouc any e^iipe upon ilic ^UTbire of the l>ody. Sul>- 

iiAvr dutimucouK haemorrhage is, however. aUo met Vp-ith 

form of soudJ jixabwd netMhiK* Mining ftoni iLijunc.%p or 

chiiigvs in ihr ItFAoiI nr ve<ts«l walk (aa in piirpuiit. vcLirvy, 

Mpdcspmb), EplstttxiA U the term giv«n to bleeding frcin 

ifUtt. Hy Hwiut«ineB(a in rncanl the vomiting of blooii ; it 

vither imvc bi:rTi ?iwrt]lowcd, as in sonio CASes of ffHtctLjred 

ft xhp. nkulU u'lii^rf Thr- pbArynjml mnrrnu irpmhrjin? ]i:is 

lom. Of il mav have originJitod Irnm the upper pnri d the 

iftil ifoia. "f he blood is uMjfllly ciirdJcd nnd hromiisli m 

c,Maicwhiil rcMiiibling coffcc-grotinrfs. ivam llic a^Iiliii uf 

lp«lTk jtiictr upon U- Enmoptysls i^ ibe riilr givr^n t^i thr 

of bJood from the air piF^E^ic-es, whether it result fTcm 

or dif«a»c^ HKXOAtarijL i^ a condition in which blood 

[puwd m the iitinc ; iu rutuic *Lnd souicc will br. dist-iissnl 

By Ufibnia is mcani ihr pjifi'^.nRf of d.irk fiirry hlorw! 

rt lh« Faeces. It is aKavs iho t%idtfntf oJ <I(sra-.c or injury 

ifte ini»!mr iufficicnrly £xr from the .inun to allow the Utjod 

bttuin« jilf^icJ ill thmattcr by tlic iittiun of ihc ime.siiiul 

BIrvxi dtri-.-w] from ilie rectal mucoits membiuii^ usually 

lit bright rnl colour. 



Oo&fUtntlMial lUTecU of Hmnorrliaffa. 

iht bxnxvrba^r ts ^vere» :i^ from divi^cMi oi a larf^t; arl«ry, 

reauJo feofn vyncopc. The surface of tht Ijody becomes 

IL chinitiy, a^od pale ; ihe Hpbi ectt^ and eyi^lida. livid : the 

Twt ga^P^. bi*^ re^pimiion^ b*rom^ qwkU ant] vi^hing. and 

l&nim«8 after perliapfi n f«w cor^vtilsive twiicb««of flic Imib-f. 

iMiCAS is rctAiiird al all, palicnlb often complain of tEic 

Mifi^i ^^^ ^ srnf>r of iucn^MUg darknefi^, irrjmediaEely pre* 

tfthe fnial terminal ion. 

|]f the ba^fnotrbac-c tfi not t4o C'Tt'Jit af. to kill immcdiatclv, the 

Libiints, Mid on mcovcrinf i^ in a condition of ^cvctc coll'^p^ 

ir«&, uhic b lonUnic* for "im^ timer ; he iv also li^blr lo 

4tUckf of syiHTopc, any one jf which may be fatal, 

Jcfrmorrbaf;;!: h mntc kt.vIiuiK but commuuus, iu in cases 

uterine filiToid.s, the patient bccomcn profoundly anitmic, 

Iip4.cai?(. Acid (xjnjimctiva-ptarly white; llicic 1:1 dy^pi^uai 

CO the tnfiulltciciiil amount of blood prciienE. and in cr^i^se- 

tbe patient ii t:xtTfmc\y redtleofr. tosaini; ubovU m bcd^ 

•odden cxeriiun, and cvc;i sometimes the attcinpt to *-it up, 

ltd by a **nsaiiun of f;iiTJlTi*rss ; noises ah- hp-rinl '\t\ ilie 

thesigM becomes dim, or eve:i temporanly lout tamblyonia|. 

'rrrrc headache miiy be complained of, nil ariMUji liom 

aiUDfttiap Tbe pulse oflcii becomes what is known as 

in cbararirr, ij., fTi-qur-nt, lar^r, and L-ompit!»siblc* 

ipuog entirely Uitwiivn each beat, and markedly dirrolic. 

J 4— 3 



311 A MANUAL OF SURGERY 

These peculiar features are due to the sudden passage of a 
amount of blood through a vessel which is practically emptjj 
entirely collapsed. From the defective tw-d-^^go, cedemaof' 
extremities may result. After such an occurrence, the 
may continue in a state of anemia for a considerable time. 

Children and elderly people bear the loss of blood 
badly ; but whereas children rapidly recover from the imi 
effects, elderly people do not. 

Qeneral Treatmeiit of HEemoiiluf e. 

When the loss of blood has been severe, the patient must 
kept quiet with the head low, whether syncope is present 
not. Stimulants may be necessary to maintain the heart's 
but should be given with discretion for fear of re-starting 
bleeding. If death seems to be imminent, the arms and 
should be bandaged, or the abdominal aorta compressed in 
to conhne the hlood as much as possible to the head and tmnk. 

* No patient should be allowed to die of h^morrhaffe.' 
was the dictum of the late Mr. Wooldridge, of Guy's H 
based on a knowledge of the value of transfusion and 
by Transfusioti is meant the transference of blood from 
individual to another ; by InfiuiDD, the injection into the vessels 
the recipient of some fluid which can temporarily take the 
of blood, and the success of the latter method has in some 
been so great that the former has practically fallen into disuse. 

Transfusion may be accomplished by two methods, the (tin 
and indirect. Direct or immediate transfusion consists in injedii 
the blood of the donor directly into the vessels of the recipient l 
means of some apparatus, such as Aveling's. The objection i 
this method is that an individual can rarely spare sufficient bfa 
to be of any real use, and hence the results obtained are, as 
rule, most unsatisfactory. Indirect or mediate tramfusion is canid 
out by whipping the blood obtained from some healthy indivifhl 
or individuals so as to remove the fibrin, and after strairi 
through fine linen it is injected^ either pure, or diluted with sal> 
solution. 

During the last few years it has been recognised, ho««* 
that the success of this proceeding depends <ni the introduction rf 
sufficient qiiantiiy of fluid as a temporary substitute for the bkx 
which has been lost. K\thcr than on its quality; for it has ba 
proved that the transfused blood of another person is ra 
destroyed and eliminated. Hence transfusion has now been 
placed to a large extent by what is known as Infiuicm, whicb 
sists of injecting large quantities of some bland fluid into 
vessels, and by thi^ means greatly improved results have 
obtained. All the apparatus needed is a metal cannula, theend 
which is bulbous, blunt, and bevelled, which can be tied into 



HEMORRHAGE 



ai3 



1 connected by means of a rubber tube with a reservoir 
ig the fluid (Fig, 60), A vein, e.g., the median basihc or 
saphena, should be expo&edt tied below and opened by 
idinaJ or obUque incision ; the cannula, Riled with lotion 
exclude air, is then inserted and tied in. The amount 
must vary with the circumstances and the effects pro- 
■ut, to be efficacious, some pints are» as a rule, needed; 
»r 5 pints have not uncommonly been employed for the 
As to the material} a warm saline solution is the best. 




60 — Imfusion into Veln of Fqkearu. (Down BtrorHERs.) 

y consist of the following ingredients : Chloride of sodium, 
ns ; chloride of potassium, 3 grains; sulphate and car- 
of soda* of each 23 grains ; phosphate of soda, 2 grains ; 
ter, 1 pint ; but a simple solution of the chloride of soda, 
im to the pint (or about -5 per cent,), at a temperature 
' F.p will accomplish all that is necessary, and a 
n syringe or hydrocele cannula will be found in an 
ncy quite sufficient apparatus. As a rule, one injection is 
is caUed for in dealing with haemorrhage, but where shock 
snt it may require to be repeated two or three times. The 
rystals of salt should be dissolved in a small quantity of 



XI4 A MANUAL OF SURGERY 

boiling watei, so as to sterilize it, and this is then diluted tal 
required bulk. 

Another plan which we have used with success consists W- 
introduction of warm fluid into the rectum, or through an. 
needle connected uith a tube and funnel into the loose 
tissue of the buttock or abdomen. In the latter case the 
must be held at some height in order to gain sufficient 
and by this means several pints may be introduced. 

Of course, in each of these methods all apparatus must be 
scrupulously sterilized, either by boiling for some minutes or] 
elfective immersion in carbolic lotion, 

Nfttonl Amst of Hsmorrlu^. 

This can best be described under two headings, viz., U) i 
temporary arrest, and (2) the permanent. The processes occurril 
are much the same, whether arteries, veins, or capillaries are i 
volved ; but since the arrest of arterial ha?niorrhage has be 
more thoroughly investigated, and is the most important, we sb 
deal mainly with it. 

The Temporary arrest of arterial hsemorrhage is brought aba 
by three main factors : 

(j) The coagttlAtion of the Uood, which is the stnt qua nffl. I 
occurs in aud around the vessel, and ^\ithout it death won 
ensue from the merest scratch. The greater the loss, up to h 
of the total amount of blood in the body, the more coagulib 
it Ixi comes. 

(2) DiminatiDii in the forca of the luuit's action always foUai 
haemorrhage, from anaemia of the cerebral centres, a beneiki 
provision of Nature whereby coagulation is facilitated m 
the flow of blood checked. Unless the syncope is profonn 
stimulants should therefore be carefully avoided, for fear of canal 
a recurrence of the bleeding by increasing the power of the hcart^ 
beat. ' 

(3) Changea In and aroond the vesul play a most importfli 
pari in completing the process, , 

They consist in the retraction of the artery within its sheath W 
reason of its inherent longitudinal elasticity ; if, however, it body 
partially divided (or, as it is called, * buttonholed *), this coiatiti* 
cannot obtain, and the haemorrhage is more likely to coDtinBk{ 
As a result of this retraction, the rough and uneven inner liM 
of the sheath is exposed, and upon this the blood coagulates ■*■ 
flows, thus K'^^'^^^^dly producing; what is known as the AXMV 
coagnlum. At the same time the transverse muscular and datf 
hbres in the \'essel wall cause contraction of the open moutb,ii' 
thus, as the force and calibre of the blood-stream diminish,^ 
{external coa^'ulum is ;d)le to increase in size by fresh deposits ■ 
fibrin, until at last its resistance is too great for the diminish" 



HEMORRHAGE 



a"S 



: impulse to overcome, and the sheath is filled with clot, 
extends to the divided mouth of the vessel. From this an 
i coagulum also develops, which gradually extends up- 
as Car as the next patent branch. By such means the 
rhage is totally arrested for the time being, and preparation 
or— 

Panunent closure of the wound in the artery. The exact 
lism of this step has ^cited much discussion, and some- 
iivergenl views have been expressed as to the means 
»y it is accomplished. Probably this want of agreement 
isen from the fact that the conditions, under which^ the 
itions were made, were not uniform, some observers 





— Earlv Stage of Oblitera- 
•r Artery after Ligatdbe. 

Mnbas 13 seen above and be^ow 
tcof ligature, that on theproxi- 
uppcr) side beiaij ihe larger; 
imcing cell Lnfi It ration of the 
of the clots is also iadicaied. 



Fig, 6i,— Later Stageji of the Same 
Process. 

The dots are shrinking, and the lowest 
portions are being transformed into 
granulaiioD liftsiie Proliferation of 
die tunica intj ma is also seen, reach' 
ing beyond the apices of the clots. 



these diagrams the arteries have been represented of normal si^e for clear- 
saJtc ■ io reality, the lumen of the vessel ^vould be much contracted. 



I apparently drawn their conclusions from transverse 
as alone, and others from longitudinal. Tn reality, it merely 
ts of a modification of the general process of repair. 
M" the cessation of the hemorrhage, the internal coagulum, 
n consistence and dark red in colotir, extends from the 
1 of the vessel, or from the site of the ligature, to the next 
eral branch {Fig, 6i). The vessel wall contracts upon this 
lum, with which, however, it does not unite, except at 
lear its base. As a result of the injury, a simple plastic 
tis is set up, evidenced by a hyperaemic condition of the 
I waJl, due to dilatation of the vasa vasorum, and its infiltra- 
rith leucocytes, which also invade the coagulum and cause 



3l6 



A MANUAL OF SURGERY 



its base to become decolorized and firmer. The leucocytes 
up the clot, traversing the natural lines of cleavage 
result from its contraction, and gradually remove ii, a 
giant cells, probably derived from the leucocytes, 
assisting in this process. The tunica intima of the vcssd 
proliferates concurrently, causing a secondary infiltration 
the larger fibroblastic cells in the part of the thrombus w 
adherent to the vessel wall {Fig. 6^) ; whilst a growth of 
hudsf which gradually increase in size and encroach on 
lumen of the vessel, springs up in those parts where the apex 
clot lies free and unadherent (Fig. 62}. Thus, the base trf 
clot is transformed into a cellular mass derived from proli 
of the tunica intima, and by the development of new v 



of' 



G5S 




iS 



Fig ftj - Karlv Stage of Orgamzation op Thrombus, to show th 
Infiltration ok tkh Clot with Leucocvtes asd Connectu-e riwti 
Cells ubriveij from the Endothelium. (Tillhanns) 

from the vasa vasorum into granulation tissue ; whilst the cellular 
buds which grow from the walls, and extend nearly to Ihe 
next collateral branchy are also similarly changed. The free 
conical extremity of the clot contracts, and is gradually remove^ 
partly by the activity of leucocytes which infiltrate it from tiie 
liase, partly hy the erosive action of the surrounding granulfttica 
tissue. A similar set of changes occur at the distaJ ^de cf 
the ligature in an artery tied in its continuityf although the 
ihromhus is smaller and Ic^s firm. The ligature itseif may te 
infiltrated by leucocytes, and replaced by granulation tissiKi 
or may he encapsuled. A rod of granulation tissue is thus 
developed^ blocking the vessel, and this» by the usual process <f 
repair, i^ transformed into a firm cicatricial cord in the course of » 
few months (Fig. ^14). 



HXMOHRUAGE 



nr 



The arrest of fiitmorrhoc^e from vcin^ and c;tpi]l:iTics Is. .\s a 
lie. marc t*a-*al> accoiKplishciL ihp <:»lh|r>F i}f Ihe walls, lu^rlliei 
[vilb ibe Comutic«i of the external ooaqulum. I>ring aiifficietil for 
|)urpo»c. The later sT«p% are ^in^ilar to thueo cccuninp in 
iia«i1try, except tlul there ii but little tnienml co^ii^luni. In 
ci^Utin. un]»H there is present somr coTKtilittiotial condition, 
wch ■! hiKOiophiliA, the mere Ultink- to^^eth^r of th<^ wstlls i» 
WftocflC 10 aUow CKȣuh(tion tu uike place, nnd Llias ^op ide 

florglcaJ TraNtmant of HmnotThngft. 

VfrynuLoy differ en C method* are needed, under varying cirrtim- 
aiDc«t Igr tho cfifectn^e arresd of havuorr^i^t. il must be 




C<»VKT|W TuMTK OCXVntVJ^ IMH LCHKH OT Till- VeMKL, &M[> VAKU- 

Two glAst ctlti *r* vaa in thv ceair* 

tnemhrtcd llj^t dJctslAl mL-ssuie ovcj tlie bleedW-point wUl 
iJvip iDtnpornrilv rherk the nio*i f iiriou^ out Lnrr^t whilst means 
ti Et^ pfcnuiwtit sloppafie ajre Iwiag air^rt^'ed- 
H'ir** jAf bUfdt^/:, ih^tif-h pr^fu^t, dots not c^me frtm txuy cm 
rauit ibc Mi(jf'*i>ii chh ^vjiiI iiiins<-]f of ihc fi.j!iowi:i« 
hSTOKcs; vhitrh ATT ATrAn^tfd more or l«ss in tho order in which 
Ibe; would have to be used : 
1' Md may be cinploycd in the form of ice, cold ^atcr or 
Off limple ex|toMiTe to the aii* all dots rags pledgetiL. etc., 
t«movt<d for tbic purpose : it must, however, be remembered 
appbed directly to an optn wound may cou\-oy ncpsis. 
Uc^tSKut ia mo5t variable for general ooiinjc from \-flHtular 
•ttOurcs Of into cjvilic-t. Mich as llit- niouili. va^^iiia. or ^f^Uuin. 





2iS A MANVAL OF SURGERY 



3. PcMition. — Where the bleeding is from one of the extremitii 
especialiy the lower^ «lflT»tioii is a most important hctv i 

arresting it. The veins are emptied by the force of gravity, H 
this is always followed by a reflex contraction of the adciidt 
proceeding of which surgeons avail themselves in order ta e 
sanguinate a limb previous to applying the rubber tourniquet ; 
operations which we desire to reoder as bloodless as possible. 

3. Direct Fiessiire. — The skilfuJ application of an anliseplj 
dressing, combined with pressure, is often eflectuaJ in arresta 
haemorrhage. General oozing from cut surfaces, which can \ 
brought into apposition, as from an amputation wound, may b 
checked by applying a firm handle over them, or by jncorpwad 
a purified sponge, ^Tung out almost dry, in the dressing. 
ca^'it]es or hollows, either natural or made by operationt hleeifii 
may be stopped by plugging with a purified sponge, or by 
of dressing, or by graduated layers of antiseptic wool. 
form of packing has in a large measure taken the place of the 
* graduated compress,' which consisted of layers of lint devdd 
antiseptic qualities, gradually increasing in size, superposed om^ 
over the other. Any such dressing, if successfully applied, shooHj 
be retained firmly in position for twenty-four hours, after whidv 
if no further hemorrhage has occurred, the bandages maybn 
slackened^ but the plug should, if possible, not be removed b 
some days. 

4. Hot Water of a temperature of 130' to 160° F, may !■ 
employed with advantage during, or immediately after, an optsir 
lion, A certain proportion of carbolic acid or corrosive subline* 
should be present to render the water aseptic, or it should haw 
been previously boiled ; it must also be sufficiently hot, othenri* 
bleeding is rather encouraged than checked. It is supposed* 
act hy stimulating the involuntary muscular fibres of the vefld 
wall to contract ; but probabiy the coagulation of the albumind 
the blood is an important factor, as unless the water is W 
enough to blanch the surface of the wound the bleeding is td 
stayed. 

5. Ohemical Agents may be used to check oozing from spongj 
parts, or bleedin;:^ from organs or cavities which cannot be reach* 
hy the surgeon. If they are applied locally, and act primarily b] 
causinj,' coagvilation of the blood, they are known as 8t7ptici.Ci 
astringents. Such are the liquor ferri perchloridi or pemitrati! 
tincture of matico, tannic or gallic acids, alum, nitrate of silvo 
fibrin ferment, styptic colloid, etc. If the drug is administere 
internally, and acts by increasing the coagulability of the blooE 
or by causing constriction of the vessels, it is termed a HonuvUtJ 
— f-g., opium, erfjot, turpentine, hamamelis, acetate of leat 
chloride of calcium, etc. In applying a styptic, it is essentia 
that the surface of the wound should be thoroughly cleansed, an 
all coagula removed. A portion of the dressing dipped in tli 



HJthiORHHAGE 



•"« 



wlution b applied to the sur^ce, or th« drtu; is sprinkletl upon It 
in the frmi uf .1 p(i<4xEtr. The objpiriion in rh»* usi' of rhf«e agents 
Klhal kcaUnji liy primary union H hable 10 he iniorf^-roLl wiib. 

$- C»nt«]isxtloQ is not vcn' brgclv cmplcycd for the sustfA of 
hfruThofft!. c3(ccpt froin bunc-i and fmnj tismt^ itiirkcn(<d liy 
irAAininilioii, wTirrrr r(Tli;t<lior and cuntriiction of the ve»r>k Arc 
ddbcult. U ««d m nf> u'iiy mierft^re w-iUi primoiy union if tho 
tkb la no< 1o«Jctied> for the miculu sloughs formed arc cjuitc 
ttcflic, 4ad will cillK-r bt .ibst'ibttl ur ui!»l uiT in llie disclimpits. 
7W gr«at objection tt^ this nveihod i* the riik ^t seconciary 
tamrrhuEe iA'h«T> th« sloiigt)^ ^paj*:!!!.-*, Thif c.iultiy tv iJumC' 
tMioMo for the UlxxIIc^^ rcmijvul of vn^ubi lumoura. cither 
ttip]vi[to-cavi1f*y,or a r\tri]Lirliii\ kniff^, nr l]ic \f\\\\ty.siy cl^tiip 
jBJaflEcry, It mu«;i tm rem^^mbcrod ihat, tn ordvr to tTn«ciuu.l]y 
wltte inouths of the vc«£oU, the cnuivry muM ho at a dull red 
ulh/X heftC ; a hHi:hc red'br^l iron cul^ ihioui^h a vessd U4 
daah' i.t a knifi-, and iKirs nrii Moji ihr hfl'rm^rrhA^r, 

ITirt tki hifititie IS "If" jmofi*, and ^n^inatts from tomi diJiniU 
vpin visuh. othci and more vigorous: mcni^ures will have to be 
idsfCc^, IHjCiIa] pressure will suflicc to Ane^t it fir ^ time whilst 
(npualkin^ ;*rp liHn^; maile to ligshire or oihcmiiiir treat thf* 
vcqiiM v^cdAot. H po&dble. ;i ligature $houM be Applied with 
ueucptic precaution*, but other means arc u^d : 

i> Amjciwiiift nas iiitrotluiTcd by the kite Sir J^n^c^ Sintpfpon 
**a vucbod of fhe^rking ba'morrbJtfe in order ro olivinte the 
■« of IJRaturtt«. Tbc introdoction of ai^eptic abcorUible ;inimal 
tOlUie» bu made Aicb n method only nccc^Hary in cxcrptional 
ofcun^uoce?^. Four dilTeicnr id;uis tif a|>p1yin^ iiciip;e^>u]c luve 
U«Dd««<ribed» but the prinnple iindF^rlyin^ nil 14 lliv- it^imr. A 
•W& il pnaeecd cither under tta- ve-;iei (rum The ikm, or ovtr tlw 
''■■d from the surface of the wound, and. if applied accurately, 
wi IS ijutt** *uflifierit lo iljiy fha lil^adln^. wiih it. Iu:we\<i, 
linvciim^coiinbiDMtthtf pr««&ureof a loop of silk or wire pa^^i^d 
tfue-ofS Eishion around the cods of the iMfdle ; somotintc^ 
<>«nc\tr, the needle i^ mtroduct-d in a direction pAraliel to the 
vcmI, and then twi^^d so ;m 10 fuSK ir^nw^'rAi'ly iindrr it, 
frefacini^ St ci^ain amount of tortuon a^ ^vell ati romprcsbion. 

3' ?ArctpnuiU9 is ft pUn of stopping h^inorrh.-tfjc by cnu^hin^f 
^ ii^tJvd cud of ibc vc5wl liCtwcctL tbu Mioog nnd deeply 
icrf4li?d rndii of a part of forceps with -ariwcnr hnndlt-N proviiled 
*ith h catch; tbos^ knoAvn by the nnme of Spencer \V«1U are 
i^niort convenient. In dealing with small vcttwU. it 13 quito 
wfidcQt to leave the forceps Applied foi ^1 few minutes, perhaps 
f'riiuiag ihem Iiefore femov-d : whilst wiih the liifi^ci it ihsdvis- 
iMe ^ to Apply a l;f:**"re. !n deep v^ounds in which il would 
t« difecuU, or jdmoAt iinpossil>lc, to tie ibc vessel, ihs? (orccps 
V^T bf; aieorp(ir:iled in the Eli€!k^ni£S, uud uot leiiiuved &r 
iivemf'four bi>urv. 



A30 



A M^NUv4L OF SURGERY 



3. Tonion was used as a means of sealing the ends of diviU 
vessels before antiseptic ligatures were introduced. It to^ 
be applied in two ways, viz. : (a) Limited Tonion, which 
employed for the larger vessels. The artery should be drawn oA 
of its sheath for about half an inch with one pair of forceps, ibI 
held close to the tissues by another pair applied transversBlf, 
whilst the grasped end is twisted sufficiently to thoroughly ckiii 
it ; it should not, however, be twisted off (Fig. 65). (i) Ite 



•o.-^ 




Fir.. 65 — MtTHOU OF APPLYING LIMITED TORSION TO A L^HGK VKSSIL 



Torsion is used for the smaller vessels which cannot be so coo- 
pletely isolated from surrounding structures ; the vessel is lud 
hold of with its shealh or connective tissue covering, and twisted 
as much as necessary. 

The effect of torsion is that Ihe inner and middle coats Hi 
ruptured just abo\'e the spot grasped, and tend to curl upwarfi 
into the lumen of the vessel, whilst the outer coat is twistedi^ 
beyond (Fig. 65). A coagulum forms upon the injured structuTB^ 
and the subsequent processes to secure permanent occluaon »• 
similar to those described above. The adTftntifu claimed a 




Fig. G6 — iLytiXTi- ot' Torsion on an Artery. 



favour of torsion are that il is easier to twist the vesseb tifli 
to tie them, that thtre is less liability of secondary haemorrha^ 
and that no foreign body is left in the wound. As to the »• 
of application, it is doublfui whether torsion has any advanti^ 
over lig.-iture, and certainly when antiseptics are employed ibe i 
two last statements do not hold Rood, for secondary hastncc- 1 
rhage is practically unknown in aseptic surgery, and the catp* ] 
ligature cannot be looked upon as more of a foreign body tbiA 



dwiu^ed cod of « twisted vossol. Jt is, how6\«r, occasionAUy 
~ ~ hi plislic wi»k, wbor« exact co-aputiun of law !>ui£:iq» 

f UgMnt is at \h^ pr^a^at day ih«' nicst common method lor 
jrfTiiu:^ biccdini; from a definite M>urcc^ 

Tk DutcrUlt ii**rrf have v;*ricd (^iijw<|i>r^ii|y fjijni tinir tij 
(iffff, OrigJriiJly iiilk or hempen flifn;i<U wi*!! wAXrri were em* 
(Idnd, and iDAAmuch .is no steps weie l.ikcn lo piinfy thom, 
aM» ifcwy hftd ftlwiiys to wpuraic by ft pioccw <if ulccrjilion, 
nittini; Ib^r w^y ibrau^lt the vessel vr^ills. il is mil smiirismi^ 
th>i teccdduy hjtmorcliage frequently followed. The ends of 
the IJickhtre vrcre kit lo(v: utid h.ingin^ oitl of Ibc wound, and 
tvre ocdjionolty polled on by the surgeon tn ii^ccrtj^in it they 
mt rrady to ciinip aw«y. Siiicc ihen cfi«ris have bf^rn Tijjiik 
kxttua a ligature of iufficitnt «li«ngch to secure the vessel* 
rf luftcicQt jwisUnar lo nmmt^m its hold in fspitc of beinj; 
ttikol in itie bodv i)uld». ^nd yd u{ ^ucb maierul hs to Ut? 
cnhn ^lly AliS4)rlwd or so pure and urimlniinf; a« (o lic^CMTne 
aia|«ulM] in the lift^ues. Cai£p.it tuiiably pTt^p.ired is the 
■ildial a)D«| commonly in U3c, and 
oawiuJi dA coiruiiciciNJ i:4lgui. even 
«ba nn^Vrcd au'prir by imm^r^ion in 
" Md, lwcoiTi«« iu>fl Jind tin- 
u)d is absorbed too rnpidly, it 
And midcicd more r<:«i^t^nt 
b) flocphi^ if for twelve houra in :l 
uMioacd cbronticocid (5 pnrtA of ^t I0 
: of thrwnk add in 100 purt^ of wntcr)i 
wi vht€€]artit\y for cwi^Ive hfiiLf^ in 
-coparU ol uitphurouK acid i^olution. 
•fa^Rcniili colour. It ,%hoijld alv.-iiv& be immersed m carbolic 
kMfj pet G«nt-) for M>me hour^ before use^ 

Uib«££fvl iiT Mrrilij^cTfl Mik i> ^inoiliEt ^uikI n^tzai cuenipkiy, 
*^ ininud tistucv. Kuch as k;mgaT(H> tendon and itripv of ok 
iou, h^vt their advocates. 

U^ufo nay be appbed either to llic divided end of an 
*ntrjh VI open wound, or Id an nnirry iit its coniinijiryH th^ 
■dffttxM] fioa) mea^niof rxxlu^ion li^npf inbothca4«ii\«ry similar. 

Wbta applied b Mr ofitrn rttit uf a divided vessel, CJ^re should 
'*likmiDwl(H:t>i li^turcllielhtLltne^stof wbicli i^proporlionale 
■e tbe Ivnvn of lh^ v»95p1 to hir lifrd. The attrry ^hoiibl 1x! 
^nlv picked tip with fbrcsps, »o a« Ic indodc ak little i;urraund^ 
^h9«uea« po«»itflc. and where a ^hcatti c?iist(. should be with 
^iraftom il. The lii;Aturf U ihrn paucd nnmd it and tied tii 
* Lane vthich will not ^lip, /^.. tlie reef IcriLit fKiy. (^7). Wbtn 
^He 4pplicjilkon nf a IJEi^lvirp is difbcull, -is in very dense fibroid 
**>"». It ntay be advmiiilc to pnta it under the vcsfitl by inean.^ 
^Mixdifsiry curved needir, and then to tie it. 



Klf.. 67 — Hf RF Knot 

It It then dried, and i» 




M2 A MANUAL OF SUSGERY 



When a vessel is to be secured in its continuity, the surgeoD 
the advantage of being able to choose the spot to which to 
the ligature, sn as to interfere as little as possible with otbir' 

anatomical structures of importance, and to give eveiy 
ance to the collateral circulation, whilst ndt influeocing the 
tion of the interrial coagulum by the too close proximity of 
branch. Details of such operative procedures wUl be found i 
Chapler IX. 

EtTocts of Ligature— 1. On the Veiwl WaU.— The im 
result, if the vessel has been tied in the usual way, is to di^i 
the internal and middle coats, which are separated h'om the 
and curl up within the lumen of the vessel, whilst the outer 
is constricted and thrown into folds within the grasp of t 
ligature. If a vessel is tied in its continuity, the same 
is produ<:ed on each side (Fig, 6i). An internal coagulum so« 
forms upon the proximal side of the block, becoming adhemt 
to the iMse. The changes already descrLl>ed, by means of which 
the artery is obliterated and transformed into a fibro-cicatricii) 
cord, then manifest themselves in due order. An exudation d 
plastic lymph and celts occurs into the sheath and around tbt 
ligature, and if the latter is aseptic, the whole is embedded a 
this plastic mass, which undergoes the ordinary changes swa 
in repair vmtil a firm cicatrix forms. If the ligature^ hotteier, 
is sfptii and irritating, it has to cut its way out through the vesaA 
wall by an ulcerati\e process akin to the separation of a septic 
slough, thus exposing the patient to the risk of secondary hrmor- 
rha^^e from the disintegration of the internal coagulum. Tbe 
periixl at which a septic ligature is separated varies with thft 
size of the vfssel, from a week or eight days for an artery the 
size of the radial or ulnar, to twelve or fourteen days for the 
subclavian or carotid. 

Of late y['ai>, liowever, an old idea has been reFUSciCatcd, and 
has ;^ainei! :i rojisiderable amount of support from some surgeons. 
viz., th;it <icohtMoii of a vessel is satisfactorily accomplished by 
merely bringing the wall^ into close apposition by an animal 
ligature of ?,uiiable size, and that division of the inner and middk 
cojits is iioi only unnecessary, but prejudicial, and tends to (ivOor 
secondary ha niorrhage. Where asepsis is fully maintained, satis- 
factory fuchisinn follows either plan ; but it appears to us that 
the divisron and curling up of the inner and middle coats must 
facilitate the deposit of Jibrin and process of repair. At any rale, 
il-wouki seem siifer to apply a ligature to a main vessel on the 
face of a ^timip with suflicienl ti^^hlness 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 In- advisable to use broad animal ligatures (such 
as strips of o\ aorta, as su^f^esled by Harwell), and only to lighten 
the knot suftiriently to occlude the vessel with as little damage to 



U.E^aORRltACE 



au 



tk CMts a^ possible, ipcbil&t the same plan may also l>c adopted 
ttdo^injc with oflcric^ oi ^rcat 3L£e, ^ucb .1^ Ihc innomiiulC' 

r Tlip UfjUnra itsrtf utfrlr?igtirs clun^f^s, winch iPMilt in it^ 
[arul ciT total ibtorptic^, if siich hv poKbiblc. or ir it* becomiofi 
empaled a abstolulcily unabsorbcrit. The lcucoc>(t5 altnck 
It) ych nuucTul. !fuch 01 mIK ^i calt'ul. in.Miiu.it 1 11 g lUe;ni-<tc]vrh 
taat^ the ribnll^t-. »n^ KiinTly rtfinovf^ lliezn tiy tht* same? 
d^riiv* power which \v^Ai^ 10 tbe Absorpcion of n Kmall aseptic 
Mfb. Mulbnuclaitnl cells arc often pTfHtni, nnd proliably 
IaW ume paul ui die* pmLr?)?i« OiiLiiuay uupEL-piLiF'J cal^ut 
»tl* up m w^irm blood wnini in half sin hour, forming a P^^PX 
aB«,v{uch is. rapidly removvd; bul vrh«ii it h^i: b«vi^ stHspM 
li niuljiccis of »u]phurixi» or chioniic acicj, 11 brcoincb rnoro ' 
BsAinuand lakes a <x:in»ii:liT^I>l« llmc 10 (]lMp^x-.4rp varyinj^ with 
bF»%lhodof prvparftlion. Th<* orHinArychromiirizod (fyi Li«ually 
lull for about ft raitnTijht. rinnllv cvcrjf' Iracoof il ciisftp]x^»rt, 
4DjitipUcc is takcii by fl riiifi nf tibrous liwuc- Silk U TiiiittLtHy 
jUftbcil ami rrmn\ni, httl mnch mnrr slowly. Olhrr ;inimal 
ubttsccft employed oir Uctit with in l}io i;arnc wuy, and cicn 
ftl'crain is noe unnlicctcd, il^Tiuriooc bccomlnjC rouKhcncd and 
i&ffatlyaockd. 

y The eflecl on itip OlrenlEtloQ W I he »ainp, w-hethpr ligature 
<rfef ocbet y\t\jx oi occlu^itm i& iJ^jplecl. ~Ilic pusJuicc? of the 
W«od throuj^h the vcs*e] ceA^w, ;»ncl it?t pto\im»il end an- far »i^ 
car aei:; [Mtcnt biaiich. thou^i^h jem^ninic MiiiLi^k^hai l]i^]^J.1drtLt 
fcvi ibori lime by Ibe impaci of ihr? blLiod-ttrriim. suun Ix^^inv 
iiontrjct :iiter tbe coaiiulalion ol it^ contLnils, liod lu uluinatuly 
wonmd into \ fibrous cord, which may or may not lie pcr- 
nais bi a hIhmI diMance- In i;iic cn&r^, whccc ^a aileiy 
biboa tied in ii« conttnuiiy. thtr channel h\s ti4!«ii knotvT) to 
ff'af*^"! *^y eanntimlion of (he cicatrii. Bitxjtl ia co:i\t'ycd to Ihu 
I iht Imib bclo;i tbt ltj;dturc by ^iiii>1ojnuMn^ brAnohcs 

.'i-L, .pi^it^Uy utidrrgo i]vlal;ilii»o, Jiml FSt:ibli«ih n ntlUttrtti (inuh- 
in, vtJtxirtttly frf« ta nij^irmin a% 1 genprA^ nil^ The viiAliiy 
■/ itte nut. n^ew coUnlcrnl branches ix-^cmc ptTm:irently 
<ni«teiL leTuriJ^cncd, and tortuous, and their uvilK tlilckened. 
li in 4JIT Ti*-aHin llic <iilhlpral rirnjlatinn is insnfiifirnt^f^anKir^ne 
a l\W-y to supervene, starting in the p;iriii funhctt a^^'ay ftoni 
i^cnireof the circulation, or in ihc siruclurcs ot ba:;! vitality ^ 
*vl vcudiiift upiward^ Lmiil a p^rt \:t reached vliiiih receives 
■anfi Mood to l»ep it alive. 

Att«rlAi B»morrhA^> 

throe forma cf Anciinl h.-rmgrrtiogc arc describtidt vi/., primary, 
"^rtiumy, and srcnnilary. ^ ^ 

hteuy Artolol HjBminTluig* if^ met whh iin^lrr 1^0 i.un(Iilicin« 
-•*« u opCQ ^XMUiJ. ot where au artery is ruptured ur 



a»4 



A MAitVAL OF SUKGBBY 



occurSi conKtiiutin^ dtber a ««^~«ro bnii^ if tbc xrttry b bbaU. 
or if the s^nwl n Urge wh^c ia comiTiorly icra>cd a 'dilW 
Iiuurnatic anf^tmsm.' a li^rni which ne miiMilcT ctxtrcmdr go- 
leadm^- The gi^er-il mips for (he HirKicAl trE?airniriil of !to< 
conditions arc cx;tci]> the same, ind alibouf^b Ihe a^nt m- 
plovcd to linnlly nrrc^t the blccdiiiff x^iirics xcconiinfi 10 Kbi 
?^ur<FRr)n's perNonai pmlilccticniA, >rl the underlying princi|de> 
hold ^uod in all cis&s, VV« «h;tlJ Liinit ourselves matiilj Vi 
sp&il*intf oi th« liKiaiiri-", nt \it almoal always employ ihia ag*tt. 
A- Primary art«nal hsmoirhu^ from ah opes irooad. T^r 

hliMtl 1^ htrr^ potiir^U £i>rih iijuiii llir -lUif.iit^. ^luJ i:at^jHf^ fiK^I. 
ii> that tbv full coiistilulional t^IJvcl^ .U'.' r\^|i'.'Ufi)t:ctl, 

The priuciplc^^t ihMl ^-uule ui m the Tr«fttin«iit of i>rinui>' 
arterial lif morrlia^e w«re ttnit tcco^puscd by the late Mr- lobn 
BelL [lui ilie impoEianee of jLLtiMK upon ^ucli principles, Andnai 
iiuMing to tli^ Himtemn phn (A ligature at a diRUncc, v>aft im 
fully insisted iipoif by Guthrtc, whose lar^c <-3ipcficncc, confirmed 
by thai of hitcr miii;vu»s» dt-[iJ0iisiL\ttca their Accuracy* Thcj 
may \tc miinrMied a* follows : 

r. Tfiat the vfssti wusl be suvrffi at th^ part tp-ftmidti, on ciperaCi^ 
to cxpofiC the blccdin^'P^inE being undcttnkcn if neccat^l)' 
H»wcvcr mikch ih^ p^il nuy be i]i[dti;Lt(ri] vith lilood or pu^ 
the rule of cutting do^n to cxpn«c- thr woinii]«d \«w«id x% li> bt 
Adhered to, with one or two c>ccpitE:»iis noted below, and tUf 
tor two TGA^Crns: [a] It i^^ often impoa^ible to know the en^ 
mnrre nf the hii'mntthaKc? nn!«* it ii Uid I'arc Thui. lla 
btcodirg from a punclutcU wound of the front of ilic leg, whirh 
wa* appATcnily derived irom the anterior tibial artery, was pfovvd 
on inciiion and carefiii diNsecijon to come fmin the peraneAh tirc 
pitncltiie lj;Lviii^ ]HJ^.^(-l1 benwen the lionr^. In ihr? nxitla J.iid 
groin Huch ini!(tukeb are readily in:Kle. (M Proximal li^lunof 
o v«t»6t;l at sumc di^iancu aI>o\c Iht bltodint; flpoi ifl v«rv oom- 
monlv iiisLifFiLLeikt tu ancitl the h^ mL^trhdj^c, »n<T the colliitifjl 
circuurKiii will It'r^d lo Tnaint-im It, or, though apparently eifex::i\c 
for Jt tin>e, r«iLCtion^r)' haemorrhage U very hk«ly to •nsii«. 

3- 7Adf hatU fitth iff tkt u^widfd rvtvi mnst oe AHnrtd if it ift 
conipleiely divided. w)nlbt if it is only punctured, a li|:alurc n^iut 
bf! plncfifl on cflfh <\t\p of rhr pimrnirr, ard ihr mmplrie cbviMnn 
of ihfi vessel efTecled. The e;ise with which collateral circulatkin 
is esublishcd ju^lifieb such ireninicnt tn the ca»c of all artehc« 
of Urge ^\r,e. Thtis, ivliere ihc {m'\a\ Arleiy \> divided, jets of 
blood are emitted fiom each <nid cjuite freely, and wilh nearly 
a& much force from thp dwul a« from the proxMn:il. Uccanon- 
Ally the distal end of the vessel may h.ive retracted amon^'^rt the 
inrdliaLed tissues lo such an extent as to lender ili iM>UliLin 
Impraciiciittle^ Th« siir^pon must thm trust to plugging of the 
wound from tbe buUom, but not until everv ellort haa been rajKla 





HEMORRHAGE n^ 



secure it. When a vessel has been divided close to the maio 
ok from which it arises* it practically corresponds to a punctured 
□nd of the trunk, and must be treated as such by double 
«ture above and below the opening. 

X is only needful to undertake the measures detailed above in 
es where primary haemorrhage is actually proceeding. If it has 
>n once arrested, it is unnecessary to search for the bleeding 
It unless the patient is very faint and collapsed, and the surgeon 
i reason to anticipate that a large trunk has been Injured. 
wier such circumstances it may be needful to seek for and tie 
at once, otherwise recurrent hzemorrhage is likely to ensue 
icn the heart's action becomes more vigorous. 
There are a few exceptions to the general rule of tying a 
■unded vessel at the injured spot, e.g.^ where the depth of the 
section needed might endanger important parts, as in dealing 
th the deep palmar and plantar arches, or with the secondary 
ucfaes of the carotid- 
Is the actual treatment of any particular case, the haemorrhage 
wid be temporarily arrested by compressing either the bleeding 
lot with the thumb or finger, or the main trunk at a favourable 
>t nearer to the heart, against some resisting structure, such 
a subjacent bone. The common carotid is controlled by grasping 
;neck from behind, and compressing the artery by the fingers 
iced along the anterior border of the stemo-mastoid against the 
Jisverse process of the sixth cervical vertebra (Chassaignac's 
sercle). Such pressure will also control the vertebral and 
trtot thyroid vessels. The subclavian is to be compressed in 
i third part of its course against the first rib by the finger or 
omb placed immediately behind the clavicle, the palm of the 
nd resting over the shoulder. A good deal of force is required 

(H'der to maintain the pressure, and this may be gained by 
perimposing the fingers or thumb of the other hand. Where 
e pressure is to be kept up for some time, the handle of a door- 
j well padded may be employed in the same way. The facial 
tery is controlled by compressing it against the lower jaw just 

front of the masseter muscle- Bleeding from the labial and 
•tnary arteries is commanded by inserting the index finger into 
e comer of the mouth, and compressing the lip between it and the 
umb outside. The Umporal artery should be compressed against 
e zygoma just in front of the ear, the occipital at a spot about 
- inches from tbc occipital protuberance against the superior 
tfved line- To control the brachial artery, the arm should be 
aspcd from behind, and the fingers pressed inwards along the 
ner mar^ of the biceps against the humerus. The radial and 
Mr arteries are easily commanded just above the wrisi by using 
ith hands to grasp the forearm, one for each vessel. The 
■ddMiJKi/ aorta is temporarily controlled in slim indi\iduals with 
Lse by pressure through the abdominal wall against the spine 

15 



atf 



A UASUAL OP SafiCEltY 




,il X pcnni a litllc .ibovc And lo (hu left of ihc innbilifus, iV,j 
ntfavr ic* hifiiir^lion ; in ^loiii pfrsons ihjn i* imprAsililp- 
^VMVffMM ftmarat nrtory U hci;t comprceftcd jufti U^nu- Poupcin't 
Iilfament of^unAt the ramti^ ol the as puM^. I'ltc ^itr^^c :iuiiJiJ 
!»tm;ti on llic 3.miic Miltt of the pattriLl a\ ihfr arlrry lo be coi> 
trdltd, Jiml tite i»iihrr the finger -tipsi nr thumbs to pre» lb 
v«&9«J ImckncLtds a^inflt :hc pubic ramui:. Tbc finjccrsofov 
hand pUced o^icT the other rriAy M>mctimcK bn nc^c^vtiy Co ima- 
ttiiii ^mlliLiriu coniEUiLticLor ihc ihi^h trny lir ciiHtcW liy Ihclwo 
bAnd*i. ;ind one thumb lati^ ov<*r or ;iIk>\'c thf; ulht-r. Cire miLff 
be taken not t:> let the vessel roll to one !U(Ie or the other *&! » 
escape compreanion. When the artery has to tw fonlrollcd for 
some 1M119. AS LTi fln ^rapiitj^iiun. Tht? h:indK mny 1w uiaJ alita- 
nnT«l>', the one to rcet the other. Such preuture u-itt safSkt kr 
the icmporjiry arrest of hrtirorrhn^ from any purt of (he JwFtf 
limb- [f it It' ilcairuble to ctjriilrol Uie c/rfrn'dr fmJ f^yittvr tM 
ancfTiM rinsr in ihf ;mk1e fliiring oper^t^^m^ i]|if>Ti tbr frvtf, il» 

AesislADt who £teatlie«i lh« limh tc- 
compli&be^ thJa by j*nispqn^ ibcMo , 
VL'ith vtK Imiiil, ;4n<! with the ot^ i 
mmpTPs^smg Th? v^^si^U, ihe p* I 
icfior tibiiu ftt A spot a ^n^< ! 
brcn<Ilh behind cho iiiErraa) nl- 1 
Iroliis, thr .-knierior mMway lirtvnft 
the tiJto malitoli. 

A^ dijntal coRipr<-s««>n cjaxM* 
howevifr. \k comfoiLdhly itiAiDiuiMi 
for tring. nt/fkanuaJ ^Jtmpmwm dti 
limb as by ioLimii]itci i^^g. feS) « ■ 
cln^slic hnndnj^ musl bcTCMftcdlo- 
PoKKibly the Kcirw KHimiqcel will 

\v thr br*! to at^*'y» *** '* *•■ ^ 
relfixed iiiid tight en trd a^tn jls cftfD 
as is ncccs^aiy duhn;: the open 
tian. 1m simn? ca^^s J1 i\ advuaUc 

to exiaiij^uinite the limb byefcv*- 

FiG. U— PkiLi > TuuR^wuar lion before applying the toumiqML 

The wound is then, if need \iu 
enbrfted by tndsinn^* which whilM freely ]:i)irii^' ilie inits cfxn 
should inflict the Ic^Et pos^iMe dAmrtRe on -mrtoundin^ sUuctum- 
All coaniila ^houM be removed, iinJ the wojnded ve5«J looked 
foe. Li uuiy \yc needful Il» relax the luurniquf-'L mid allow a jri 
or two lo psciipe, iri order lo ascerLiin its pfHition. Bolh ends 
fthouM be sought for ;md tlrd. a proceeJin^ easier <^id ihun done, 
Tbb especially applies to the disiul crtd, which retmcf^, t^ 
ufteii Uoei> nut bleed <iE the ItiTie of oprrdttoit. btil may hmtHk 
out when the i^olbter.il <ircril->non hernmp<i**tiiflhli»iliivl. 




B< For BubotitMiAOTtfl Bupturo of an Attery, ^^ p. J36 




VMUOBHttAGH 



f: 



&««imrcbt, laurmodtAto, or Rcactioiur? Artod&l Hftmorrtuwe. 

Sdfh flr« ifar i^trnt >pp)ieil to bleedini; whtcli recurs withio 
' ' t r hour^ ci »n iccidonl or operation. It!i occuncncc 
■ ii<c of tile tailiirf: uf the means rmployed lo pci' 
cjiiciii&y -irc*l the priiiL>ry Ii^s of Moud, rind maj tt^ult fnini 
TW main CAUU-t: {.t\ Defonivo .^[iplifT-iUon of a ligature, which 
df»cff, pcrhap-simm including; wilbiii it other structures as v><;ll 
M tbc ancrial w.dl; fjr f6) tlic cuh^uI^ lyiiii.' in llicr ruouLbs of 
hfAd vrwwh ar** nnt viiffirimily firm to wirhslami ihe inrfM^mg 
Mcia4-pri?K«urc which KUpcn'cncs after the shi^k has pj^ssi^d Auay, 
K «hKlb may Ik due to excitement or ihc inJLidicioos Admini^tm* 
cut uf vtimuUiitsL. A» A [ulc, it i> tlatt to the M^cxmd of thckc 
CHVs. inci t* |li*o not very ^rinu*, tnasmtich an tt r^nn only 
int« frcon the snuiler vcvmIs. nil the l.irger ones ha\-ing, \t U 
?Twtncd, been reco^paised And lied durijig the opcr-ition. The 
' if 1. boH'r^'i;f. ntJt Ik- applied Jo ihr tmthig ni hlood at 
•■i\ i^riim V) common .iHtt op&rAtioni^. l)ut only ik!ti?d 
ix !rj(.^^^ cAse< which dununii trcaimcnt. Considerable pair nnd 
tauioa may be cntucd by the acctimoUtion of blood in the womuL 
l^VMntni,— Elevation and ihe prf?<Hur« of :i firrn handa^e art' 
dto qufi« sufficient lo Arr««t ihii form of bleedmf^ : but if un> 
MKoni!^!, it wiJI t*c ncccsflary to open up the wound, wash it 
•I (kith hoi or ci.'U iulion, and tic Jtny vcwel fuuml llewljiiy. 
Thr A^iu-i] f jiiiT«Ty ni:iy tvfti be empkiytd to check ooan^ fiom 
oaiixiftl turbc««., and it it i« not allowed to touch the ^in, 
tbe Ground kept iiMptic, no delay in it* he^ilinj; nucd be 
Should iLe bleeding per^M, uiilif«p[ic plu|;gLiijj 
ber»«onpdia 




Socond&ry HFemoirho^e- 

1Ul*i title 4ie indudrd all f{>rrnN uf h^inorrhLt^^ from 
which oi'cuf after the ]ap!£e of Iwenty'four lionrs. It 
I jvl^aIIv due to fli?p&i!t, and was (ormeily very common, being 
- i:u)uctit CAUM o4 a fatal teimination : mil since the introduc- 
hfc of inttticp<K sm^erv il is liut Hule ntxn m the yi jtlite of 
thoac *ho Attend coTiicWtiouily to fts detail*. Where nmi- 
t^psk, however, cannci b«r cDSciently carried cut, it^ in the mouth, 
pBUTux, ctc^ il i* Mill met with. 

The rva>du&«aU] CaoM in ihtr production of ^picomlary b.i-nior- 
da^ n u-ithfiut doubl i B«ptic condition of iht^ n'ound, Thi« 
Wy acl in vanouc ^vj^yB. Tbus, in :i ve^e^ entirely divided, 
tW cocci nuy gain cr>Uf*ni.c tlir.tuiih the open mouth lo the 
iatcnxftl an^nm, and by c;iu'^m|{ ii« disinte>:r;LLi<>n b:eak 
difWQ the iKurier which Nature hJid raited a^^iiin^t i.\ir.h An 
wcutreDce, lliis procc«i 17^ ns^iMed by nn uJceiaiive loim of 
pcnKimtx%, vhich lcadi« to the macctntion and vioftenin/: of an 

15—2 



A MANUAL OP SURGERY 



absorbent ligature, and to weakening of the vessel walls. Uj 
in this latter way that secondary hemorrhage is induced 
vessels ligatured in their continuityt the loss of support 
the opening up of the septic wound being also an ele 
danger. We desire here to emphasize the marked alt 
in all the conditions existing in a septic as opposed to an 
wound. In the latter it is not only the clot in the lumcnrf 
vessel which is relied on to prevent accidents, but the vital 
of all the tissues is calculated to work in the same direction, 
ensuring the patient against haemorrhage ; in fact* the 
of secondary hemorrhage in an aseptic wound is p 
impossible. On the other hand^ when sepsis su 
destructive process replaces that of repair, and the acri 
the part is temporarily paralyzed by the toxic influence 
micro-organisms and their products. 

Various other conditions may be mentioned, howcvtf, 
Oontributorr Causes of secondary hemorrhage : (i,) The 
may he coarse, irritating, or septic, or it may consist of 
too readily absorbed, (ii,) Its mode of application majj 
faulty. Thus, it may have included other structures, 
become loose, ofFering an insufficient bar to the blood- 
or the sheath may have been opened too freely, and thai 
vitality of the vessel wall dependent on the vasa vasonim 
be diminished, (iii.) The ligature may have been placed 
near a branch immediately concerned in the estabhshment c( 
collateral circulation, or where there is a considerable back 
or at a spot where longitudinal tension is expeiiencedj 
if the part is not kept absolutely at rest, (iv.) The 
of the arterial wall at the site of ligature may be un 
being possibly the seat of atheroma or fatty degenera 
most important complication if the wound becomes septic. 
The stale of the blood may be unfavourable to the repair of 
wound, whether in an artery or not, i.g.y in albuminuria 
diabetes; or it may not coagulate satisfactorily, ca 
internal coagulum to be inefficient, (vi,) Increase of the 
pressure after the ligature of a vessel may lead to 
hemorrhage, as in plethora, Bright's disease, traumatic fe 
from injudicious excitement or the unwise administra 
stimulants. 

The Phenomena are usually preceded by those of septic 
tamination of the wound» to which a slight occasionai 
blood is added. This continues with more or less frequeof^ 
severity, but tends to increase until either the patient is 
out by the constant repetition of small losses, or is destr' 
one or two severe gushes from the larger vessels. The 
the bleeding occurs, the less serious it is, as it probably 
from the smaller vessels, and can be easily dealt with, 
however, it does not supervene till late, as on the tenth 



fHhh day* it iisLiallr iiHses from ilw Isir^r tnzoks. ind is 

tcu74JuiDgly Mvere. When Jl originates from a v«iscl tied ia 

h» contkiutty, ii c^cocrftJly comes from tli« diataJ end. and that 

Is cb« loUowia^ reisiDns : {u) Thr iDlsm^ ctu^lum h hf-re li-«t!c 

finn. 3nd fotrnii Ltlcr than :it ihi?r proxim.'nl 4^d; (A) tiie pressure 

ktibedkUJ »dc ol ihc li^aiurc, which isa.t first nil, is coiilinttnlly 

tttMac it» ilie coUal<:rnl circuklion U GstaNisTi«d. whilst 

;raiiiullj IE gr^diijtlly dimirUhrv us ilie vessel ccnir^ris, vinit 

tU blood-f!ow in dcf!cctcKi into othc^r cbATineU; nnd (c) the 

QM vcm vosonim Alwnyr. run into itnd along the ve-'j*<cl waJI 

03^ mnc diicction as ihc bTood^^lrcam. Hence llic erlTrcl of 

ifcdattni: ibc :»rtPTy in it'i vhcilh amf ligaiing it is (o diminish Ihe 

t^ij 3f th« arterial tunics and Eo impede r^;iiT just l>elow the 

pMalii:aturc, 

Tbe Treat ment lv ji tn^lEcr of gr^ve unxieEy Iq iIic ^lugcon 

ini£ Ibrf MTountl ^(?t£ into ;i he^ilrtiy st.ile^ iaismiich ns he t::tn 

avw t>« ctfUiD thai it will not bjviuM out a^'aio, although the 

bbwfin^ nay bave l^ccn tcmpoiranlv sU/od; aoncc !«uch a oasc 

susi lie iiMnt laitrftilly ^^^uhcd. If the «uuud ifi iu 4 liiub. a 

~ ]u«i should b« lightly Adjusted Jibo^^e it us a precAucionary 

BO thxt at a momeflC's notice iE may be ti^liteD^d. 

Wfc<n Ariiifig /rvni itn iJrffr^ tulirily dividcti ^ro^<, as in an 

Ivn^ooikiD stump, vIvvAtion of ih<- paif , if Kpusare Ic ilic exiemal 

or, lathing ii ^iih cold lotion, and then redressing it and firmly 

hmdigin^, muy tw all that is needed in tht early nrid rndd o^i^ti^. 

[Jl ffcurrt^nct; will ueocTi^iiaCc the ti:ot>titLiit' ul tht: wound, and 

;i[;fJir:itinn of Ii^(iirp4 tn iho hlj-r^iling points, if praciicatile. 

tc actUAj c.iuc«r^' may b« «nip]oy«d wher« the tintn^^^ -ire eoo 

io hold ^ liji^tLirc. Mcjirs should be ndoptcd to remove 

«lougll5< as bv u Volkin^iiii's spoon, and If possible to render 

wcmnil a];cptic by &A;3b!iin^ il oiti with i^lmn^ carbolir lotion 

13 3o», with pure c^rhnhc .icid, or with aolution of chloride of 

The wound lihould then he po^'dcTcd with iodoform* pAclccd 

cyonUt^! ^aoze, and f'ncn])' Ik^ndagcd. If occurring btcr in 

?, the wound should I* frw^lv opf^nod up, :ind an iitiempt 

' scctuc the l>ltfcding vessel. H this !aiU, owin^ Eo the 

or Kptic ^UXt of the ti»iuc5. the artery must \jc tied 

pH tiyaxct o* rc'ainpulaiH^n [^^^i formed. When tUtr Meedini; 

DttA ftom tbe main vessel ne:ir the trunk, as after amputation 

Ittbc iboaJdur or htp, proximal ligature can fdonc be depended 

a».Bbiiu)d local trtLitnicnt bo uii^uLcv^id. 

WbHi coniing /fom an tirlny tvd in Us nmtiimity, ihe s^me 
■tBM ifc mdkatMl abov« fiI>ouJd be adopted in the e-Arly sl^Res. 
Lticr on, t^* treatnaoat viiri^a a Jiille according to the &icu;ttion. 
If trun a ve^Mil uf l!»i: trunk, iiucli as the caiolid oi il:nc, the 
VMa4 muM be frcoly op<»ne*1 np, :^nd the artery secured ag:ibi 
*boviatid b#iow, whiUl ev«ry effort \h made to combat the septic 
cviditiQa by plu^ng ^ib antiseptic malcruiU. l-'niUng tW, 




ap A MAlfVAL OF SUSCEkT 

if proximal Hennire k impo^^ibtp, onp can only mitt lo pir««ntnL 
Jn Ihe arm, riitcr Lining cold., presfiiT«, and eW^'atton, ovt« wonU 
rc-tic aIx»vc iLfld below thioue^ tli« onG:ina[ Vfound. If this biU 
q lieatuic shuuld he amlted hi^tirr up ilirougli a »pAratciad«% 
cyr hnally nmpitatinn he psrfomi«d^ In tn« ltg» bouv^vr, ii ■ 
flCArcely w-ise U> aticmpl rC'Li^tur* ai a bijjbor ii|>of , owing to 
I he Ic^s abimdant co1l;ilcml circulAtion- If ibc hfcmoftfc^p 
r-c4srs, g;iiiiiirni- i^ vrry liki*ly lo ffusiir : whiUi if <h*? Utlrf lioo 
nol supcTvenen ha^mrwUtis will prf)l^ib]y not l»c i^ffiecte^i. L'nOff 
such circumstaacpcsamputaEion murd be UTidcrukcn without ikik;. 

Bliredin^ ffom ihtr sm^itleT vf^iek r.ifrl) r^^iuiie^ iruch ariefitMC. 
tn thnE the walls, wh«ii c?n<:'« diviiled, rapiJly colbpM, and lbu» 
filiociually check iurthcr \oah of blood: but if Ih^ \kT^ 
vctiis aie involved, t* vKiy <:uiLMtl<riiil>li; ■ltuuuuL uidy bt: lunl, Ihe 
blood writing np mi a dark, purplUh 5tr<^m from The *xwind, anJ 
r^odering iu .trrest thc< more dimcuJt from th« fad 1h*l, «kc«pl it 
veins of tlic largest sict, (here is no definite jct or ku&It t:> ftjiifc 
ouc to ihc vkouiiiicd ^pol. TUeda.DK«raof vcrncu» li<Liuoiiha«:citr? 
fourfold: (:) Thr conttitiitinnal fiympicflns ariMnp from ibf actoil 
loss of blood, dctniU of which have been ipven ahow ; (3) ihl 
thrombus which f&rms umy btcomc displaced, and ^i\« riM i: 
MTious *iym|>intns sts an ^-mbolus; (j) the poshibilily of M-plic 
infcclion of the thrombus lying in the mouth of the vMset, «nd«f 
py^rmin dcvclt^pm^ ihcrcfrom, muM not be forKoltcn ; and {^) tbc 
a&tnu]Ceor»irtjitoTeiiifl. ^^.hi^hp ihuu^h an occitirencc, foftunaldj. 
IniT inifh- rnt:l viith, i^ frauj^ht with rhe most urgpm dan^^ to 
the paiit^nl, The air becomes churtied up in the cavitits of ii« 
rifchl !tidc oE the hc^it, teaming a. spumous, frothy mixturf 
umciigvl the tX}luiTin<t <:iinirir. which the hurt can only «iih 
(lifficulfv eject : thu* the drrulaiion i* btourht to a <a»nilttill ko 
iipite 01 forcible cardiac contractionii, and tbe patient di«« Iroa 
uittmia of the lunfr^ and brain. 

The Oftuae of iht^ cntiy of hit is uMially the! vmundmEE of viraa 
\f\n In x^hat is known Li!i the 'dangerous region ' of the n^k v 
uKilla, but Dccattanalty it may occur in oth«f poftilions. Th9TV it 
but little bloijd-prcMurc within the veins at any time- bill darJBt 
Irk^piraiioTi the movern^^nls of the ihoraK exeirclM an asptialor^ 
or ^uctton eiTect upon the blood \n the veins of the neck, a moit 
important tleirient in the maintenance of the ^^notis flow. Any 
condition whicli teuda lo prevent the collapsing of the walU el 
the vrin^, or brings ^boiit what is leinKNJ ihcir fiiiiallntiiB, 
predif^poi^ct to thif^ accident; Ihuf^, they may ba held opoti at 
tipotr- where they pierce the deep lasdn, or by tntt^lcs-^.^., ibc 
platy?Jtiia— vbii;h by their contractions can tiavca aiEnilai eSedi 



HMMORBHAGF. 



»J' 



coAt9 are thfckcDci! hy mflammatioQa, or suntmoilcit liy 
led li«?(Ufr. (It Imtlnn'hnW a^ hy rxrUinrj of i^ poTtinr of 
«3lh Of divirian of ^ l>r;iDch c]o«c lo iho m^in trunk, or if 
Imction x-i cxcrcisc<i upon ihc pedicle of a tumour conldin- 
A «fMiiilcd vein, tlicn the oriiicc iWAy remain p^li^nE. mid air 
~ily •mrkptl in. \l ha* been dymin^tr^iied lioth by cxp«n- 
i animals and alvo b>' clinical exp1^riencc ih;it a ccrtRin 
if air CAD be admitlcd without dtiing much perm.in<j^t 



- — TTit MHran<*o( air into a wound«l vein is accompanied 

•t hininf-, i<uri;lin^, or tiuckinf? ftound. which iis (|ULte cbarac- 

A tc:^ tiijbl>lc3 of air may also l>c seen cltogine about 

:jipmiirv \\\ (be vT-ii^H. Tht* efftrr of this acrrd^nr is Tn pr*>- 

'n Ai>d 4f-\vre f.iiriit*SiS, and if th^ palif-ni i& conacious, 

ot dyepDtra Ltiid dj^tri-s^, which i^ p^irtly avrdbc in 

ilv due to oliHruction to chc Bow of Utjod thiuu^li 

\s. xhr |>iiImt liecmiies rapid ^nd ahno'^l imfifrrr|itlhrt\ 

pupik vkidoly tiilatod, aird death tieually foJlowe, pr«c«dod 

hs c">nvulsion». ahhoLjch Ihe f^lai iwue may nc poat- 

doe' a fcvf liourTt or, il Js even ^Uicil. diiyK. If the pallet 

no aftB't-rJTfcK rrmain. 

L,— ThiF. acdilcrnt thould be prevented, if pos^Ule, by 

Ihe i^caicsl cnrc in licnhnff wilh aII tcin'i m opcr.'vtion? 

nwt- Shoulil it, hriwciirr, kjc.iiuf, *iny Ursh i^nlrjncc 

be ai oei<f rhpckrd hy jilacing a finger over the bleeding 

W pmrinc tolion mio the wound. The vein should he 

b> hhf.iltirc AS «x>ri as possibk. Compression of the 

beiRZi rmimmpridrd hy v»mr authorities in firdn In 

'OUt Uic nir that h^s entered ; Init there is iiltle chuncc 

lis thi!i eod. Tn comlTal Ihc gcncfai symptoins, il is 

^1 to nuiinL'kiii i fcood M^pply of blood lo the brain. The 

ifcould tv joti-rred. jind, tI need be. the hnib^ rni^^d Ami 

i^td or tJit alxlomiiul aorta compre^wtl. ^limuliintt iind 

nal rc:ipir4lion may be iiacd ^^ith cLtl^untufce m orcler to 

balun the biaH'n iiclion or lo o^ciuunie tUr pulnioairy ob' 

Warmth and friction ibould also b« applied (o the 

Li of Veuoua Ettmoirbace.— The aanic moana to a lar^c 
mM L)e tiiifjluyed 4^ lui aiteiiuJ Utt'iuunh^gc, but it i6 
fpiquenily required, since che vciirtw coilaps* naturftlly, ;tnd 
the bk^nliri; «iiop), When fimall voins arc dividod, thoy 
bo li^tureJ ue- in-istcd. if need be ; but it U never adviK^blc 
[urif lilt uTiol« (:ii<:uinfer«i)c« of a iftifi^r vein if il can be 
ftince, when wicli i« punctured or lorn, Ihe wmmderl point 
n <rfim \< 9e<i^red wilhojt cncrcachinj; upon the cahbre of the 
ibe. U\ Ai\\^uU\i\a^f^ \l i« \xs\ii\\ to lie lx>lb tbc iiMJn aitcty^ and 
■Id. \\'hprr it IK I'.iffir^ih to re^rb a vein in order Ed tiv it. 
of th« wound may be retorted la. 




324 



A MANUAL OF SURGERY 



punctured subcutaneously, so that extravasatioo into thci 
occurs, constituting either a severe bruise if the artery is 
or if the vessel is large what is commonly termed a * 
traumatic aneurism,' a teem which we consider extremel 
leading. The general rules for the surgical treatment d 
conditions are exactly the same, and although the agec 
ployed to Rnally arrest the bleeding varies according 
surgeon's personal predilections, yet the underlying prii 
hold good in all cases. We shall limit ourselves mai 
speaking of the ligature, as we almost always employ this 2 

A, Primuy arterial hsmorrha^ &om mi opm wound. 
blood is here poured forth upon tbe sur&ce, and escapes 
so that the full constitutional effects are experienced. 

The principles that guide us in the TnAtnMnt of p 
arterial haemorrhage were first recognised by the late Mr 
Bell, but the importance of acting upon such prindples, a 
trusting to the Hunterian plan of ligature at a distance, wi 
fully insisted uporf by Guthrie, whose large experience, con 
by that of later surgeons, demonstrates their accuracy* 
may be enunciated as follows : 

1. That thi vfssd must hi secuud at the part wounded^ an op 
to expose the bleeding- point being undertaken if neo 
However much the part may be infiltrated with blood t 
the rule of cutting down to expose the wounded vessel is 
adhered to, with one or two exceptions noted below, ar 
for two reasons; (a) It is often impossible to know the 
source of the haemorrhage unless it is laid bare- Thi 
bleeding from a punctured wound of the front of the leg, 
was apparently derived from the anterior tibial artery, was ; 
on incision and careful dissection to come from the peronc 
puncture having passed between the bones. In the axil 
groin such mistakes are readily made, {h) Proximal liga 
a vessel at some distance alwve the bleeding spot is ver 
monly insuflicient to arresi the hemorrhage, since tbe coj 
circulation will lend to maintain it, or, though apparently ei 
for a time, reactionary hemorrhage is very likely to ensue, 

2. Thai both ends of Ihf i^-onnded ivssei must be ucured i 
completely divided, whilst if it is only punctured, a Iteatun 
be placed on each side of the puncture, and the complete d 
of the vessel effected. The ease with which collateral circi 
is established justifies such treatment in the case of all a 
of large size. Thus, whero the facial artery is divided, 
blood are emitted from each end quite freely, and with 
as much force from tht distal as from the proximal. Oci 
ally the distal end of ihe vessel may have retracted amon| 
innltraied tissues to such an extent as to render its is( 
impracticable. The sur[;eon must then trust to plugging 
wound from the bottomj but not until every effort has beeji 



H HEMORRHAGE 315 

When a vessel has been divided close to the main 
vhich it arises, it practically corresponds to a punctured 
:he tninkt and must be treated as such by double 
■ve and below the opening. 

needful to undertake the measures detailed above in 

primary haemorrhage is actually proceeding, if it has 
arrested, it is unriecessary to search for the bleeding 
the patient is very faint and collapsed, and the surgeon 

to anticipate that a large trunk has been injured. 
I circumstances it may be needful to seek for and tie 

otherwise recurrent hemorrhage is likely to ensue 
;art-s action becomes more vigorous, 
e a few exceptions to the general rule of tying a 
;ssel at the injured spot, e^., where the depth of the 
leeded might endanger important parts, as in dealing 
>p palmar and plantar arches, or with the secondary 

the carotid. 

:ua] treatment of any particular case^ the hemorrhage 
rmporarily arrested by compressing either the bleeding 
he thumb or finger, or the main trunk at a favourable 

to the heart, against some resisting structure, such 
tnt bone. The common carotid is controlled by grasping 
}m behind* and compressing the artery by the hngers 
5 the anterior border of the stemo-mastoid against the 
Drocess of the sixth cervical vertebra (Chassaignac's 
Such pressure will also control the vertebral and 
roid vessels. The subclavian is to be compressed in 
art of its course against the first rib by the finger or 
ed immediately behind the clavicle, the palm of the 
I over the shoulder. A good deal of force is required 
mainlain the pressure, and this may be gained by 
ing the fingers or thumb of the other hand. Where 
; is to be kepf up for some time, the handle of a door- 
dded may be employed in the same way- The facial 
ntrolled by compressing it against the lower jaw just 
the masseter muscle. Bleeding from the iabiai and 
aries is commanded by inserting the index finger into 
ithe mouth, and compressing the lip between it and the 
ide- The temporal artery should be compressed against 
I just iD front of the ear, the occipital at a spot about 
Vom the occipital protuberance against the superior 
, To control the brachial artery, the arm should be 
m behind, and the fingers pressed inwards along the 
in of the biceps against the humerus. The radial and 
»s are easily commanded just above the wrist by using 
> to grasp the forearm, one for each vessel. The 
i>rta is temporarily controlled in shm individuals with 
assure through the abdominal wall against the spine 

15 



234 A MANUAL OF SURGERY 



injury ia sure to be fbtJowed by exceiaive bleeding ; sponUneoos tabca 
eccbymoses frequently occut» as also bleediDg fnmj the mucous mem 
Hence no operations mast be undertaken on such patients unless absol 
argent, even such a small matter aa the extraction of a tooth having 
btal. 

The TrMtmaat of hEmopbilia should be directed more to correctiiig 
constitutional defect than to pursuing the usual practice in dealing 
hsemoirha^e. TheapplicationoradmimBtrationofhzmostatics. andsubii 
which tend to promote coa^Lation and the fbrmatioo of fibrin. shouU 
resorted to. Calcium chloride, i ounce to ^ pint of water, given by oM 
OT a T per cent solution applied Jocal^y^ has been specially ncommendol 
late, whilst fibrin fennent and cocaiae have also been succeaafiiUy etnploTil 
Position and pressure should be attended to, and in severe caaea the 
cButeiy may be useful, or prolonged cold 



CHAPTER IX. 

f JUEIES Aim DISEASES OF ABTEBIES— ANEUBISH— 
UQATURE OF ABTEBIES. 

IhJhtIu of Arteries. 

LtD&on of an artery is the result of violence applied directly to 
vessel wall. The effects produced vary with the severitj^ of 
injury and with the previous condition of Che arterial tunics. 
atheroma or calcification exists, thrombosis often follows 
y slight injuries, and dry or senile gangrene may be the 
alt ; but in healthy arteries a good deal of violence is needed 
produce such an effect^ as their natural elasticity enables 
•m to yield or slip aside, and thus the remote consequences 
! usually insignificanr. 

Baptore or LMentiw may follow more severe blows or strains, 
!-existing weakness or disease of the arterial wall predisposing 
it. It occasionally results from attempts to reduce old-standing 
Jocations, or to break down intra-articular adhesions when the 
ssel has become Rxed in an abnormal position. If the rupture 
luti^, the inner and middle coats are usually tom through, 
d by projecting into the lumen of the vessel constitute a valve 
lich prevents the passage of blood, and leads to subsequent 
mmbosis and occlusion- In other cases, where llje injury 
the coats is slight, a thrombus may form, which leads to 
iliteration, or, if the lesion is limited to one side, the clot may 
tome organized over that spot without interfering with the 
men of the vessel, though leaving an area of weakness from 
bich an aneurism may subsequently develop. Again, when 
implicated with a septic wound, an ulcerative form of peri- 
teiitis may ensue, giMng rise later on to secondary hemorrhage. 
. is also stated that the outer coat is occasionally torn without 
tjury to the tunica intima, and that an aneurism may result from 
hernial protrusion of the latter coats through the wound ; such 
noccurrence must be exceedingly rare. A dissecting aneurism 
p- 149) may also under certain circumstances result from such 
'1 accident. 



3Z3 A MANUAL OF SURGERY 



CapUlArr HvsiQiThace. 

This is usually of little significance. It is characterized 
general oozing from the wounded surface, the blood 
down to fill the cavity from the bottom. It may be very 
dant from inflamed parts, and especially from tibro-ckat 
tissue, which prevents the closure of the vessel mouths. It< 
usually be arrested by a little pressure, or by the applit 
cold or hot waCer^ or by styptics* cauterization, or plugging of I 
wound. 



Methods of dealing with Hnmoirhage from 8p«cUl Bonrat 

OftTOtld Aitnj. — Treatment a impossible unless the surgeon is <at ibei 
whcD bolh ends should be tied. 

JugnlfcT Tain. — Tie, or alilchn if pos^ble, without occluding the 
lumen. 

Beconduy Bimnohn of the CmroUd.^lt may be difficult to «cure tbo' 
ends of these vesseTs either in the neck or head. e^.. in a cut ihroalorai 
tured wound of tbe inrernaJ maKiUary. Under such circumstances, li 
the exlemsl caioiid between the superior thyroid and lingual has been 
mended as more satisfactory than tyinij the common carotid 
Cripps), in thai the cerebral circulation ia nol thereby aflected- 

liiddl» M«iiing«at Artery —Trephine over a spot i} inches behind 
fiKtemal angular process of the frontal bone, and i^ inches above the 
scoop away or wash out the clot; secure the hleeding-spol by 
passed, if need be, under the vessel by a full-curved needle, or by 
pressure, Or plug the canal in the bone with gauic or sponge, where 
increasing the trephine opening downwards by cuttirtg pliers, 

VflrtBbrtl Arterj - -The source of such bleeding may he difficult to 
as it j^ ^icarcely possible lo compress this vessel without also iocludEDg 
carotid , and hence misfahes in diagnosis have often arisen. It may be 
however, lo control the carotid alone by pinching it up by the fia^ers placed 
either side of the sterno- mastoid, without interfering with the vertebtid- T' 
meat must follow the usual course, vit . of cutting down and tyinj tf 
bleedinp point. To do this the incision must be enlarged, or a new one > 
along the posterior border of the slemo-mastoid in order to define the ti 
verse prcMiesses of the verfebtie. In the upper part of its courae, the n* 
may be secured b\ clipping away a transverse process if necessary, i^ 
being taken of the nerve rOQt!^ : otherwise, plugging of the vertebral diuL* 
the use of sEypiics, must be depended on. It is most essential thai the c MJj 
should not be lied bv mistake in these caseSn as thereby more blood is dint* 
to the vertebral [ruiik, and the bleeding is correspondingly increased 

The Internal KunmftTT Artftry rarely calls for treatment, since a punctm 
^vcund of This vessel i^ usnallv complicated with some graver mischief tuhtfCti 
liver, or lungs. H recoirniscd, tie at the bleeding spot, possiblv renrnwif* 
costal cartilage to gain access The vessel lies about \ inch outside tbebtfoTi 
of the sternum 

Int^routal HsniOiThaga usually results from penetrating wounds ■li^'^' 
volving [he rib. and is not easily slopped, on account of the position of >^ 
vesrielsm the groove. Tittttrntnt —Incise the periosteum loQgiludinaJly aikiil''' 
lo\i'er border of the rib, and detach it and the vessels from the groove: ornof^ 
a portion of the bone, and thus expose the bleeding point ; or in lome <■• 
a suture passed round the rib a little above the injury has sufBc:ed ; or^ i^^ 
pressure may be employefl by pushing a piece of aseptic gauK, likeftp(» 
through the wound into the pleural cavity^ and then stuning il tightly fi* 



HJEMORRHAGE 333 

atrips of ^uie. » that on pulling apoD ii the vessel may be efTectutdly 

lis of the TesMls of thA BxtnoddM require ireairncul according to the 
s counciattd above Only one or two require special mention. 
ds of the PklUAT ArohM were Formerly much more dreaded (ban they 
■neat, when thorough antiaepaia and the use of the elastic tourniquet 

to explore the depths of a wound without much duiget or difficulty, 
ition of the Nvound will usually indicate whether the bleeding comea 
■ superficial or deep aicb, but In case of doubt it ia well to remember 
sure on the ulnar trunk mainly aflecta the auperficial arch, wbtlsl 

on the Tjdial will chiefly influence the deep. A wound of the super- 
:h should present little trouble in treatmenl. as it can be readily aecured 
I forceps and ligature ; but the deep arch is not so easily dealt with, 
LSt over the base^ of the metacarpal bon<!s» and 10 expose it the wound 
Eteely enlarged by a longitudinal incision, and the tendons lumed on 

or separated- It may be possible to secure the vessel by forcipressure 
and riieae may be left on for t^enty-fbur hours if a ligature cannot be 
Of course ine strictest asepsis is needful in such cases, and passive 
□t of the fingers must be early undertaken^ in order to prevent trouble- 
hesiouB Failing auch means, or in septic wounds, a modification of 

graduated compress may be employed , the wound is caiefully and 
bly plugged with gauze» and over thi$ the fingers are firmly bandaged, 
lent is kept la bed. and the arm elevated. Pressure on the main vessels 
scarcely necessary if the compress is accurately applied The bandana 
3e relaxed at the end of rwenly-fourhoure, but the deep dressing should. 
4e, nol be touched for three or four days. If, in spile of this, bleeding 
Lhe main vessel or vessels of the limb must be tied. Liealure of the 
od radial at the wrist is generally inanfficient to control it. as there 

a communicating branch of some siie passing from ihe anterior 
»us to the deep arch, and hence it may be needful to secure the 
I ajlery, ascertaining first. howeveTn by pressure that such \^'ould be 
Hus . for occasionally there is a high division of the brachial, or a vaa 
s may eiiat, which may compel the surgeon to tie the third part of 

ing from the Flaatar Anh must be conducted on exactly similar lines, 
llnteal, Beiaiie, or Fadlii arteries may be wounded by stabs in the 
Trtaimait — Enlarge the wound in the direction of the fibres of the 
maximus, i.t.. downwards and outwards, and secure the bleeding vessel. 
tteal trunk emerges frem the pelvis at the junction of the middle and 
iirds of a line m>m the posterior superior iliac spine to the great 
ter, the pudtc crosses the ischial spine at the junction of lhe middle 
fer thirds of a line from the posterior superior iliac spine to the tuber 
The sciatic emerges fi-om the pelvis just above and a little enternal to 
rrroot The pudicmayalso be divided in the perineum by a penetrating 
Failing ligature of any of these arteries at the seat of bfeeding, the 
nnk of the internal or common iliac may need to be secured 

Hmnophilift, 

.zmophilia, or the hemorrhagic diathesis, ia meant a congenital or 
try disease characterired by a tendency to peraislent and uncon- 
e bleeding from slight wounds, whether open or subcutaneous. This 
» ia often associated with eKiravasation of blood into the joints, and 

ccmsecutive phenomena. The family history of such a case is 
intereaiiag. the disease being usually transmitted through the femalf^s 

males of a succeeding generation, whilst the former often escape 
' The pathological cause of this affection has not been ascertained, no 
in the vessels or constitution of the blood having yet been discovered, 
hmwirba^ is actual'y occurring, nothing abnormal is noticed, but any 



*34 



A MANUAL OP SURGERY 



iajury ts sure to be fdlowed by cicessive bLeedirtg ; spontaneotu sabcal 
ecchymoses frequeatly occur, as also bLeedicg from the mucous maai 
Hence no operatioos must be undertalien on auch padents unks absoli 
urgent, even auch a small matter as the enlraclion of a tooth having 
iota}. 

The Trutmmit of hemophilia should be directed more to correctiiij 
conalitutional defect than to punuine the usual practice in dealing 
hzmorrhace. The application or admimstrationof hjemoatatics, and subsi 
which tend to promote coagulation and ibe formation of fibrin, ahnild 
resorted to. Calcium chloride, i ounce to \ pint of water, given by 
or a T per cent, solution applied locally^ has beec specially recoannendsl 
late, whilst 6bnQ ferment ajid cocaine have also be«i successfuUy ttD[ 
Position and pressure should be attended to. and in severe cases the acad] 
cautery may be useful, or prolonged cold. 



CHAPTKK IX. 

imtJSB AKD DISEASES OF AETEaiES— ANEDEIflM— 
LIOATOEE or ARTERUIS. 



loJDitefl af Arteries. 

of AA ^ntrr ii. :}ie r^^ult of violence Applied di»c1iy 10 
ftfvtSttlwiiU. Thf: cfTecis produced vary \n it li the »ovehty of 
Aeii^ryuiJ with the previous cuiiditluu of Uit drtciial turned- 

^ i%b| injuries -i^^d dry or eemtv c^ani^r^n^ ma^ h^ ibe 
iHOll; but in DC4^1thy flilGric^ a ^<K>d deal of vioIuiKc i> nccttcd 
Id proibc« such an effecl, a« iheir natural rlfLhiii it> ^n.tlilci^ 
1^ to yield or slip sfiidf, and thiTt lh« remote con^cjiKiic^A 
nusiuilly Jn^ij^Ux^nt. 
llptan or wcvntlott may follo^v more severe blows or sttURs^ 
9i^nitIi^^ wr^knru or disf-asr^ of the arTeml wall predisposing 
ViiE U occBfiionaJly rosultsfrom atlernpislo reduce old-«tAndiRg 
ddoc&tiocis, or to break dov^Ti intrA-artLct:lar adlK^ions whsm the 
)4ecl hJkh beoxDc ^xjcd w ttti Abnomial pi:isilior. If the rupiarc 
^lUUal, Ibt innnr 4nil iniddJf.' co^ts Are UMinlly Icm ihroii|;h, 
■tdby proj«ctijif! into the lumen of the vessel constitute a vah-e 
*bcta preveata tbc passage of hlood, and Icad^ to subsequent 
ttnHDboau and oocmaion. In other ui&ca, wheie tbe iajuiy 
b Ihe cDEita i* *ltgli1. a ihrombu^ may form, which leads to 
flblhaniioo. or, ii the lesioa is hiniled to one side, the dot tntvy 
tworae orc«ni£od over that spot without interfering with the 
brm* ol Uic vewiel. thougli leavitig iii area uf veakne^^ from 
*bth an uwurissn may ^ulisequvntly develop. A|,'ain, when 
fixnplicMeil irzlh a fieptic wound, an ulceriitive form of p«ri- 
Mentis viay eii&uc. givmk; libe tjilct ott t(> secondary ha'ni4^rha^> 
ilBiJ)h> t»i4t«d llttil the auiei co^t in occ;1^iM^^lly torn wuhuni 
njjujy to the turka in:iria, and that an aiieuri^fti may resuh kom 
ibantt] protrusion of iho latter c>>ats through the wound ; Ruch 
uoccnrrcsice must be exceedingly tare- A di:>scctini^ .iiicunmi 
f^ ^(j) may aKn iindrr c«rcairt rimimtitances result from such 




23fi A MANUAL OF SURGERY 

Oampleto Enptnre of an artery may lead to but little luei 
rhage in a severe lacerated wound, such as is produced whi 
limb is torn ofT : the inner and middle coats give way at a hi| 
level than the adventitia, and curl up within it, whilst the g 
coat and sheath contract over them, and thus prevent bleed 
If, however, the artery is ruptured in a subcutaneous injury,i 
as a fracture or dislocation, extensive extravasation often eoi 
constituting the condition badly termed a DUTqm Tmi 
AneuTiBm. The objection to this name lies in the fact that t 
is no true sac wall as in an aneurism, the only boundary 
sisting of an ill-deiined mass, partly coagulum, partly inflammi 
exudation, and in part thickened and infiltrated tissues. A sin 
condition may ensue from a punctured wound dividing a ve 
where the track leading to it is valvular or becomes closec 
clot or some external application. 

Symptoms- — The patient usually feels a snap, as though sf 
thing had given way, accompanied by a sudden pain, localia 
the spot injured, and often shooting down the limb in the hi 
the vessel. These are succeeded by the following phenomi 
(a) Locatfy, the formation of a diffuse, rapidly increasing swd 
the skin over which is at first normal, but soon becomes 
tended and bluish, and finally bright red and cedematous, v 
the tumour is threatening to give way. There is no incrc 
local heat except in the later stages. There is usually dis 
pulsation and some amount of bruit, synchronous with 
heart's action, although these subsequently become less obvi 
(*) Distaliyy diminished sensibility in the limb quickly foU 
together with loss of pulsation in the vessels and a bJ 
temperature. It hangs more or less useless and flaccid, an 
colour it is either somewhat white and blanched, or may bec 
congested and cedematous if the extravasated blood presses i 
the venous trunks, (c) Generally, the constitutional sigffi 
haemorrhage and shock manifest themselves in varying de( 
according to the amount of blood lost and the character d 
violence. 

Results- — (i) The swelling may increase steadily in size i 
continued extravasation, until the skin becomes so distended ; 
rupture or slough, and then, if help is not at hand, the patient 
of haemorrhage. Occasionally the bleeding continues intt 
internal cavity, or into the tissues of a limb, to such an extei 
to cause death without any external loss of blood. (2) Svppur 
may occur from auio-infection, or through the small valve 
wound, accompanied by the general signs of fever. The w 
swelhng becomes red, hot, ccdemalous, and excessively ta 
looking like a large abscess. Rupture and external hsmorr 
will probably conclude the case if surgical assistance cannc 
obtained. (3) The pressure of the extravasated blood upot 
veins or on the arteries needed for the collateral circulation 



WyVRlSS ASD DtSBASES OP artbihes 



'fi 



^HbamoG gjaifitme of Ihc extremity. (4] The process may 
beoone ayott or itA-^fimitti aflci a tirnt: br coagulation occuiricg 
n th« divided mouih of the ves^l. which is thvis occluded, 
C^tCTfil cifCUlntioD miiy he csl-ihl:Khedf And ihixa ihc hoaJtb 

led^ilAlitjr of the hmb Arc nuinUincd, whiljit ttic blood clot b 

L'<4f1w1 or org^rib^ii. 

bl »di^-idod nrtcry ^mmiinicatinj; witii 4n open wound, vi^., 10 
cixdDwii dinti tic liQlh cnd«. To do this, the clrcuLition must be 
rrfotafilf arrc<(lcd by^Ln nl^Litk hxnd, -1 Utv indaiun tnadn. ^nd 
xJ outfiila removed. Tbe blwding poinii aie tlwn «ou((hl for 
indtiea, tbc toiuittquet bdm; if nccc^^ary reta?«d (o allow them 
botvoonie evident. If the distal end ouiriot be found, >t will 
nH be vise to do^t Hit? wound, bul il should lie <iUiffed with 
SiisK^ukd idlowed to ^runulAttf, a lOkurmc^ut't being k^pt looitely 
ikui xht hrab ready to be ti;:hten<;d ul any incincnt, if □ucf>svar>\ 
\^'ljca ^upputuliun is ihiedteiiiu^. the bcuitu plan n\u>i be dduptcJt 
UTT-.trae incision and tying the end<i of th^ vff4*i/'l if thi^y can b^ 
buid; ^^| in caus i\'her«< from (li« o-ditmAtoti^ nrd uitht^AEthy 
lUfe of th« 4urT0Lindinj; p^ris ihi^ is impr^icttcahlci It will be 
QKiUBiiy cithci tu lie iIr- iiirini tfuiik or the cardiac side uf the 
rupmr*, or to tmst tn th# prr-^nn* tif -t ^railiiaifd <-nmprci«H 
If GiJi^T^e 18 mnniinorl or if tJccond^Lfy h^emnrrhaji^c occurg, 
unputitioa iA the only lesouice, 

tawtnttnc Wonodfl »jf Arti^rics. tf completely dividing the 

«u<I, are always followed hy ha^monh^Re^ which^ however, 

Vty be nnulde to e^^capc if the Wl]^]nd in the fkin is small or 

^^uUr> ui if the Ripening is closed by hlood-clot or dressing. 

LrDLtrr ihes« f irninist^nces, the sij^itsdueCdsubnitanenu^mpturf^ 

rJa vw«el wdl be produced. The amount of tbe bleeding in open 

^^ciAd* vane* According to Ihc charDCtcTi direction, and extent of 

Uk ledin, ami with the M/t? of the vessel. If a hir^ artery is 

doaly cut acTota;, the bleeding will l»c tupion*, wlnisi from a 

MnOveiMl k floon oeavet, owinf? to the contraction ^ind retraC' 

ftaiof the coatK. When an artery i» buttonholed — *>.» when a 

HuBirKnuTnt of Ihn wall is cut lliiuu^jh — llie Ljtiijuiilm^e may 

brcontisuous aod proionffed, ^ine? retrr^ctinn cannni t^kr* place. 

Tfaetnatmtot ol tbio condition consii-tf in computing the division 

tf ^ injuied trunk, if it ia a small one, thus allouin^ of con- 

CExaion and retraction, or, if the vessel inof lari^e :^i/e, in ^ecnnng 

bxhends t>y bgature, afl«r dividing ii^ 

UUie wound is in the loni: ^xis ^the vessel, there is but little 
09inc. and c^Kiseijiiently but flight loss of blood; whiht if 
traowvap or obli']ue, tioih ronuaction and reltaclion tend lo 
iacmM Itw Ell* of tht opening, rendering it more ne^irly circidfir, 
ttritberefore the hstmorrbofc in such case^ may be eonsiderabb 

IfiiOisll.An^ iftdi^'ided ckat: to itionipn from akfgc tnaiu 




^ 



A Jtf^NC/HI OFSURGEXr 



trunk, the b1cx>d reftcapcs with a jet, the atrcn^'lb ol vbicb o 
l>iopLJiiKm4l« lo thtr bluud-(iic^»uie in ihe mun txtuik, jux) wl 
tc th/- &if^ of tht* vessel diWd^d. In ifuch i ca«0 Tb« mail 
tniDk mu!it be ii«d above und below tbe woumli and dt^'iled 
between the lif^'uturc^, and the diiitil end of the divkl^d bnad 

In piinctitrvd wotindfi of akrt«nes the size of the penecnti^ 
body IS all iniporlant* A vc6S4il may be tfavurud byt nm^U 
without biL-Jiiorrhft^e or Any »tib*<cqucni ill dToct, but t l^fcci 
piiritlvirf! results in c:xlru<isatiaii> U il ccams after m time, 
Ihv t>lood-clot U absorbed, *n(\ iho wound in th# vmmI <lo«td 
by ft cicfllrijit which mny yield iMcr on to the blood'pn»(iire» 
And t;ivc n« to a c-irc»mw.ribcd ^uicuriwn- TbiR occurrence ijt 
noi rnfrrfiurntly mri with in ih*^ nri^jhlwHirhood of ihr »^i^ 
ii« A result of KliUfi WQund«, invohing the radul or ulnar iruokii. 



Pig 69 —EvriCT* oir Wocitfi>H in A^TBRiAt. WaiL (DiAGMAmt^nCt 

ing, buT not m^ich . (^, nmAll Fnuttver^ inciuaa wcund gnp>*i bwa « i Ht^ 

to rerractkir rjf urTiriiil ninir* 



and hence is rot uncommon arion^ wiDdow -cleaners or vo6x- 
walcr bottlers, 

ATt«rlo-V<tiou« Wound* are not «o rionmonly m«t with in 1^ 
prestrni day as formerly, when venci^cction wft» in vogu6. Thtf 
JolJow pvnctraiin^ wounds which involve an artery and veiA 
Ivint! in t^lostf tonliKt. *.ff„ at thr bend nl the elliort L>FtiAe«3> 
the median ha^iiHc vein ^nd the brachial ivrieiy, in The oecV 
between the internal ju^lar :ind c^jratid* in the |^in betwreo Ihf 
fcinorfll vessels, and occasionally in the ortwl, Two distinct con 
dUions may resnll. 

An AneortAtnaJ Yartx i^ produced by a direct communicatiod 
betwi^ei) '"in ^ti*.j\ :ii)d ;l vi*in, no dilated pusagQ inlccvtiUBf 
between the vcjseU (Fii^s. 70. A .tud 71 U The /enous vvalb, un- 
6ltrd In wjlli^tnrd AHt-ml pr<^?<sure, are by this nieans dilated and 
rendered varico«c. A pulnnting venous tumour is thuA producvd. 




WjVKiBS ASV DtSCASeS OP AHlKRl&S 



m 



\t il'iUuiior o^crdlric for -i ViHiiblc diMnncc -ibcxe and Iwlow 
oMBing, AiiA Ai t^ch tieal iii ihr hr.in a lour] whi/j:rng ooimd 
l'fet>kMl4|49uiic<l by '.iomc; ^luthoti tu that caut^-d by .in mi 
BfUOHKrtlfe bu3:zinK in 3 thin piper hoi;. 




A D 

7a^-lHA«>B*«> or AAftUHiuiJtt. Va^u ash V^Aibuix AHnrnihi* 

I^MkiMt. — As ;i Hilc, nulhiui; is tccjuiictl Wyond ihc nipplitiA- 
^ffjfl ela34ic Ik«(uU^«- or wipporl in pr*- vent fxinh^r t'n!ir((ir- 
*3t Should ;uiy inconvenience rcstili fiom its prnscncc, firm 
P^'ttufc may b« applied over the aricry obovc, dv^ the sae. nnd 







vteBpon IbE vein liclow : and f^iUn^ i1ii«, tbe wboln ttxAss may 
fentnored, Ji^lunno both artery an^ win above and below the 
CMim«fiicAtk». If tbe arter}- can be reached without intcrkr 
i*C vith tbe vdn, U will sviiTice to tic the formci above ani 
boM tbe ilnonnaJ opening. This oirr--ration should nul lie 



240 A MANUAL OF SURGERY 

undertaken in the neck for the carotid - jugular varix 
absolutely essential. In the orbit electrolysis may be used 

advantage, 

A Varlcoae AnanilBm, though brought about by the same 
differs from the above in that an aneurismal sac exists 
the artery and the dilated vein (Fig. 70, B). It is produced 
the vessels are placed at some distance from each other, or 
extravasation of blood has separated them. The aneurism i|] 
the false type, its walls being composed entirely of newly-l 
cicatricial tissue ; it is never very large, but is almost 
to become difTuse. The physical signs are similar to thoM 
aneurismal varix, except that the aneurism can be sai 
detected by palpation^ whilst a soft bruit may be heard ova 
and the distension of the veins is not quite so marked. 

Surgical Treatment is always called for in these cases. If 
aneurism is small, the dilated vein is tied above and below, 
aneurismal sac extirpated, and the artery secured in a 
manner. Simple ligature of the artery above and below 
abnormal communication will sometimes suffice^ allowing 
blood in the sac to coagulate ; the veins will subsequently 
tract considerably, when the arterial blood-pressure is renu 
In the less urgent cases digital pressure to the artery a\ 
the sac is occasionally successful. 

Tnflajnmation of Artetleft. 

\'iirious forms of arteritis, involving all the coats of ihe 
are met with, which are usually named from the cause prod 
them— Traumatic. Infective, or Embolic. The terms E\ 
and Periarteritis are used to distinguish inflammatory condib 
which either start from the tunica intima, or reach the 
from without ; in both cases, however, the middle coat is also 
a rule involved, and the process may even finally spread bejool 
it, so th;tt the whole thickness of the arterial wall is attacked. 

I . Traumatic or Plutic Arteritis arises as the result of sodH 
injury, such as total or partial division of the vessel, laceratkih 
bruising, etc. The phenomena are merely those of repair, reswM- j 
in^ in occlusion of the vessel, viz., congestion of and exudaDS j 
into the vessel waHs from the vasa vasorum, together with jHniito' 
tion of the tunica intima; they have been already described tf 

p. 215' 

1. Infective ArteritlB is a condition in which the arterial WW 

becomes invaded and softened by bacteria. It results mt* 

frequently from inflammation spreading inwards from tta 

exterior (periarteritis), and is seen most commonly in connectka 

with septic wounds and spreading ulceration. The vasa vasoroD 

l>ecome dilated, and exudation of leucocytes occurs, as a resoll 

of the l>acterial in\'iision ; the peptonising power of the toxii** 



'VBiES AtiD DISBASBS OF AitTBRtES j^t 



prtMlucfHl !ca<I* to *ofteainff of tlie vessel wnlU, the fibres 
lose ihrir cc^bcsion wilb tath other. Kni-tny, ihcy m.iy 
e so iaifnired in ihcir TcviitiiiK |H>ncj a^ ;o yi^lil before^ ihc 
iaoi-prvMurr and fauwe IiitmoTThagi?, unless rhrombud^ b;is 
MBVioady waltnl them. In the s^nvillcr artcri«£ Ihi^ is fioiucttmct 
Ifaecttt, but in tha«c Urcf^r Xhan thr milial there is con^^^dcmble 
hifCT of bl^ediiiA;, tijJecidly if ibc iniuuon is tonfineJ Iq one 
•I the veswL SefoniJ.'try hiemorrhij5e from \r9scU tiwl in 
ccnriauiiy )« usually due to IhiFi cuuse. and bkedinL' iiom 
CAt^tioft IS nt^u i;i(!uccd in lliis wavi the; ve^^U ndving 
ibv 5Uppori of \ui]ijuzuiiii^ Iihsue^. ami beiui; murr? oi \v:sa 
AtMi *tf anc;iH«mAl lwfoichan<l. Acut^ absc^ss^* mny erod^ 
Ita ««ll« <)t in artciy in a eimiUr n)%nnor> a^ :i]vu timlj^iv^ni 
ivtaan^ Septic lig.klurc^ m^y proLlncc the mtvig ie»ull5, ^vbilsi 
idiciakctl^r A|:riit smwurm-s rrMrln"* the walls from wUhin, as 
Infrfthr thromln(*i or fmboliis- 

Art^riti^- When a \\-9f^ t^ blockc^d hy n <dnipl(; 

obliicialiitu A5 A resell nf ^ fiimfifc? j>1ji^iic AHi^rUis U ibc 

114*1 |Lx-ftcr^. I5iu if tbr r.mlKiInt ront.imsnme iniuiinp nr 

material, at in a caKc of infective endocarditis or py;cniia, 

r(!tuJt« may foliow. puch ar. an absces?^- or if Che; irnlant i* 

JBtmac, the ;fnicc3a nuy ?(top &]iuit of suppuralimi. and yet 

Mnnt-im envnes from dilalatiozi of the soltcnctl waJL "llie 

process U Ihe movt common cauKe of sfottiajinut xacuiism 

Arat« Eodj&iteritla b uiei uilli tuihet a^ a |T;3th(ili]j!jiuiI 

t), iliaTi aih a <:onilition of any clinical import. It i* usually 

l«d with acivtt- pnilocarditis, tiowcvrr produced* or may 

ij ftomc of tlcc clironic forms de?icnbecl below. It » 

hy Ihc pir^uce on tbe inner a.^ix^Lt uf ttie ve?istl of 

l«M riised pAtchM, som^uhai piiiki>ih and f^elatinous 

inco, H?k »nd elastic in coiibt^IcEicy, and ;dthoii^h Eho 

Ic4tb the ciLdotbelitini i^ tisiially intact- It ts found in 

««ia, or hi sniflllfr vessels, especiiilly iinr intliTned wounds. 

. Chrome BitdAit«nU0 is an cxce«dingly common afl«ction. 

j^ |->Jlo^^ini; forms mny be dcstrilicd : 

if1« CIuoqIc Endaitei^Ua, ii-suhuiU hi Ath«ioiu«^ Thi» 

\\ < fjn^Tanc ly iVninil in i*ldrrly prnjilr, bur rijifTially 

and tJiotc who h*-ivo suffrTt'd from dironTc HdKht'ft 

fOUl. or typbitii ; or it may arir^: from coiitinvLil strain, 

bmce It \\ uKU'Jly pic.«<ni in tbr yjv-Ai cotwcxiiy of the aoitic 

Vit the spoc where the impart! of the blrMwl-^iircarn i*t most felt 

ti «;v<ted from the ventricle, or id places nheie the vessnl* 

rr or around some liony projection, or at tim bifurcation 

lin aitriy. nr where a Irirge l>iarH:b is tivcw off. thus 

a mdik-n d^trea^c in itv lumeD> It Is mrpfy fmind in i!io 

arteHM. except thono oi the heart or br^tn. 

ncftMtgic^ pbeoomcaa observed are al firai an inftltration 

lb 



u^ 



A MANUAL OF SURGERY 



of ihe deeper parts of the lunica Intima with round 
(Fig. 72. e), which may or^ani^e into fibroid tissue, or mayi 
together and underi^o degeneration (/and/^). These patches] 
arranged longitudinally or around the mouths of large hr; 
The tunica media i^ more or less involved in the process, 
the adventitia is often thickened externally. The patches I 
like pale yellowish spots, somewhat elevated from the b 
surface, and irregular in outline ; they are small at first, 
increase in size, and coalesce one with another. In the « 
stages the vessel wall seems thicker and tougher than usual. 




- A 



Fi(i. 72 —Section of Atukkom^tous Cehebral Artehv. ( w 50 ) {/.iehiMM^ 

a. Intima con^ii^trrahlv chickened^ 0, bounding elaatic lamdlA of ind 
f, media , tl. :idv«niilia , -'. ntcroaed denucleated tissue with mosMS ol ' 



detritus, f, and /,, dtiritus ^*iih cholestrrine tablets , jf, intimAinfil 
with lpi]crx:yltrs ; A, infiltr^ticm of adventitia with leucocyle<<. 

later on it becomes weaker and tends to stretch. Fatty d 
lion of the newly-formed cells results in the exudation 1 
fluid or cheesy, constituting the so-called ' atheromatous a 
ahhough no true pus exists, the pultaceous material con 
within consisting: of fatly tiraniiles and debris, with oil 
and plates of chok'slLTinf (Fi;;. 72, /j)- It may lie 
entirely, ^eavin^ a weakened spot in the wall of the v 
from which an aneurism mny arise : or the tunica intima 104 
give way over it, allowing iUt: cuntents to be swept into tbi 




tHJUUlBS AUD WSBASES OF .UtTEHSUS 



3-*J 



jii'iilatlon. wb«r« Ir prohahly <}o«« no barm, and ih« ratv 

l*fl behjJid is known as »n ' jit'irrozn;itoii<f ulcer.* The 

Lt kbs by this lime beconK ^ufiidcntty thick to resist (be 

UnQd-pmsure, and bene* no immeduiitf ill result follows tlir 

tnack ic lbs it»»«r cofti*, jilthoii^h siibseqtwntly dilatation mav 

ttkft ikkKc, ^vcfi thotij^ cicAtrifiiticr) of th« nicer hn« occurrcd- 

-Sobi the btood mav ^nd its wa>' tlircuj^b the opening into the 

nhsoacc oE ihfT w;ill iml sirip ii|i ilir irtmr fn^ni ihr outrr UyrrK, 

<msi]taHiig a *dieADciiDg anftunsin ; <3T a localUnd ihramho^U 

vttT U Mtfmiocdt Cflusine ocduuon o£ ihc vcs^^cl 

!Ai4 «Koninv>ii1> ihc chc*>y cootci^ls of ihu i^bsic^^ ifcic more 
a aaii4f««AaiH!« >iiTd Uirr on infihtairri vtirh lim*? !ftili\, fKSvilN 








JA t^ lutmaikiin of caJirdir-mi^ pl4le%, ulni;li arc elllicr covered 
ffldoih^Utim, or ^xpoted to tTi^r blo^KJ-strpAtn, ;ind hciic« 
■tber cause UtromlKMis or may becotne dfriachcd and con- 
ui cndulu&i or ihr Utxid iTi;iy get in under the plate 'Mt^ 
fcfs] a ififtectiftg amrurtMii. 

k roodilion of vnduneriii^ rvi[^en<vd by prolifrriitHDi of llic 

<uia intiiat ifi always mot wiUi in chionically intL-tiTK-d iiusties, 

41 «1m la dubEtci) , su4,h ;li"."S nut, litiwevcr, nin on I" .itbcrorna. 

(i) Cknttlc SjrphttlUc EmUrtumifi U oiiimioiil^ u^cl v^ith in 

rente m tlw \mt%M*ty sla|([c of llio diw-iien and is rbjiJ-Llcr^-ted 
n ovcterowih of tbc tunkA inti^na (1-ib» 73 **)» which is 

16— a 



S44 



A MANUAL OF SURGERY 



morn 



usually limited by Henle's elastic lamiua. (£), but is soi 
associated with infittTation of the media {c), and much 
of the adventitia (d). The change occurs in the smaller 
especially those of the brain or kidneys, or in the neighl 
of gummatat and but rarely in the larger vessels, altl 
considerable percentage of those affected with internal 
have suffered from syphilis. It differs from simple at] 
the greater amount of Che cell proliferation present, and in 
tendency to contraction of the arterial wall, with occlusion 
the vessel, rather than 'to weakening and dilatation^ \M 
involving the cerebral arteries, various forms of monoplegiit' 
even hemiplegia, may result. 

(c) It IS still more or less an open question whether ite 
called Endarteritis obllter&iu or prollfetuu is truly syphilitic 
not. in some cases a syphilitic history has been present, hi 
other marked instances it has been entirely absent. The arti 
become gradually obliterated in persons apparently sound 
health, and as a result the peripheral parts be^me either an: 
and waxy, or congested, and even gangrenous. The 
intima is converted into a thickened and vascular mass, 
narrows and finally occludes the lumen. The process is 
associated with considerable local pain. 

(d) Chronic Tubercnl&T EndarteritU is met with as a 
tioti of the tunica intima, with or without thickening of 
advcntitia, in all places in which tubercle is actively dev< 
in fact» tubercles are usually formed in connection wil 
smaller arterioles, which can be readily demonstrated in tk 
maler, and as the mass grows the vessel is slowly occludad 
replaced by the typical anatomical structure of the 
tubercle. The tubercular endarteritis may, however, 
widely beyond the focus of the mischief, and in almost 
portion of pulpy fjranulation tissue this change can be seen. 

The vessels may also be attacked by tubercular processes faJ * 
without, and if caseation is present, the walls may be ercdn^ 
ami tubercular material thus find an entrance into tlie circulaHo"^ 
causing emliolic obstruction and tuliercular disease elsewhere. 



vhi 



Degeneration of ArteriM. 

Fatly Degeneration uLiy occur independently of atht 
involving merely the tunica intima, and manitestinf itsdf jlj 
small patches, yellowish in colour and stellate in snape, 
a rule, it is of but little s-^-nificance ; but occasionally the b 
tration is deeper, and the tunica intima gives way, causing tW 
so-called fnff)' fiosion, und then an aneurism, possibly of ita' 
dissecting; type, may arise. The most usual seat of this trouUi^ 
is the aorta, 

OAlcarenuH Defeneration (I^^ig^ 74) is chiefly met with as ■ 



INJURIES AND DISEASES OF ARTERIES MS 

lary phenomenon in the smaller arteries of the extremities, 

ccurs in elderly people at the same time of Ufe as the calcifi- 
m of c^irtilages, etc., and commences by the deposit of lime 
i in the muscular fibres of the tunica mediat tending to form 
ueous rings which transform the elastic expansile vessels 
r^d tubes like gas-pipes, through which a minimal supply 
lood can alone pass, the amount of which cannot be regulated 
1 a healthy artery. 




Ftn 74— Rigid Calcaaeooe Aktkriks. (Fhom Collbgk of 
StJnGcoNs' Museum.) 

The limb in consequence passes into a condition of chronic 
tmia and impaired nutritbn, resulting in coldness of the 
t or bands, cramps and spasms of muscles, sensations of pins 
] needles, etc. The endothelium is not removed except in 
: later stages, and then thrombosis may be produced, or a 
tilar result may arise from the lodgment of an embolus from 
>ve. Senile gangrene is a not uncommon termination of such 
dial changes. From the general rigidity of the vessel, and 
method of deposit of the lime-salts, it follows that aneurism 
tot commonly produced, and in fact spontaneous aneurism of 



146 A MANUAL OF SURGERY 



the \e5se!s insolved by this form of degeneration Js amongi 
rarities of surgery. 

Amyloid Desenenitioii of the viscera commences in the 

walls, but is descritted elsewhere (p. 46). 

The Effects of Arterl&l Infiammation uid D«guiantioii an 

local and peripheral. Locally, TbromboBij is likely to occur 
ever the lining endothelium is removed and a raw surface 
upon which fibrin can collect. Under this fibrinous 
repair is often accomplished without further complication; 
the blood-stream is retarded, or the lumen of the tube 
complete thrombosis is likety to follow^ the clot extending 
distance up or down the vessel, or even from a branch into 
main trunk, which may be occluded by this means. 
is also a result of any weakening of the arterial tunics, 
tion of the artery may follow, both as a result of thrombose,: 
from excessive proliferation of the tunica intima (as in 
or tul:«rciilar disease), or from gradually increasing pressure 
without. Lastly, Spontaneous BuptnTO is another local 
occasionally met with. 

Peripheratly, defective blood -supply and consequent 
Titality are the most marked results of arterial disease,]' 
to various forms of ulceration and gangrene. Thus, senik 
grene results from calcareous changes in the arteries, fctty< 
generation of the heart may follow atheromatous changes b 
coronary arteries, whilst softening of the brain may ensue 
various affections of the cerebral vessels. Similar results 
also arise from emboli detached from areas of local disease. 



Anenrism. 

Xtv Aneurism is a tumour filled with blood communicating 
the interi(>r of an artery, and due to dilatation of part Ot 
whole of the vess<?} walls. 

Cansos. — Aneurisms have been divided into two great cliSsrt 
viz., the spontaneuus and the traumatic, and a necessary disW 
tion hits been made between them on account of the factthili 
the former the coats of the artery are primarily diseased, whcrti 
in the latter they m^iy be previously healthy. However, it tnol 
not be forgotten that persons with diseased arteries arejast* 
liable to injury, and even more so, than those with healthy vesBi^ 
and Ihus no strict line of separation can be drawn between tfcl 
two forms. The causes of aneurism may be conveniently groo|* 
under two headin^js : 

K OhAngeB in the VoBsel WftUs, by which their resistance > 
the intravascular pressure is diminished. Many forms of iitf* 
whether starting from uithin or without, predispose to aneuri^^ 
dilatation, such as atheroma, or thuse changes due to syphiliso 



AJtEVtaSX 



'AT 



Itoat, CApeciAlly if occumnj^ in m^n about middle Lift* [Miirty lo- 

mly year:; ol ajccJ. in mKohl nlthouifh Lhc artcrt&l Cunics Timy he 

^cjJkcacd. the powci; of ibc hc^it ^uid ihc Jcsulliiiy blouU' pressure' 

b b^ tK^ mraim dimirikhrd. C^lnfirAEinn, cin rhp ot^ier banti. U 

■oaUtic to AncuriKnul diinifltirsn. Aay form of injury, either 

difcci l>Jon', fi pcncUatinK vround, or n wvcit ^trflin, may su 

pBierJm: hHIi ibc iiiletE^ty i>f ihr v'-i^a^mjI^if rii:ii>^ ^^ lit ri'Siilt in 

nxnaixi, Jind, indeed, nny dc^ttriv invnivin^* an ^rlrn;iE wnll 

Mit be looked on as i weak spot predisposing to d]lat;itir>Ti. 

Tbc lo4fiinei»t of an m^^/w in the Mnnllcr nrturics is MfLtc:d to be 

■ tt dne most common taiif^^ of ihc sivivUmpnns i1il;anlicin at 

ihts« MMueb, e«pe<ulty in Itic brain and cxtrtmilie^ of 3roun|f 

I' bcnate in the Blood-PKWure is smother essential to the 
ijrnu£i:n] cif jui-uri.iina, ^iiil ilie iiio>t ci imiMfm nrigin of thifi i^ 
l^vy ifniM or 'jr/rf nM, which Iv^U I'* irr«|-ala.r excitement and 
m amsM Adioa o( the h<ur(. btc.nily l;»Lioricjub t'mployment, such 
■# A fccv oinoni^M aitiians aiiiJ iiimrb^inics or cc^uUr cxercude. 
iloKBOt appear to paitiadnrly pfrdisjposf^ lo (his coitdiiitui : but 
im^abT bii«rmituctt efforts, irt \t'hicii foi Ibt? limd being «very 
|«*(f is »trainc>d to ii«( utmost, are very liubTc 1o dcEcmiinc it» 
ocont&ct. A iLiyS eAcrtiuu iji lIk- buiulit^- oi ^Iiouliu^ field by 
« rUvly m^n, jtrcutiiomrd ifk t^drnMrj-orriipfllinns^Uvery likely 
V produce 80cne &«rii>t>A vm^uL'^r LcrEion, tiich ac aneurism, 
*pc^iluii, etc. Hcn<c j^ncuriwiis nic more? frequently seen 
iDaac>< ir^en than In women, in ibr pn^pfirticm of seven to 
Wic; wh:l*it th*'y at^ triich nior*- rommon iinong the dwellers 
■ X-yibcrn cliniAtc^ tb.'in in tlie more l>.^th^irt,'ic and oftse-loving 
i^kfthiunt^of the Soiiih. The cncc^o" -^^'•^ Activiiy of the Anglo- 
Sum rncT rtfieciaUy pie^litpo'ir ihrm to thi»H disease. 

Itnetiiit uid Fonofttloa of ftn Anfttmsm. — Gteit importance 
kto btro Uid upi:iin the wny in ivhich 4in anounsm ariscii, and ti^ 
b«brlbrT or not the dilTerent coal^ of the \cs5c] oic represented 
biu«:illt; but ihp m:4itcr is tr^illy of liiile mtmieni coinpAii^d 
«h Ibe tux and ^apc of the tumDur. Somehtnes it arises from 
tte jiddin£ of the heallhv en d;t>e--;?icd waJI:*, whilst sometimes 
boc ia m Icaioa ot io» of tKe tunica udvrntili;i : mid, a^ab. other 
mn cotmnencc by :i remtj^-^d of Ihe tiinir^k iniiiriji or p^rl of tlii* 
tbc^u. J-'onnerly much £.tre^^ wag placed on tho lerm^frH/ imii 
^Si^u-T as Applied to aneurisms, the tenu * true ' meanloj^' that aH the 
ccBia of tin? vo^l vtrie pc e sett [. whilst Lhi? ^ false ' weic thusc in 
wbkft Ih* «ic wall compri*!**!.! linle or none of the original nrrerbl 
tmoc&^ Ihtts distinction is of comprtrati\cl^ bltb^ value, since no 
OBwant which las Attaiocd to any ^i/c is in rc^litvlritc^ The sac 
caoonu taan or lese evidently <>f ;t diMrnsion of /ill ur p.-irt of the 
onpiut waQs of th» v««fi«l whilst ii is ^m^U ; but a< thr nneiirivm 
botvfts. the orif^uul elruciure \f- lo^C »it?hi cf. and, indeed, a rt- 
pUcni by 4 I1WS& of ncwiy'formed fibiouA tissue, due to jl con< 



14S ^ MANUAL OF SUItGERY 

d^Dsation and matting t(^cther of the surTounding 

with or without an internal luiing of laminated tibnn depoated' 
c^rts where the endothetium of the turcica mtima has disa] 
The cont^ls of the sac vary according to the age and size 
aneurism. Whilst still small and with a complete em' 
lining, it merely contains fluid blood, the amount of which 
with each beat of the heart ; but as the tumour grows, the 
or part of Ihe interior becomes lined with a depoMt of fibrin, 
which^ again, other layers form, until possibly in rare cases 
whole cavity is occluded, and a spontaneous cure results- 
oldesl laminae lie next to the sac uall, and are dry and ye\ 
white in coloui* (the so-called a£tivt clot of Broca) \ those 
recently deposited are softer and more reddish, whilst that 
formed is merely like ordinary blood coagulum (the/fliiiiw fW' 
Broca}. No single lamina covers the whole area, but they 
arranged layer over layer in such a manner that the oldest, 
necessarily the smallest laminae are most external. 

Three chief vorletiM of aneurism have been described: 
fusiform, sacculated^ and dissecting. 

I. The Fiuiforiii Anenriflm (Fig. 75, A) is one in which the wl 
lumen of the vessel is more or less equally expanded, so thattfci 
swelling is tubular in character. It is due rather to a getKi^ 
increase of blood- pressure, or to a widely extended disease tJ thl 
arterial waHs, than to any localized lesion or injury, and heoceil 
more commonly met with in the larger internal vessels thanil 
those of the extrfiiiilies. When it does occur in the latter sin» 
tion, it gives the case a much more serious aspect. Not onlyil 
the vessel dilaied. but ihe lube is elongated, and considmhji 
structural chanf^ts are present in the walls. The tunica intimii 
usually represented throughout the whole extent of the sac, boti 
thickened and atheromatous in patches, the margins and surface 
of calcareous plates being indicated by flocculi of fibrin, whid 
are attached to them, although no regular laminated depoa 
is present. The tunica media is stretched, atrophied, w 
practically absent, whilst the adventitia is much thicketwd b 
inflammatory new formation, and by incorporation with the sn 
rounding tissues. The progress of fusiform aneurisms is geoenfl 
slow, so that in some situations, t.g.^ the thorax, they may atW 
enormous dimensions, ami cause grave symptoms by tta 
pressure. A natural cure is almost impossible, and hence, 
unchecked by treatment, a fatal termination may be caused l 
rupture or by implication of important neighbouring structun 
F'requenlly some portion of the aneurismal wall yields mO 
than another, and thus to the fusiform swelling is superadded 
l(x:alized sacculation, which by its rapid increase in size nu 
quickly destroy lift-. 

2, A Sacculated Aneurism (Fi^' 75i BJ is due to the yielding 
some weak sptit in the vessel wall which does not involve t 



ANEURISM 



2(9 



!e circumference, or, as just mentioned, it may spring from a 
orm aneurism. It communicates with the interior of the 
y by an op>enmg of variable size. All traumatic aneurisms 
of this type, whether they are due to the yielding of a 
riv, or to the partial division of the coats of the vessel^ and 
t they are most commonly met with in those of the ex- 
ities. It is possible that in some specimens all the original 
liar tunics may be present, but such an occurrence must be 
mely rare. Generally one can trace the inner and middle 
to the mouth of the saccule, and there they are suddenly 
the wall being constituted by a mass of hbro -cicatricial 
*j upon which laminated (ibrin readily forms, thus increasing 






A B C 

■K.. 75 —Dl AG VANS OF Fu-ilFOHM, SACCULATED. AND DiriSECTING 

Aneurisms. 

r fin* ihe wraJls are eipanded. bul mote or lew normal in texture , in the 
■ccBlated. the normal structure of the arterial wall ceases ahraptl)r at the 
Hnmencemenl of ihe saccule ; in the disaectingn ihe arierial wall is split 
ito (wo lamellz. 



liickness and power of resistance. Their progress is, how- 
much more rapid than that of the fusiform, and they 
rally rupture or become difhise, although occasionally a 
ral cure results. The blood, as it enters the sac, impinges 
ist the wall furthest removed from the heart, and ihence 
rs bade in circles, coagulation being thereby favoured owing 
e retardation of the blood-stream. 

A DlMUflliig Aaahtuhi (Fig. 75, C) is one in which the blood 
sa cavity within the wall of the vessel by stripping up the 
" from the outer half^ the line of cleavage being \vithin the 
He coat, half going with the adventitia, half with the intima. 



ISO 



A .StASUAL OF SVtiGHRY 




As a rule, it » the result of extensively difTuMKl ntberoaiA wl^H 
hits weAkcdcd ihc Miucuirc of the lunicA media. « tha( &houM 
i>nt-p the hlooil fini nn nur*nrr ihmuffh an iihi-ruinalcAib ultcJ 
mto tbis^ Irtyet, it U oxieII^ able to Ecmrnttr tlio inner fron^ tlv 
outer hnif. U if^ it^unlly mel with in the Arch c( the uorla^ The 
blood thu^ ilrivrn into a. cul'dc-%,-ic m^iy rt;nuin limited to tki 
cax-iiy for some lime, f)t it may find it* wiiy oLiEward^ tlminiri 
th» ;iilvcmiti;»» flnd liocomc ultimately diflased extemAlJjt * ^ 
may fi.nd it» ^vay hiicic thrtjujjh another alhcronialou* spot aAs> 
the iiilfMiir Vi\ ihr VF?urL Thr c'tindilioti c^EiiioL he rcco|piaed 

Syznptomfl and Si^cna of ^ CiroumBorilwd Aneuriam.-Thcficmay 
l)L diviLJc^d jnLo \\\\j i^ri^mps ; tlic^ inUiuaic and cxtrm»ic. 

Intrinilc filgns. — A Umnnir in piestnt Itj thr courwi of a irasrl. 
"'h)rh pul^(t& synchroiiOdSty Willi itw h«riirt"s1ifrat. Th* ptil«|]on» 
aru diMonsilc t»i uxpfinsilo m chiitiictLT, r.f., Ihe wbole twiMa' 
incrca^cH in i^£e at catli syMuk' of the h^^TU And that evenly 
in ^W dir^ritons ^^ ihfit if the lumonr i^i h^hily ^a^jird in any 
position thft fingerii are Mparated. If the suppiyinj v^?«*l i* 
comprc^dcd on the proMimAl side, the puUntiob center, and tbe 
tumour dimlnibhcs in ^\tc *ind boconiC8 fofter, Thb u mor^ 
markr^rl in fusiform than in aflcctilarcd iinenfi*m-t_ Ttw ap|>IiLji- 
tion of pri^^um to tho mc itnc^lf nhiliit the aflefrcnt trunk i* 
comprcucd al»ovc will still further diminish it* wa:. On removing 
iht? pn-ssurej the swelling legttins its old dimcnwon* in a certain 
dpliniip niimher of beats, usually not more than tu'o or three. 
frc^H'Ltiic on thi^ distal side of the »ac mcLkcii it more tentse and 
the pulsklioii more niArkcdi tm1r%^ such t:t>mpre!V(ion xi very 
prulonKrd. C>n ausmUntiiij?; iht-. luinnur. a hrnil of v^uiablc 
character may h& heard. Usually it ia loud, hartli, and tystolk, 
but somebmo^ iiuiet and nms-icah It is occnsnoncdly douUe a 
»>me fmtn^ of utcculaLed aneuri»m. and in the 4orta wheat 
regurgiLacion ilinni^h lh<^ aurtic valve*; i* iUho pfeseitl^ The 
l>ruit IS i<jude!it and mo«l r:Lsp]nf; in the fusiform v;irieiy. Ui<i 
miiv bi? al>9ent \n Ihir luiccul^ted form, where the moalh \it ftmill 
aiiii the L»\ity nenity full of lIoL Great dUleii^ion of the MCtt 
unfavoiirahlp to tht prodnftion of ihe \ww\\. 

T^ie Eztiliuto Signs of ai^euriem are thos« occurring tn tm^- 
liounnj; oi dbul Mructitre;^ from its coiiAtanlly Icicrcasuic AM 
and pTMHuro, ^nid the i[UL-rrcience pfoduc«d hv it witn the 
circulation. The pHl&t in ih« vessels btl^f^ is diminished and 
delayed, being smaller than in healthy conditions, pcully from lh« 
ol^sitruclion experienced, but also in some casc» mm the pressure 
uf the n;ic L]|3on the trunk alH>ve or 1>elow the tumour' Tlie 
dicrotic notch Xi. usually absent. The «mallcT vosmU ongued in 
eslablitdnn^ coli:iter-tl cuculotton may Ik; comprc^aMd, and tbut 
the vitality of the limb con.iidetably imp^ured. Prc^^iufc on the 
accompany ins >'^ii> *^ '^■'^^ te^ulls in dicninmion m their calitae. 




ANEURISM 



■51 



awt ccdefna di«t;)lly, whijsi jj^jn^^rctte may be llie fin.^l oiilcomc 

i Uc CAflc is lurt frlficicnlly UCATcd, Conipicssloi; of ntrvu occa- 

«toi aci;T,ilt£u. t>pns[ii, ;inc1 p^rAlysi^i. MnuUs arc liijiplAceci, 

nTondn], and -ittrntwtrri : Aflh/t mny Iw eroded, an pvidp-nccd by 

J ikvpn <o(i£t.'Lnl iMnriL: pnm, anrl ovon ApontnrteouA frkcCMtc 

df ensue ; tthil-il jeinii ^rc cncTi>Achcd upon nrid di^^iir^nni/ccl. 

?m, «)rh i4^ !lw ir^rhr^ or irt^iph^RUS, ^fc i>ftrn injnn(Hi-"*ly 

I r,(Mnct«l and laid open by ulceration. It is an iT^wrcsting tict 

L ''i sou that reisil^n^ tisMic^, such n.t Ijooc, afc miich more likely 

K k be eroded than ore d.i^lic. yielding Mnic(urc^> such an car- 

V lilCe:, UhI in t:;l?^p^ H-bcit ihe vrrlrrhviil (iiliinici iii enctrmtliiril 

t^OB by an abdominal or thoracic ancurnsm, the bones always 

iVjfiM prettier dcwruciivc chan^^cs than the mvertebrni disca* 

T^r iDai^>7d djtfttully in propelling the bluud Ehtout'b the 
iKinuAlly inducr:d coMairi ;irni)iiiil oi compt^n^ilr^ry hy]>Frcirjphy 
ttxhit k^rt, Occ:a«fonJil]y /irf'^ft <:on!;istinj; erf fra^mvni^ of 
bvitled fibnn may boctinii^ delAched. nnct eitht^r li;j^d to a 
t^cntUttKMi cuic, ui l[> i^dii^ceiit? uf ibe piiils siippli«d bj the 
w»«3, « lo d»ith of Th^ indiii'id^iflt if iht^ br.'iin 11 involved. 
Ott^m* nuy aj£i> ba mduc^d ae :i r^i^uh ui tli« diminithrd 
n Um tapply I0 peripheral parl», c^ptrcially if ^s^<xi'ltcd wiiZi 
H fitnCtfciKJc with the vcrous reiuin. Il h usually of lEir dry lypr 
" i flvdvtng nicnrly cme or two lingers or toes ; bi« when aliark- 
e^ntxv oWhy partSi or if due 10 vonoitb con^c^tion. it become.^ 

T^r DiJhrtntlAl DiAgnoAtft of a cirr-tim«^rTb4>d Aneun'sm is ncit 

Aftoill, at A ntl«, if tlue wciighl it j^vjin lu the .ihcvc tymptomt 

ud^^ns, but tbc ioHo^inj^' runditi-in!^ in.'iv simulate 11 ^imcwhat 

doady ; 1, A f*fwciw# or ^krvnt\: a/titta siiuAiri] near .in Artery, and 

Mmg /mHimifr/i f'uiuttwB frum ii, is r*-coKi"sed by tlie imiKiUt? 

Mi^ meirdy beavinif in chnr.icleT. and not expansiJe: by th« 

imlBbon cnuiiif: entirely ii the tumour is hficd learn the vessel. 

tt ilvwed to fill} aA'.iy fruin it by ;is^ikt7iinK a ^uJt;d>le pijMtion ; 

vf the uxe of 111? tiimouT nnt dimininhini; ii ihfr piil<uifion is 

iteppid by preAAun^ on th« vessel above ; and by thu fact that 

*far UoppAc:^ of the pulwitioa the ftrst beat is et^uail to ihc *«!'- 

Kqncal unc^ wbcfiira? lu an ^neuri^iLi il aliiiuai ^ilwav^ ii;i|uirr?> 

moir than oop Iwat ro re-e*itahli*.b the streiifpb *nd forrp of Jh^ 

iiDfHilte. Moreover, the pulM^ boJow is not affeclod in the lume 

■ "ay cr to tbc *uinic cxicnt n^ v>hcn nn ;inc^iri»m is prcscnt- 

I X KHhatm^ Mrtomu 01 na-fus tv kncn^n by iK-in^f r^irly limited 

HCOKtly to the lin*^ of the artery, pnlsalinn beinj; pre«m in sitiia- 

Htbo* where an AnciiT\tma\ dtblalion c^ouid noi b& felt, .ind bcmi^ 

n \ea$ forcible and rrciiliir in lit. character. The ccjnsislcncy of the 

•»dliii|> H iiior«? vatiablff. and prrssnrc over the afieii-ni Uunk 

ikxt 101 dimtaiih its si:(c to any marked extent. Moreover. ^ 

ttwoott is usually inorc adherent to tbc deeper utructute^, and 




9p A MAliVAL OF SURGERY 

its limits are not so accurately defined* 3- The pain cam 
by an aneurism may cause it to be mistaken for riutimatim 
neuralgia {t.g., for sciatica in popliteal aneurism), and in evcty 
case of obstinate pain of this kind the arteries should always lit 
carefully examined with the intention of eliminating such 
possible cause of the trouble. 

natural Tennin&tloiu and BmoIU. — 1 . Spcatanaou 
though o£ unusual occurrence, may arise from a variety of ciro*' 
stances, and is a well recognised phenomenon. It is only 
with in sacculated aneurisms, (a) It may be due to the 
deposit of fibrin within the sac, which not only limits the ei- 
pansion and extension of the aneurism, but may actually incnM 
to such an extent as to cause obliteration of its cavity. Sucfaf 
termination can only occur in sacculated aneurisms vritb sottl' 
mouths^ and that mainly in vessels of the second magrutud^ 
hardly ever in the aorta or larger trunks, the impetus of tbt 
blood stream being too great to permit of the necessary deposit of 
fibrin, (ft) It may arise as the result of the sudden coagulatioo of 
all the blood in the sac from the stoppage of the circulation, ora| 
to the lodgment of an embolus either at the mouth of 1^ 
aneurism or in the distal part of the trunk- {c) Again, if the Pt 
becomes inflamed, consolidation may result with or witbotf 
suppuration, although the latter process, as will be seen aikOOiil , 
attended with serious danger to life and limb, {d) Finall^i t 
sacculated aneurism may become so large as to compress tbs 
main vessel, either going to or coming from it, and thus hria( 
about its own cure- In the non- inflammatory conditions the stf 
becomes more and more firm, the pulsation less forcible aod H 
distinct, the bruit diminishes, and finally consolidation is effected, 
a firm fibroid tumour alone remaining, which gradually ^riuk^ 
whilst the collateral circulation is opened up so as to supply tte 
iimb below. 

It is by no means always easy to rec<^nise the fibroid ma* 
resulting from the spontaneous consolidation of an aneurism, wA 
to effect a diagnosis the history has mainly to be depended oik 
The existence of a tumour in the line of an artery, the probabb 
occlusion of the main trunk, and the fact that the circuJarion a 
carried on by means of collateral branches, are the chief points 
which can be ascertained by a physical examination. 

2. DiffiuioD and Enpture result from yielding of the walls oi< 
sacculated aneurism, perliiLps as an outcome of some mechanic^] 
injury^ or in the case of internal aneurisms from simple over- 
distension. 

When an internal aneurism suddenly gives way, the palienl 
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 th* 
mou(h if the trachea or ccsophagus has been opened. Sometimes, 



ASEUaiSM 



ail 






iMPMttf IftUnaJ aiievTi;sm» leak alowly, and tbe final tEtagv U«t» 

Wlmi an ffxlnnal aiiruTisrT> yields, it may do so •iltnKly or 
']uddy U ibtf blood btMroiues elfus^d itf^ty (constiiutrng wliut is 
npHuiies callwl a trahft-^ fVKMnmjt tbe tumour p-riKludlly 
■asuca lA 3i£o, And iu uutlinc becomes les9 dearly Imut^-d ; tht* 
pdatioa dvimiuiiihtfs In force iuid (lisiinrTrirss, and il)c sii^ns of 
fMAttf* upOD ih« veEt)4 or oervt^ b^ome more ur<g«i]i, until, 
piAipSh CanfTCDG »upcrvcfic^ or After ^ time the prDCcM may 
ouc^ ksd even u bp^dUucuu^ cure iirsult. If ll»; Anciirisai 
•'Vfnn^ tatdd^y, ihi* fanj^fir pv^ivnrrs wvprf pain in tho part, 
lid) liKoniss tonfte, :>woJ]«n, »nd l^rawry; ^LI puk^tion cca^t 
tatt in tbc ADcumm And below it, ?Lnd jfAngrrnc of the limb 
tLfCfirudi or cvm iWth from ^yiKxipt-. Jtrivici^ frnin tlif? nxiiotiiU 
il biMd extrJV-iKHlPri, cither cxtrmnTly if thn skin jjivc* u-ay. or 
Mitt the tissues and tinder the fAsci,-*-^ Suppur^tioa mux- also 
KCir in Ibc^bc aucs^ the vkin licnnminK red und mtTaBtied, 
ud l^lly rxtKiTi;i1 mpnjrp mny f"llnw. The (e4.-iiKri]tiiin i>f 
01K aneureuiw H by no insane timpLe, tipecially wht^n Iht^y 
t««K lalhinectt and the mor.t careful nltention to the hisloiy 
ndloibt fact> to be nuclc out by di^pul c^amiuaLioi; can alone 
irtftniiir lb(* nLiIvtre iff Ihe c:lv. 

3' Bq^OAtioii of the \ac is :in exce^dinyly serlou*. bu< by no 
ittfa a common, compiicalion oi aneuritim- It mny anse in 
Icblmnic «i*>'»- i^) Aftf^r iitc-ituie of the main \c*?tl ^ibovw, 
e^itijlly u'hrf] the uoimd bpLfJine* Hepiic. antl thtr^ iw A 
pud de^bl ol Joo*H« celLubr ti^^ue around the ^c, as lo the 
iiULi f{i| ,ifici d:ffusii>n, paniid or complete, of an uiicunsTii, 
*Wc it;e cuviiy n GUed ivilL ckit, ajid there i» |;!ieai pie^MLrc 
tal tnitirfii upon snf round in^ parts, AiitF> inflection nr tlie 
pfc^ncv ;)l^ An infective cnibolus may linally determine the eup- 
purili^c prc<t::S5. The tumour ^tiow^ «i^n« of tnfia mi nation, 
W( hin. red, puinfub and swoUnif and the skin over it m-ay pil 
(H pfKturt ; vhihl fever and general cniistiliiticmal di*tiirb.ince 
vt ako pfceoDl- Sooner or htur, if loft to iit^lf, ibc tumour 
poinb at ooe spot aitd buisi!^, t^iimc exit to a mixtLLre of blood 
dut. ptt^ and a fearer or lr« ^iniounr af bripht red IjIimmU Tbt? 
pliiFnt either dies immediately from uyncope/or a UUle Uter from 
tteotdary h^morcbAfCc and jicptic- poiniminf:. (Jcco^LonaUy. but 
Wt raidy, the aHerctit irunit l^ccomes piu^^ed by a thtombu^, 
and spcmiuwotut cure may thereby he induced. 



Troatmect o( Anoumms, 

J- flmtnl Tie&tm«iit rtt<i> cJitLLr }»: cnL|.»]oyrJ m &n accessory 

bvnw^i tr*^irnp-in, fir mutt In' .Iqicndrd nr cntit^ly in (-a%r>. 

Ime local n>B3nR aic impKiciicable nr contra indicated, Kuch a£ in 

utcWttmsi aiul i« then to l)c iooh^d on rntli^^r as palhativtt 




3S4 ^ MANUAL OF SURGERY 

in nature than curath'e- The constitutional habit of the 
must be carefully investigated^ since aneurisms are 
either with plethora or with an enfeebled and cachectic i 
the system. 

In pUthoyic individuals, where the disease tends to nin 
course, absolute rest, both mental and physical, must be enj 
with Ihe removal of all sources of irritation and worry, 
bowels must be freely opened by a calomel purge at the 
mencement of treatment, and watery stools should be sul 
quently induced by 20 grain doses of pulv. jalapEe co. two 
three times a week, so as to increase the plasticity of the 
The force of Che heart's impulse may be diminished by the 
aconite, and even venesection may be useful and advisable 
it is very excessive. Iodide of potassium is the drug upon 
most reliance is placed, both for reducing blood- pressure and 
cases where a syphihtic history is present. The diet must 
judiciously and gradually diminished, all stimulating articles ' 
eliminated, and only highly nutritious material allowed, and 
mainly of the nitrogenous type, with as little f^uid as possibfej 
Various special methods, e.g,, Tufnell's, Valsalva's, etc., h>i 
been recommended, but as a rule it will suffice to limit 
dietary as much as is in conformity with the patient's comCnti 
and well-being, and not to allow more than about a pint of ftni' 
in the day. 

In -,1'eakly indhiduab, whilst enjoining strictly a recumbfat 
posture, the surgeon should prescribe iron and a somewhat xo/Xt 
liberal diet, in order to improve the quality and plasticity of tit 
blood. 

IL The Surgical Treatment of aneurisms has varied muchil 
different times and in the hands of different surgeons ; the ctiH 
ditkon, situation, and surroundings of the tumour wiU abo 
materially influence the line of treatment to be adopted. 

Whichever of the plans described below is chosen in anypir- 
ticular 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 int^nil 
aneurisms also co-exist. The following are the main methods 
made use of in the treatment of aneurisms : 

I. Compression. — Although compres^on had been adopted 
before Hunter introduced ligature of the main vessel in the trc»l- 
menl of aneurisms, its value had been lost sight of for a tim^ 
and for its re-introduciion we are mainly indebted to the activilj 
and skill of the Dublin surgeons, who proved that in well-selected 
cases a cure can be efTt'cltd by its means as comfortably, safelji 
and successfully as hy the ligature. 

The compression may be tonlinuous or intermittent. If «*ff- 
mittait, pressure over the main vessti leading to the aneurisp) 
is kept up by means of the Jingers (digital compression) or by 



ASEVMS^r au 



wcduMCAl appJtanccs for tts. Ictti^ a period as the pAlient cnn 

beat, ithxh 2» a rule does not cikCecd thirty minutes, if thctt 

citXBy ncfvy? in ihr imfnnlUte iicighlinurlimul luhir to br iilsn 

fifVed upon. Tbere sevms to be no pccc«sity to complttely 

snest Ibc tlow of blood tbroui:^) the sclc. so long a^ the hlood 

^tsotm is efficiently ciimimshcd to permit of coa^l^lion 

iitbin it. Cimtinvnit prrvsurr- ctiti, u-* :t Tulr, only litf mAinEnineil 

lAder an anipftlhetiCi :irid in inch c:u«e& the* cirruhaioii through 

ihpacis entirely stepped, so ns to allow not only ol iC:f contmt- 

[mti. kii abci of the upid tufli^ublioii in fionie ui»e?> of it^ 

frintfptv r^petblly if v.uoi* ;irm]iinT <rf cloi is ulrMidy prtiM^t, 

u JD tlie majority of the ^icc^Lit'i^d :iiieurism6 of lUv e>;ir«milie£. 

S-jch prc^fttiic m«y l^t cfictttd by ihi' ^uj:cr* of relays of dressers 

tikinfe* shifts uf Itr to fifliM.-ii irmiulr^ ut ii thiif^ ; huL iiiaMiiuLh 

L'. !hiv U *»ices»iivrly tirinp; and diftioiili ;o m.iinT.ifr rffirJi^mly, 

'rts Ahoulo tit m-ido whereby eomo wci|;ht, s^ich a.r 

:„u >hol-t*AC, rests upon tlic thumb or finder employed, 

IWcbj iditving mijs:ul^r slitiin- Tmirniriur:* rnny lie simi- 
Wiy nnployefl, hot arc IcKt nfltUfariory^ Mnco thf^y rp»]uiro mor^ 
^tUui 4:v] Accurntc adnprAtion, nnd nrc Jinhic not only to aUip 
Ml /^ phicct but «]m> Io hn:i«c the coaIs of thr? vcwi. The 
M( ipfilkuicr of lhi« nntiirr is pmbahly Petil's lmiriii<]iif't 
iTig. 6*}, Esmarch's eUslic b-indu^c has also l>een uwd ^\ith 
teccMpi, principally lot atipuntms of lh<- lower exlrcmiltc?!, 
ioUMy the jwpUte.il. The limb in litsi elevated for uontc 
■ODMl^k. ^md iheo Iht* ebsiir b:ind>i^p ;L{ipI]e(f fniiii Ihi* 
tti to tbe upper part of the thipjh* p;i^ing loosely ovoi ihe 
Joca mw i- An indiortibbcr tourniquet is then plnccd round the 
tippK jart irf the thigh, so a> to aric%i the ciccLiUiicn mmplcldy, 
Tbr limb may in Ihii vay be Wti with impuniiy almost bloodlcis 
far ui bouT and a hall (Htid's utttM). 

A> to the ;Wk of compreisaon^althouRh in suitable cnscn it 
ccmiDU Uu^ hcvu ^t^t^K^^vl. iinJ sliuuld be |^i\cii a UU! befoir- 
F<K«ediDg to li^;tiure. v«i it i4 imde^iruble n> 'petwvvti* with it 
for too looj*, l^at ibo colLftlL^ral circulation is incrca^d to sm un 
■Jciitible ^jLlcni. aikI thu.^ the bueces& cf the subsctjuenl oper^Eion 
uftrfartxl whh^ EsptH'tally is tliisttipcasein [jlethorii. imlividnaK 
■ilfc higfi aTtcrUl lenMc^n. Or^ the r>l^ier hand^ m f«eble^ wt^nkly 
piEkcols, where ff.in>;n:rn; of the limb rnight Ijc anlicip^ited, the 
fpcninif lip of the- ccIUteral circviUlion by coiiipres^JOUt even ii 
tU anmn>^Tn i%^ nnx rhr-rHiy nirrd, may prnve arivam:<(Teoiis to 
th« liOcecH of the f^jlrtcc|ucm li^'atnTo, N eeess;iril y , in aW rmses, 
tt* pan of the skin to which presiuTc is applied must he carv-- 
Uiy |:4iTtoctnl fiori) IotjlI init^iiion by the use tif <ky aseptic 
dwAAff powderc, b\ ^bAyin^ -md rt-moval of hair*, ^rtd by M-cin^ 
' ite the MirfAce c{ any pud employed is perfectly tirtooth, and 

evv' rink led bencith it. 
•^ of tbc m^iii vcnwl leailinjj lu oz comiui; fiorn the 



as6 



A MANUAL OF SURGBHY 



ihf OpeifttiOQ or A&tyUun, ccrtsiiKLinff in l^iying opct> ihc ne* 
turning mit the clrntr., nn<l Mcurini^ Ihc vcs^cIh alx>vr nnd bclo* 
(Fig- 76. A). iVifoniirii. aih ti WA^^oiiginally, nilhou: rfn;r^iliclii:i 
or aneiscptics, it was n;iixir;i1[y arrrndcci wiih {(ttr^i iDorta)ii|': 
but in the pr«!ccnt dav tt hns been r«^UK<;italcd with loiw 
RicidilicAticnn, luicl uicd with grcnt success ji^ ExHrpotA 

By And'B Uetbod (KiK- 76, Bj» tbe aneiy wa* tie<l }Uit Jilww 
the SAC on ihi? <:urL:]i:ic £i(lc ; but this -ilso proved danifcrcuit 
}iincc vccondary h^morrhai^'c frciiucctlv rcmUcd. rith-tr from tb 
ravitj of ihe aneutism bectunina ujlum"! oirm); to aqiiib. w 
from injury to th4< sac during the operation, or from theaiti-nif 




A. B. C. D, L. 

JUoih Br And'* opcntioc . C. iTic Hu,ntaii 



A. Itcthod c4 AblvIIoih B^ And'* opcntioc . C. iTic Hu,ntaiiiA opvaUja; 
D, Br 



wall, wliicli \s \n .ill ptobiilkiliLy ditt^Asecl, yirJdin^ ml the mi« of 
ItgAEurft from H^ptic p4?n;iri<:ntis. 

Himt«i'B Opff«tion iV\^. 76, CJ, which conni^ils of tiniure of 
the nMiti vcN^cl on ih« cArdjAC side aI some disLuicc lioiu tbc 
Ani^LinsiTi, Wflfi firiil pt-rfotmcd by biin in ij^^S- Tl»c obf«rt to 
be Aitninod i» noi to alisoluldy cut off the b]ood-»u|wily to ibt 
Mic, but to allow ihc blood to enter tt wiih 4 ffrcntly diminifliod 
impul^. 3Lid in small amounU at first. tliij--w pcnnittinic of 
thp coninciion of ili4- ftfic wall, and of the gradual depoctt of 
fibhrouM doc within ji. Th« nc thus Incomes coiuolidal«d. utd 
linally irjin^dormed mto a iiiash of hnii libroid liiBu<;. It in moot 
bkely [■> sui-ii'cU Ici tljostr tuHth i^bt'io tbr? aututiikm B v^ 
delirtecl rind noi larg/- i>nciiiph to evercisi' injurious pressure on 
airmuiidin^ P&rlt^, whilst it i^ al«o de«Urat>itf ihal no bmccii of 




ANEURISM 



■iT 



see should micrv'cnc I>clwcfn the point ol ligature xtA 

ic ll should tir Hu^riUiciPj^ if iBos^ble, tli^il IIir vt^ssul 

beattby omdiiion at tbc ftpc^E H'hcr« tb« lig^iiure is to be 

Tbeopcratioanmn^'rHdu'Eif^^O) in cascv where serious 

^irULOl, «ug(^esltng thai iht^ whoti? .-irirmal vy!«if?m is ii^fffMrtc^d, 
b1 raodtring ^xtj sud<len incrcan; of tbc btcxxL - pr^sure. as 
^ ocduaiaa of a nuiin rcvtcl, undc^irubic ; {^) where pressure 
vtc tb? >i;see] clues iiul contiul ihr- dtruliitiui] ihiciu^'Ji ihe 
or; ij) viMr* the peiipherAl wtiela »r« exitusively rnldiicd; 
'^wbm ^itgr«n« of the hmb \% thr^cening or prctiCDt; or 
Jiihere boa<s orjomis have l>e«n aeriouftly involved* 
Uttil Uffttan 1^ mainly priKrlised for Hneurisni^ sjiuaif^d la 
(DHikijt^ wh«7e il is impracticable to d«^t with the artery on the 
qtJhi iklc of tho sac, mch as the innoinimitt, Iowct purt of the 
or ArM pfiTt cf ilir sut>cldvirtit. &r««dor'» OparAtion 
I* in lyin^ th(* mnin ininV hr^ynnd rhp ^ar, wj as to ir>t;ilty 
dF Uic drcubtiotx Through it (Fig- 7f>, l>]. In W&rdrop's 
Option A liRAlure i,i placed on one or inorc of the disla) liiiiichcii 
iri(. 7f^ E), in ihc fomicr the srt< oJtcrt pATlially c<>llap?i«fb al 
(inland thitt nlbwK mf lh(* rlrposil of I'lhrin ; hue ir hrts b#<i^Ti 
j||ipMed that the cure is i;-^ualJy clfcttcd by an cxtcnmon qI iho 
jlJ coaguhttioo from the ^itc of tiR^tvirc to the snc. In tho 
;ccdinii:. vhhcic iht cirrijlHihinitonlyp-irCially controlled, 
ration of ihp ti/p of the Aneurism goes on much more 
r^uid tbc du:>cesof the deposition of dot in the sac &re 
igiy le?»cncd. 
h u not uitusuaL uflti tlir ;lji^)1 it at ion cif a ligature to a tnuin 
■Hffy for an^urim^, to obF;tfrve a ntam of pulantloa In Uti« SM- 
h tbi majority oJ Ci««& this only continues for a short time, and 
»by ao iQCjuisaa unCl^'oo^allIc sigi;, mUii:aiiii^ Lhc rc-establbh' 
am of the oolhitevAl Hrcdalion : Init if il commences ;i u-t^eV 
« tim days ^i<r the operation, it t« mote lik«]y to persist, and 
*dl iben tndicati> that the li^'alion of the vesbel \\i\h failed in 
:«DCiHpftblun|: the object for vrhkh it wfia adupicd. It is most 
IhqQcmty xcvn in eaw% where ihe vn^\w ve«so1 h^c tu^en lied at 
(D«e dntanc* from \\\& <;(c, a^ in Ihr Mipcriicia! femoral for 
^HfbtnX aneurism, and where one or m^^rc Urfi^c s^nA important 
laiiEcTal hrAJKhes carry blood into the artery below the lij^ture 
dirvfttly into the *ac- The moBt tivour^ble <-o[iditio[is for 
padul contolHlatioci are thoto in which the blood reaches ihe 
lOtVBni from bck)w free from impulsu, A few crises are recorded 
[iivkidi Ihc ^ilciy hai become pec\ious at the scat of ligature 
aocne mnnihs, va a frevh aneiinsm devrloptti at a sp^* ^'*" 
fefttoos to tbc ori^^nal tumour, "I lie *tarly reL-iinence ot paUa* 
tm cttds no irtatmii^i m most inBt.fcnces, sine* it di^ippears 
ipoetsiMinly ; hu* when il rnrnc^ mix \X a btcr siape, it demands 
wkui Uf«D!>on. Revi, elevation of ihe limb wid judicious pres- 



«< 



A >tAiiVAL OF SVXGBRY 




surtcver ttie trunk above theslte of ligature, sliould lint he irrnL 
Hiis iailing, the lollowmf^ courses arc open : {a) Itic Aricrv noj 
he again tied cither at a point nearer the sac vrhen fe4»ibAe, a 
IumTem .iw;!}* fftim it; \b) wlirrr lltr nnrtiri^rii can 1k« tiracLcd, 
it mny be cut Uown on nnd dis^ctecl out, the be&t covni^H 
adopt ii i1 be prnclicaUt* ; or k) ntnpuUlioD jii5l abovo^H 
aijeurUni nx^y he tjEled fi^t a> u U:it rrwniLe, wh^ic Uic 1tilll^| 
1% nipidly trtcrcMLMTiL; en lliTt^titning tu Liccome difTLiSf:'. Of «^H 

jH OompLete Extirpation of the aiieu:ri»iiiAl sac, wilb or ^^H 
ouL luyiii^ It L<p^[i, iiMv bi^ lLK.ikeU U11 ajt l!ie lM.-^1 iuid itiott l^^| 
i&ctvry method, if prULtir;iM'', 1i U thus d^^^lc with hk a Iwn^H 
Altlioui^h, owin^' to iho adhvMOri:^ .ilvv,'^y&prc^nt, conipl«t«MlH 
liori of the wall ffoiii ^urroiiLtUitii; parlb isoflf-nr^ircpiclyilincBB^ 
ATlir linLb ts pri^viously «xsanf;!umair<] by c)tr\-Aiion,aniJ in 34iiuble 
^CftSW Che njipiimm it^ rrmc^vc^ without cipmirLiE il, And the \vtaA 
lecUFCd by litfAtuTc nhovc and below, ila a\i^ any l>raaclios vrfnck ;; 
may open intd the vie. When, howcwx, a Iafkc nlccuIc c4>kiii9 
thp innin tmnk, it may lip necessary to opm it Ijrftat jUIceiitiUi^ 
iH cxtirnntion. Not un frequently the ^xrin will be encroached O 
in this diriiicction, nnd \i may have to lie removed ; a% A nikvlt4 
bnd leNull fullow^, tJVtiii^ prolvtbty to itv hiinca liAvbg bctt 
;t|n-:tdy tlimiri^hfd by ihp pressure of the Hac- I'liiv nvtboj 
vt chitdy applicable to e(n;ill ^incuriEins of the peripltrral x«ffi«ll| 
and, indeed, in the majority of mich CAsesnooihcr plAH need bt 
cimMdeTed ; 7siiritron% iirc now, however, exlcndlnj^ it* u-t lo * 
simrhr cuntlition of thv larger inink«- It H aUo attempted as U 
:tlt^rn:UiVG to arnput:ihrjn fur reCurrcQl. diihiflCd. and VuppUfatUii 
uncunwii;!. The rcsulia of this operation wlikb bai'e been rcccntfv* 
letLiidnl ate must eiiLuuia^jitig: piiiuaiy uiaoti uf the wuuod ■ 
often obt^ned, and henc«! the* length of ir«atment is oirtaiM; ifl 
chancfta of recurrence ar« removed: alatistics tJiow that tbtfaii-' 
Icaa chance- either of iran^iciic or seconiiaiy hariiioiibace> aad. iT 
the ftiietini»ni is sitUAlrd in the HeKUTP of a limK ih«r ts k» 
ftfhfiequrnt inierferi>nct with its mohiliiy, ^nrr- no p;ickand 
cicatrix or libroid tumoLir remains aj^ in oiher methods of ircal- 
ment. 

4. ViitioiTK mca^-urrs m»> 1% girmpetl tiJ^etfieT under ibb 
heudinf?. u-bere neither compression, extirpation, nor ligature It 
advif>abUr or fea^ihk-- 

BlectiolFsia ha-s been ucca^bnally emplu^rd duntii^ the laal 
%\x\y year^ in deeding wilb IhnnuHc aneLuiMTiH whcu :i saccule hJti 
de%c]op<^ in an acct^^tble pcsition. The clot thus formed it 
rjitremely ftoft and habic to Weidt up. and the rettullti have nol 
l*t:ii ^erj i^l[»fAcl(i[y. Ftjr Jc-tail^ df the mcUiudh <jf crinpljyiaK 
rleetrdly*^!^.. see p. 302. 

lajvctlon or th9 Sac vitli Coaffulatlng nulda -f-^., parchlOfidi 
£ti iron— ha& not bcca cxtcn>ivcly lui^il on accrual of the gM^ 




b CEMpha^^iv, trjurhea, &nd puhnoi^aTy vcssola. The former 

Bret may alio hr dup in prrssiir^ iipnn ihe If?ft reciureiil Liiyiigottl 

■ne. Ciiii«m^ p^fc^ii of Ihe cncn-^^r^lonokleuf^ p^^cictiK n:u«c1a, 

tDd (U6cuHt in openinir iht: ^iotth; ih<:\oKCtirkorcovcr, becomoB 

bflh juul the couch h^H, ^viih wh^i tus l>ctin dcv:xibed ab a 

l^nHallic ring' about i:» which is eictn?mely thatacfeii&iic, 

CT tnichcaJ s^idor may be noticed m tbe&e ca^vft, 

a 3ni^n3£ cf the trachea lynchrotious with the hoeu'l'e nction 

w-cjjlctl * tiochral tug '), 

AiMvi^nns of Ili« itscf^imgatch imd thfrriuir /wrlti oftrn nlinm r 

lalvfable &i2«, and nmy project pcxiienorly to 1l)« leh i^ the 

iv^val colofTin, ciiuiin^' a pulMtii^i; aw^rlUr^,', The o^ly prcssurp 

ipComs whiiili Ai^ \fty pnniiiiiFttl ;if e ihrf pain diir to erosion of 

ivrcn^br^and Ih* int«rfer«Ticu wiih deghitiTion frtmi pres* 

on th« cctopba^B, «/liich may be so great as to suggest the 

e of an cc^ophai;eal ccmtrictloti ; and, in f^ct, lieforc a 

is p4S«rd ir Any case of rrsophajiojil olislnicEion, It is 

tfrij* Dece&£Ary lo i»Iimiiia1«, if possible, Che pre^n^ie of an 

iwuuj. Au«cvlCiition in the left vciicbml groove may reveal 

breurtence of a syitolic bruil where micIi a rondition exists. 

tmineitl — .\% :i ui\e^ but little can br dcmr liryotitl urdtnary 
QKfaal fiiie:tKurc«, tucli ais rest, diet, and the adrainiUraTion of 
oeidf erf potfLSiium. Income c^ms where the tumour could be 
fct (fi frofflt, pn^HUte ovet the sac, the appUuitioii vf nn ice-bagj 
ct the hypodritok injection of ergotin, hnvr Iteen employed, 
br v^.iboul much effect; probnbly any impTOvcmf^nC observed 
■vdce to (be lest at the jamc time enforced. I'hc introduction 
{tfcoiUoliiosi wire or hcirwliiiir Was Ijcrn iitlenipied, aud ill one 
aivorasnL with p:inial or temporary success ; whJUl flrctYoiyih 
ka bMn employed where the puticntawcre heiiUhy and sacculated 
iiainscfts with but small opcninR* into the aorta, supj/oacd to 
oaL With the latter plan uf liratrit-nt bul lltlk' harm l^lii Ijc 
faw, e\*Q if no good follow, and Howdilch has recorded thirty- 
<et«ii raiPCfl »o iroaiad w:th »ev(!u i:ui<3, Tilimanns havmi^ also 
hid t«o very mcc^asful cawv. Maccwcn's method of a^cupuncture 
La trrJi aJErnfW with ^n\\r liriiouoL of liejiefil. Dy&pntra may 
fv 41 time« tcvere, but ifA^hioirmy is rarely called for, and, inde^, 
taj better be avoided if pouibic, death seJdom resultin)^ ^om this 



Sivs*^ trefttmmt, loich as Ugatvri of tht ri^hi carotid arid ri^ht 
■UftMv, or of the left cuToiid alone, ha& been adopted in 
CUCA of ODeurisra ol the a^ircnding a^rtA or o£ the arch. A 
Oauui amount of impiavemr-iLl Im?^ follo\^'ed Mniie of the opera- 
IkiK but of rfeven cas^ rtpon«J by Kitntrr five tlied uithin the 
ftru ten days* The principles underlying such proceed ings are 
oAamly at ranance n-iih those guiding our usuid treatment oi an 
■avBziwn, and it is ijuitc jiLosible that the impruvenjeut is as much 
d» to the accomp:Lnyi[ig rett in b«d a* to the operaiion. 




ado A MANUAL OF SURGERY 



the limb by elevation and the use of an elastic band, and 
ingi if possible* the main vessel above and below, as also 
branches which may open into the sac, if they can be fouod 
there is aiiy evidence of incipient gangrene, or if 
haemorrhage supervenes, amputation must be undertAkei. 
such cases everything will depend on the efhcient mainCeniDC 
asepsis. 

Tba Treatment of ui Inflamed Anenrism is always a matb 
anxiety to the surgeon from the risk of racurrenC and fatal 
rhage. If the artery above the aneurism has not been 
ligatured, it would certainly be correct practice to tie it, and 
the effect produced by that measure, together with rest, elen 
and the local application of an icebag. If the inflatnnfl 
symptoms still continue, the aneurism should be laid freeljf 
alter applying an elastic tourniquet, the coagula turned a^ 
the main trunk secured above and below. If bleeding sriD 
tinues from smaller branches opening into the sac, the can 
carefully plugged with antiseptic dressing, but a strict watcb 
over the case, for fear of a return of the bleeding. Should 
happen, or should gangrene threaten, amputation alone 
If the main vessel of supply has been previously tied, the sac 
still be laid open and cleared of coagula, all bleeding pointS9ed 
if possible, and the ca^■ity stuffed; but later on, unfbrtuitf 
amputation is very likely to be required. 

Special Anentisma. 
Anenriun of the Thoracic Aorta is dealt with rather in 
than in surgical text-books i it is, however, of such importtBO 
to demand ;i short notice here. Any part of the thOTadc i 
may be affected, and the symptoms arising therefrom Bfe 
variable. The fusiform variety is most commonly met w3 
the early stages, a limited sacculatlorr often supervening V 
disea^se advances. In the ascending part of the arch the 9 
rarely reaches any great size, especially if it is intra-pericHi 
rupture of the sac even occurring before any marked fw 
signs are evident. When arising from the transverse ptii ^ 
archj the symptoms vary somewhat with the direction t*k^ 
the enlargement. If it projects directly upwards, it may 
itself as a pulsating tumour at the epislernal notch, and 
usually causes considerable cerebral effects by interferenca 
the circulation through the carotids, or by pressure on the 
trunks. If it mainly extends antmorly, it may form a larg« 
without producing se\'ere pressure effects, except the pain 
from its erosion of the thoracic wall; it sometimes a 
pulsating swelling to the right of the sternum. If the 
lakes place either po5temriy or down^^rds within the conca' 
the arch, symptoms due to its presence, in the shape of d 
and dysphagia, are early manifested from the close ccmtiguity 



ging of the trachea synchronoiiii with the heart's action 
led * tracheal tus'). 

-lis of tile desccftding arch and ihoraiif aoria often attain a 
le size, and may project posteriorly to the left of the 
:olumn, causing a pulsating swelling. The only pressure 
which are very prominent are the pain due to erosion of 
tebrx ajid the interference with deglutition from pres- 
e cesophaguS} which may be so great as to suggest the 
ji an oesophageal constriction; and, in fact, before a 

passed in any case of oesophageal obstruction, it is 
cessary to eliminate, if possible, the presence of an 
Auscultation in the left vertebral groove may reveal 
ice of a systolic bruit where such a condition exists. 
int — As a rule, but little can be done beyond ordinary 
leasures, such as rest, diet, and the administration of 
lotassium. In some cases where the tumour could be 
kt, pressure over the sac, the application of an ice-bag, 
'pcxlermic injection of ergotin, have been employed, 
ut much effect; probably any improvement observed 
y the rest at the same time enforced. The introduction 
iron wire or horsehair has been attempted, and in one 
es with partial or temporary success; whilst etectrdysis 
anployed where the patients were healthy and sacculated 
, with but small openings into the aorta, supposed to 
ith the latter plan of treatment but little harm can be 
1 if no good follow, and Bowditch has recorded thirty- 
is so treated with seven cures, Tillmanns having also 
try successful cases- Macewen's method of acupuncture 
attended with some amount of benefit. Dyspncea may 
s severe, but tracheotomy is rarely called for, and, indeed, 

be avoided if possible, death seldom resulting from this 

I treatment, such as lieaturt of tht rieht carotid and rieht 




vrhilst in an fioftic nneuri^rn no difTcrence ik ub»n'«d^ Th» pni' 
sureeflifctemustnisolK'CixrQluJIy^^onsidcrrd. ' Fpcss^irtcm th*^ 

recuTrcnl laryngeal nerve would distmgiiish an awrtic ancwmm kva 
on*- on the right vi^s^Es ; pressure on ihr riglil im^-e in likv mvtarr 
^xcUideft an aortic armurUm. PiesituTti en the left innontnum 
v«n indicator aortic uncurisni nitlier Ihuit irnomiDate; conf«f* 
eion of t lie internal ju^tilm or itLibclaviun vein oi Jy points to c:«}r6tf 
or Milxlavian ftinruri*im. A "iracbvaltii^i:" irdicjtirsanannirivs 
of tho aorta' (P, Gould). The differences in th« p«riphtrnl pobs i 
may AlfiO jiTtvc a-^ful inforritalion- The two mdial puUc4 fhoaU ] 
be fir^t cTiAmincd; if llicy air rL^ually ^ncclfid. an AneuRtm«f 
The aorta oti the c;irdisic side of the inTiamiii;»f^ !& itidicaicd : if 
1b«y are equal and normal, an n^neuHsm on the distal lude o< iM , 
tcft suhclaviin. H the Jcfl radial pulse is alone aneorinnal, thi 
icjol of the lefl ^ultcUviaa is diseased : whiUt if the left tempcnJ 
is uE«o ELfff^ctrd, it ^ii^ge^i?; nn annuHsiT] t>( tlic tnina^ver^ pirt l^ 
the arch beyond the innommaie. When both radiftl »aJ icffl- 
poral vesaeb on the right side show Mgns of interference vrith llie 
pulse, innunun.iic miPunMii is piDlmbly pirTtenl : wbUiit an ife* 
lion of rynly one of lh«^ branches indic.ite<4 ihat Th« correspondinf 
carotid or aiibclnvion is diLited. On^ ^uurcc oi ialLicy muff tut 
bo forgotten, viz.. that any arm oi tbcst trunks may be occliidtd 
or compressed liy a nei^bliotirini^ anetinsnt v^irhotii Iviti^ tlibtrd. 
and h«nce th« quality of the pLilaemuHl betaken into con sidtoiion 
rather than itsaciual volume, and to tbit end the i^phyifRincnpti 
li a ;iscful adjunct in diagnosis. From absctu, tumcurst fr ttitrgm 
j^lflp/ti with a transmitted impulse, it is recogni^ipd by an BppKS- 
iion oi ih« general principles d^laded above (p. ^51); but «hH* 
the artery communicates an impulse ti> a maw through nhicb it 
pawcs. only veiy careful cAdriiiiiaiion will rc*«Al ihe exact aicun; 
nf ihe f UM', Pulsating or rysiic j^intr/ may lie diiilinRui^ed ffmn a 
carotid nccurism by noting th.it the t^'^itrc it riot, as a nilt, 
limited to one side of the neck^ the isthmus Uc'mg also involved; 
that the most tixcd p;ut of the tumour is in the median hoCt 
and nut under the s|t.*mO'niaj>loid mii^cte, and that the Hwellini 
moMie up and down during dc^tutitioni an aoeuriam remainbg 
fixed* 

Traatment. — \A'herc the aneunstn has l>ccu MtuateJ iieai th< 
bifurcation. iOiitp/awn has been pmcti^d wirh advantage in a Mr 
caees, Uie vessel bviu^ controlled above th« tranaverse pfOcMc 6L 
the &iatb vertebra, no a^ nut to interfere ^«ilh the afcuUtioa 
ihrnuieh the vertebral. Lusaiurf of the caruiid above or bdew 
t1i« omo hyoid hy however, the treatment tiflually adopted. Kid 
mneraJly with great sucooss* If tho aneunam ie near the root M 
tilt neck. pTDitimal lieature bec4>mc» tmpracticjible, und the dutal 
Oppratinn (BTawlor\) mu*il 1»p rrwiri^ li>; the refill* of the ijk>& 
[ready treated in thi« way are £uch at to jiivtify sungconi: in cen- 
uing the practice. 




JSEV&iS^ 



*»s 



AsiiiritB df tlM XrUmtJ Oarotld k s«tdorn met wlrb. «x<^pt » 
VKtmiiioii of one involving the biforcutiotiH Tt)« u&ual ptieno 
arc presented ncfti the flnj^lc uf the jfiw« a^nd vrcli nbovo tlie 
Cficoid carliLi^f. Pressure rusulls aw vAr\y expert it ii Led. ff,g., 
furaly^ti of orr Mr of iho tosi^io, aplionia, or tlyiptiagia. Ll^a- 

tlufc >[ the common trunk lltM^v• th« omo-hyoid is tho proper tino 
d treatment* or, fAiiinK ihjtt, the sac ma)* l>« dU^eckJ out after 
itciiiiiiK thr tn;inr>irs jiri».inj; from it. 



I 



* 



AuDum of tho IntonuO Oorotil (cxtrftcriLnlA] portion).— Thcro 
i* bol littk difrcrGnc:c hciwiren the »>fiiptoni& ftrisine fioiii thU 
<uiilUian 3Dd thcTv? c-jiuchI 1>y nu ^nnirism nf the btmrratinn ar 
ff th« exiemal carobd, «^cept that the swelling tettds to project 
Mon lato llie pliarynx, from which h is separated merely by the 
phiryngta] waU. It nppciirs m n tcn^ ptojcLiing piilNaiinK 
UBOUf, placed imrnediAlf^ly iindrr Ihe nucoui; miMitlmmf, ^nd 
knbitg dangerou&Jy lik^' un ;ibtcci» oif the totisdn The Trofttmont 
mttuts m tying the conution otrotid- 

bAnenalal A&ennia,— Any of ih» an«rle« wIthTr the skull 
tiaff b«com<< th« ^ilt* of an aneuri^n, but this condition occurs 
BDOR cj^mmonly upoii ihc iaTcriuI carolidnnd itit biauchc^ ttiaii 
upni tUrtr AHMEi^ from the vcrtebiaK altlkou^'h xhv tiasllar artv^ry 
HRKmo^fn affvct^d ttian Any other single ve^&eh Theaneuri^mf^ 
ve |E*tMraJJy fusiform in cl^araclcr, nnd thuir ori^jiri is ofl^n 
OtremHy objure, a blow ur ffilJ bcm^ sometimes adduced io 
dyUic shorn; in rhilrlrpu Ihpy nje ^lait^A ro restilt froi'i the 
Ugmofil of irritating umhnli, Th«y ^omeiiiTidK ^rcw to iv cun^ 
tiicnibte itizc Ix^fj^rr ctuMn^ obvious nvfnplom^ ; I he paElcrtl riiay* 
B (ftcl. hiive cootimjed v> ilbotit ttii,v niiiLnifcit^tiuri oi the dJseri^Lv 
uli! luddrtily triicd wtth a rapidly fat-il apoplexy <iuc to im 
ni|flarp. If there are any nymptoms, they are due rnlhcr to com- 
PNBiun of the brain than to crof^ion of the more rcj;i?ilAni bgny 
Uncturcn. I'ain may be cojuplainai of which ik more Qt le»i 
fiwd uid continuouH, ur Ihcfp miiy he a feeling of pulitntion, or 
«f opniin^ aitd ^hutling the top of the !£kuU> Si^ht. heaririKi =uid 
fl«be limctioii^ of the braio. muy also lie iotcrferccl witlt, but 
^>iMJ cbiin^t^ Jii tlic *^tTtt sudi :(A iipLiciieutitKui ;iiiuphy, a[« 
BTf Rwc tvlih, iinI«M ih«re if: direct pret^iire on ftoiurr purt of the 
<pnc tnicl. Occasionally a loud whi^^in^ bru;t tii»y Iw heard oa 
Uttculcating tho skull. The Wy ^iMtmoiib |jos)iML\ If & 
<iac>H>^ can tv i:-^li4blivh'?il, i^ U^rttuiL- oi the ciiinnron <^krutid 
■Rtfy, aad er'eo Ihi« will bi^- of little use if Ihe h^icilar is 
Acted. 

An Intra-OTfeltal Annnrlftm U rr^n^nlsKtX by Theexlsleiictf of a 

F^hsitDi.' tiHTihni; "*f :hr' .irl^it. 'vmi^iiiH protrt:«oo of ihe '■yebsdl 
^tKophtbaintosj ^ind cvn|^(--''iLJotj ut the eonjunctivid £iiid do«pir 




■366 A IHANUAL OF SURGERY 

vessels. A feeling of pain or tension in the orbit may 
and gradually vision is impaired, whilst the cornea may 
opaque from exposure, due to the inatdlity of the lids lo 
it ; iinally, the whole globe may be disorganized* The 
toms sometimes commence with a definite snap or crackr 
though something had given way in the orbit; or theyimy' 
due to a penetrating injury or to a blow. Occasionally the 
dition is congenital, or arises soon after birth. 

Several pathological conditions are included under the 
'intra-orbital aneurism ': {a) ii congenital, it is probably a ca 
aneurism by anastomosis ; this, however, is not common, 
only present in two out of seventy-three cases collected 
Rivington ; {b) if traumatic in origin, whether due to a 
injury or not, the case is probably one of aneurismal varijr 
tween the internalcarotidandcavemoussinus, orof tnietrai 
aneurism of the ophthalmic artery ; (c) if idiopathic, it is 
due to thrombosis of the cavernous sinus, or to spont 
aneurism of the internal carotid or ophthalmic arteries, prodi 
pressure upon the venous return. 

Diagnosia. — To determine the precise cause of a 
tumour of the orbit is by no means an easy matter, inasmtKh 
sarcomata of the orbital walls are occasionally met with 
ing many of the characters of intraorbital aneurism, 
manipulation will, however, generally demonstrate the cj 
of a more definite tumour, and a less-marked expansile 
in the sarcoma^ whilst the bruit is less distinct. The 
of the eyeball and ocular axis is often considerable in 
malignant tumours, but vision is not so early affected. 

Treatment. — Electrolysis and ligature of the common carotid: 
the only means which hold out any prospect of success, 
these the former should always be first tried. In the 
cases its application has been very successful, but in those doe' 
trauma it is very likely to fail, and then operation is required 

Subclavian Aneurism is most frequently met with amongst SBt^ 

and particularly those who have to use their arms much in liftiD^^ 
such as soldiers and sailors ; the right vessel is more oftn 
aflected than the left. Any part of the artery may be invohidi 
but the greatest dilatation naturally occurs in the third portMOi 
giving rise to a pulsating tumour in the subclavian triangle of thi 
neck. It may reach alx>ve the clavicle, but extends mainly b«t 
wards, out\Kards, and downwards, causing severe pressure efixb 
upon the vessels and nerves of the arm, and may also occaM 
hiccough by pressure on the phrenic nerve. Occasionally it en- 
croaches on the dome of the pleura and apex of the lung, and hB 
been known to burst into the Jung or pleural cavity- It docs no 
increase in size \'ery rapidly, l>eing surrounded by dense unyieldidl 
structures, antl it ne\'er compresses the trachea or oesophagus. 



Mo dilficajty presents itA^^lf in DUgMUA. as a mic, Atlhougb in 
\ht G&cly ^toffc* il may be soniiewli.il KimiiiAtcd by a normal 
■ilcry pinhed finr^atdK |jy iin tiotio^is of the fit^t iil>, ur liy a 
«ipcciiiiii«rary cer\icftl nb. A puliatin^- larcoma ^rowinR bom 
ttf o( Ibc DcifhboiinnK ninictLirc^ m^y abD resemble it »otne- 
vbd ckndy, Inii iJir piils^tUin i» Ibcn midy 30 limited in 
coBsK *& in an ancumiri. aQ<l u deAmtp lumour can uMuilly li<r 
Ul. 

Fttc TnBtMont of 5;il)cla\iAr] ani^urism ii aurrouaticJ vritli 
dCkJiic^ :intl the lesulbs liilh?nuiitTt;uned have bcwii mosl an- 
aBs6»rtory. It is fi^ldom (hat ^ny undilat^d ponion of tht- nnrry 
k [*fl <iiatod« the tborzix, oCh«rwioe digitai icmfrtuutu on /Af cardiat 
A&nkiehi be Aii«mpt«tl> 4Jnc? il ha^ 1ioi;ii employed nith vucccsft 
b 1 feu instMAce^. Diiect pressufff, manipulation, ^Ivnnn- 
[|nctQre or n««dling the sac SLCCordinj^ to Macewer's mrtb^^d, 
nn btm adi>p4«d with occAsiooal ^iiccc&sos, hui cnnnot be 
dcpeniied upon- Ligat^av of thr iawmitmte tmnk siig^f^t^ il«clf ait 
1te<fVTation to be ndopietl for rutc hy thir HiiniPtiiiti niPtlmd. 
Ajt^nceni records of th« fiperaiion wouJd CArt^inly enc-our:ig^ 
[Ctt»t« repeat it in any i*»itnl>lr ca.'K, ^ircc mo^ of the tntalT«nill£ 
prior to the introduaion of antixepiic Kuncery. death 
tevteng Irom *pptU iir w^timtary h;i-mnrrb;4ie. If wcMrld appear 
Oat the Hunultaricaux^ lifl-atiirc of the cntolid cr verttbral trunks 
wi tht inoominAlG i» cJi^cntiAl to siii^ccs*, in order lr> prevent the 
QfU bftckflowr on the di%l«il sidr of ihc ligitluii- whtcii (ltbe^wl^e 
iTfufs Thbcource «'AS followed by Coppi tiger (JiiiiiJiiTy^ i8yj^ 
•**! CDinpI«l6 swxcts. as also by Lewt.-us (JSK9), U;ink^' liSSj), 
Hmtli, C J. Symondn £1^94). and Smyth of NcwOrle^ra (1^631, 
Ibt ody )V|;eans «rhrE« paii<?nts have lived. In tlit lu^t CAiS« 
mntfary hsmorrhnge eruued. wMch v,-^s. hou/e^4rr. ■:onTTot1«d 
t^ tjimc '*"* vertebral and hlUcE Ihc u-oiind with shot, Iho 
p£iai (utoc^ueutly hvm^' for ten year»p 

Lifttmt tf tJkt Jint fart (tf the stibttitt^an h^ft also been Attempted 
fcf tie curt of ttrwunsmt mrolvin^ the lower pan of the vessel, 
to; It fTWst b« Gon&idcred an utterly uniustifiablc proceeding; for 
d iht aindeco cases 4>piftalcd otj. ^11 fiAve died, DiiUil li^aturt 
«^dr third p^rt of lh« mbclaviAn hnK also heeii altemplrd* Iml 
nikout miKh Kucc««ft, 

^Ihat trcfitmcnc. then, is to be adopted o^ft la^t resource, where 
Uc tba<ve meoMjres are imrmictioaHe or b^ve failed r The pUn 
loil^nted by the lat*? ?4r Willi^^m FrrRUiwin most then he fob 
"Dd, vii,, amftii^rian al thf sJicuU/r /oiut and ditlal tigoturf at near 
tW ttc w po9Mbloi Di-ital liCfitiirc alone is uttoally unauccc&Miil, 
«i*f 10 Ue £act that the j^rriil Imlk of the blt>od oeeUtd for ilie 
Wiiiioo of fh* arm itill p^it'H.-s through the <iac. and the.rr Ik no 
■*W( of chechinj; this except by thf removal of th« limb. A 
fi* tocccMful Ctisea of nuch heioic treatment have been reported. 

AiiUirr AaoKrisB i^ tLMially the rchull uf ^Ib on the oul- 



a6S A MANUAL OF SURGERY 

Stretched arm, or injuiies to the shoulder, such as 
or dislocations, or of the surgeoo's attempts to reduce 
The Sriiipt<^>u are merely those due to the preseace 
pulsating turnout and its pressure, which may cause pain, 
and Deuralgic, or oedema of the arm. When the upper put 
the vessel is affected* a pulsating swelling is fell im 
below the cla\'icle> whilst if placed low^er down it projects 
into the axilla, and may totally fill up the hollow. O 
the cla^~]cle is displaced upwards, or the aneurism may 
beneath it into the neck, conditions of serious import as 
treatment. The Dlafnoda should not be difficult. 
tnUrgemtnt and stbsctss of the axiilary glands with a t 
impulse are readily distinguished by careful manipulation, 
attention to the rules already given ; a. puisatittg stkf&maofik 
of the humirtts is recognised ft'om it by a careful consideratio 
the method of onset, and of the orieinal sitxiation of the 
as well as by a careful digital exammation. 

Treatmant. — Compression or ligature of the third part of 4 
subclavian arteiy y^\\\ be required, and both plans have 
successfully adopted. The former must be earned out by 
of digital pressure, and will probably ha%e to extend over a 
siderable period of lime. Where ligature is employed, giW 
care must be taken not to wound the branches which carry on 1l 
collateral circulation. If the aneurismal sac extends under tJ 
clavicle, it may be necessary to secure the second port of A 
artery, due attention being directed to maintaining the integnf 
of the phrenic nerve. 

Aneurisms of the brachial artery, or of any of the vessels of lil 
forearm, recjuire no special notice here. They are almost inffl* 
ably traumatic in origin, and should be treated by extirpatkn. 

Abdominal An«iirlfim. — The abdominal aorta may become A 
seat of aneurism, either at Che upper part near the origin ( 
the cctliac ivxis, or at the bifurcation; in the former case, soa 
of the braucheH arising at that spot are also usually involved, u 
the di^ase is of the sacculated type. Occasionally aneuiiso 
form independently on the splenic or mesenteric vessels. 

Signs, — \ pul^Ltint; tumour is observed, usually near the nudd 
line, and either close to the umbilicus or in the epigastric notch; I 
pulsation is expansile in type, and remains the same in chand 
whatever the position of the patient, whilst various kinds of br 
have l>efn noticed. Pressure signs are mainly confined to pA 
localized in the l^ick from erosion of the vertebra, or neuralgic CT 
pressure on the solar plexus or lumbar nerves, whilst cedema 
the lower e?^tren]itiis Tiiay arise from compression of the v 
cava. There may be some concurrent derangement of the 
teslinol functions. 



AS£VBISU 



9^ 



IohUv — Tber« arc many condilionG whicli giv« rifw u> 
nc puUaticn, hut the majority of thcn^ cnn he r«.itill> dt^ 
Its^ Eroro abdomin.ll Ancitn-Mn by cArrrfiil c\^ittmatioii. If 
irjr, under an ana?«therit, Catdific pultatinTui tnsy Iw fell 
ipigajEtritun wboi the he^irt ii: diL-vted, but should lie easily 
sea; ms nJso n derived impulfbc from the norta in n collect 
£ccc9, or A cojianinii ){iowl!). The ctx^iTEiiEuition af mlcIi a 
^CiiM tie coDilucied not only in the dorvLiI dtrciibitit:^, but 
£i»«itb th« patit'Dt IviQ^ or hiij abdomFa^ or UrLt^clmp; forwards 
wulo remove tlic wt'igtjt t)f the ristcui from the aoria. The 
puiMiiutj ttiU luidci suub cirLumsUntifs teasp, m t)«:[iiiii? tnucli 
{^biOifd. and thxii a n^Mive dingno^is nut)- U? esiablkhed^ A 
1^? Accumulation of abaomin&l kii will seriouftly tntcrt«r« with 

Tbr TnatmeDt of alnJoniina] aneurl>ifii is necessarily one of 
KTOi (liftiriiliy from it* pcfiuirn and reiationa. Ligature of iTi* 
vHaeJ c\«n on the dL"*lftl *idc hiw nc\'cr yet liccn aticmpledi and 
farotic* £LiKae n^edk-il lr<ralmcni b> rest ami diet* ti>'ff/frjjivn J[j.s 
imully lirrti rrlird nn, which Iias lieen applied Ixitb on th*- dUtrtI 
tad proximal «idc< of the s^. In six c.-Lses of proximal comprefi- 
M three succpesflcs were reported, one tailuroi and two deaths; 
b four tm%c^ of dlAtni pressure, two failuics aud iwi) dr.-tthis. 
CWorofenn i* re«!*^d for iKe :t^)plimtion, ard I,i*Jt[?r's tmirniqutt 
litt uftueiD^ boen cmployi^d. The psitient's drel is limited en 
llic Dre(cdin£ day, rind only fluid mttrimcnt ^ivcn on the day 
tl<df; the Ijo'^tU must Iw iboriiiighly !ind lonipIrMy nuptied. 
Cira [RLiftt 1^ tak«n not to injuriously compr(?i-:i the vtucet^, for 
tt* prc«aurQ ha& often to iju maintained lor some con:udcmble 
htki varying From one la twenty hours; if properly applied, buT 
Itllefiurce b iieeiU^d* It i> ^tlll wfthin Ihc lealin of pofuibiliry 
hit fcigattatv of the &ona in a suilAble ca««? rn^y prove vuc- 
loshib More recently tre?itn:enl by nc!i^dhn;; the sue bari been 
■ployed, and (plainly In Mac^wcu's baiidb at least one caw 
\irn briHianily Miccessfitb There is also one msiance on 
wh«r« the miToduci^on of iron wire into ihe sac caoaed 
improvement. 

Qiae or Inguinal Acetirlstn may ?tnse ftrrm Hthrr th^ common 

fttemal iliac, o* &om the o^mmon fenioral* and usually tends 

ifptead upwards touturds the abclomiriaJ cavity- h is frequcnCly 

in type, or^d tend^ ^ouuer or iatei to l>ecome difTu^. 

IH someltm<?% determined by llii- unequal pres>»ure 

by faisdal or other structures, leadiut; (o lobulation. 

fiymptoms turn very typical, and pressure enecls art* mainly 

iu the veins and nerves of the fe^. The Dlajfnosta 

b& well mistaken tn the enrly 9Xn^f^. hiii ^ater nn, ;md 

}y wbeo trtuac«d somewhat hij-her tIi;i[i usual, it m^ty be 

to dialicguiah from a piddling sarcoma* in uuch ca»es 



370 -* MANUAL OF SURGERY 

the difficulty has been so great as even to mislead men Lilte 
and Stanley. 

Tnwtmeiit. — Medical treatment alone is of tittle avail in 
inguinal aneuiisms; but proximal compression of the aott 
common iliac» ^vhere the situation of the swelling and the 
ness of ihe abdominal parietes permitted it, has had a 
amount of success. It is carried out by means of a tt 
shot-bag, or the tuigers^ and may be advantageously com! 
with distal pressure. Ligature of the ejcttrnai Uiac has been 
quently performed for inguinal aneurism, and with such 
as to warrant its being employed in all suitable cases. L»j 
of ihe common iliac is sometimes needed for aneurisms in the il 
iossa. The results of the retro- peritoneal operation were by 
means satisfactory', Kummell (1884) reporting thirty-two 
which it had been tied for aneurism, with twenty-two 
probably the introduction of the trans- peritoneal method of 
ture will lead to better results. In seven instances ligaiuTt(j\ 
abdominal aorta has been undertaken for iliac or inguinal , 
and in all a fatal issue has followed, six of the patients Ajk 
within forry-eight hours, only one survi\'ing as longas the tenth dl^] 

AnaurUmB of the Gluteal uid 8cifttic ArterieB are not 

monly traumatic in origin, and present as pulsating swellings 4l 
variable size in the buttock, the gluteal situated at the upper ptft 
of the sciatic notch, whilst the sciatic lies more deeply, and inf 
be partly intrapelvic^ Pulsation is well marked, and mumuA 
are heard on auscultation. Pain in the limb from pressure cm ti» 
sciatic ner^e is a prominent symptom, especially in the sciatic 
variety. The Diagnosia is by no means simple, especially fromt 
pulsating f^arcoma, and many instances of mistakes have occurni 
even in the practice of eminent surgeons. Many plans of THrt- 
mont have been adopted, but possibly the best results hithtftD 
obtained have followed the laying open of the sac, turning out ttl 
clot, and tying the affected trunk. Ligature of the interikal i&tf 
has also l>een performed, and with a creditable degree of succcsCt 
even where the old extra-peritoneal method was employed. Tin 
u^e af the trans- peritoneal plan greatly simplifies the operatjoBr 
and the more recent records of this proceeding are most satisiiC' 
tory. At the present time it should certainly be undertakeoii 
preference to the plan of laying open the sac» 

F«mor&l AneuriEm Is the title given to one forming in the coum 
of the superficial femoral artery. It is not uncommonly tubuhii 
and occurs almost invariably in males, and as often on one sdt 
of the body as the other. The Diagnoaifl needs no discussion, « 
the disease runs a typical course, and the n«fttxa^at coaasta 
either in compression M the groin, or ligature of the common of 
superficial femoral trunk. 



■dtfBV^lSJif 



r*-- 



iMuUn of tlte Pnfucdft F«niom Artery is :i ver)^ rare eon- 
ihlitc, p«.---tniini; tht cidinary lcatu:cs ol ii pulgaiinf; tumour 
tfnloi ^moinx^ tbc niu5clc3 om the inner %ide of the Ihigh, tnil 
ouoi^ nu diniimiliuii of the pulu; in the ^upliipul t>r itbtAl 
nscUi The Mip^ffiruLl fi-iTior:il iimy tw fielt ccur^irt^ over it, 
ha jaitc dbtinct fn>in tl. Cuniprcr«*(Oii by it fthot-lm^' in thn 
Ctin,c4 \ry ji luuiniqiict^ rniiy l>c sufficicnl to cflVct a cure, wbiM 
MOljfv of the foiniti'.m firmoral ui external iliar rnfiy Ikt re^iurttxl 
bv*fafc»«sary. 

IVpllteM AJieorlua (Fi^. 7^) Oixuin almott invaruibly lu luen, 

>*^ jMftifiilarlv in i.iilnr«i (CHppt}, It rnnstiliUps n piiliiat[n£; 

:mc«ir m Ih^ nani> rcndflrmg the kitoe pain- 

y nd fCiff, An<i Ao vaitch do ihc »ytuplomh 

mnbic tboi>^ ikf ^hronlf. rhrLirtJiUhDt, liuii 

tifwcry tjuch rase thn poplir/^al %\tnrf KhouM 

tv cumiced. The hmh t^ utttAily anmi 
xad the ancitritm. which i* of n ^acrU' 
Cypp, teiuLx lo imiitiUtf? mpiiily. If rhr 

nin in^lluiK » «iu;itevl to the frcant of the 

^^ttri, tiȣfc it^ iloc^cr Inter on ol the kncc- 

^aot bccocninfi implicated, and neiKhbnur- 

<V hKie» <'atriuu%; t^hrn it exlenOs pcw^ 

^My. diffusion n a not unconiir^on coni- 
^(odiM, and \tt \xTy likely to lead To i^An^refic, 
KceuDt of the ptcumc excrcbed nut only 
19CI1 ihv vein, Lul nSo upon thr? nrlicvihir 
truUtN ol th« popliteal Artery, n-luch circ 
lOM ui^>oTtant uctorH In mfUMtninii]^ the 
^QiAttcnl LiEiLuUiioi]. The duMEitDAib h^i.^h 
Id Ife maile fiorn chmrir enlargement ;ind 
J^vtcct of the (^liLwls in the ham, but in 
l^ctt ihcic i» DO diMurliaikcc of the iirL-uU- 
honbllie foot : from hur^ tumoitrs hy their 
■Wt cf mnbiliiy nnd puliaTif^n ; or from solid 
tt«Ki:i, /^,. pulwlinK »ifirx-/imii fif ihc f«^mur or tibia, &oni 
■bdliloin be rocoi^nisK] by nltn^tioii t^f the irciieiaJ piiiKiples 
limdj ilevcriliHt. Ir 'A ffW in^arres ^pnntanemis rnre has 
ravll.Ll from rhe pretfturt; at the sv<c upon the atlcry al>ov*i, 

TNHjliaaL- C4»nprc5wan in eminently sacccssfiil in many of 
iWsc cascf, whether applied in the ^rmn nv hy \i^miiii-h''i inclliod- 
Lifalureof th« femoral ariery nt The apex of Scarpa'ii frumfflc ift, 
*»Wfr. the pUn most cointnonJy adopted, and with the Br&itcst 
«*««k In casicsivbero dthcr of thc^c mclhod-i have tailed, or 
*fceit the aneurisnt faoa liecome diiTusc or recurred, cAtirpPttion of 
^Mc kibe bcM ixiurw 1o udopt. 








ays 



A UTASVJL OF SUKGERY 



Idcalura of Tnaels. 

As ulfMLdy mentioned, aricrii^ Jnny n^rcl to he tigaiund mdlf 
two con<titioiu» cither when divided on tKe futw ol A wound, Oft 
tbcir coDtiDuit^' W« puipow: to deal only with ibo latter in tbk 
s«cliun. 

6owcf blood to I lit' ptirjphL'is, 111 .!:.:■.■ i.i;i ■ .ihnft. 

OAilOUA A V\Ol.Llld) <JJ to pJUlE^uli: the LUJC Ul *Ul JkU^UH^atii, Oi t> 

diniin'Kh Ihr rnrr t>f growih of some riini<inr. or lo hmc6ci;Uli^ 
inHuoncc some peripheral organ by leduciDg its tjiIoad<ujpp)y ,u 
in lyi^K the internal iltac lor enlarged proi^utc), or ns a pi 
liminacy to TririiA tn^ H'HW MtT^rxAni filruclnrrt :cuch jia the loofOf. 

Thi.' InitTXunentii nr^c^f'H nrc ^la iaWoyva: KC^ilpeU, dtarctng 
forcvpK, dircctoT gt liliint dii^ocior, fofcipre»<nirc or nrtecy forcc^ 
blunt licok-1, rcirnctor^ for deep wouna*i ancurum needle, Hgt- 
liiip, iirptilrs, iuiil sutures. 

TheUAtciUil 10 be employed for the ligaiur^ haibeendtKtisHit 
elf^whcrv. bo^phuro-chromici:^ catf^ut is that mottC commonljr 
f^mplovc-dt and for its applic^lion to an arter> m its oootiowL]' 
the fijlluniii^ pUn may \k fido].)li-d : A fine lo^ of calKul 1iAvii( 
been pass«d und»r tli« ve&iel by mvJtns of a.n nneuriun netdm, 
ft prepared lignture, consisting of thr^ filrand^ of ca1|;tit about 

10 inches louj^. kD(>ttccl together at cacU end. i» threauka ihrottcb 
til? loop. U'lncli IS [hen u/i[hdru.wn, currying lh« ligature mxicr 
tbevesML The advaTito^«« of cliis invthod Are. ih^c Ibe aneunnn 
nocdlcbcinjt; threaded wiU] such fine gut, paaseAcauly and witfa^ 
OLit friction, whilst the itse of llie luup to diAw ihc )ii:a1uic Wk 
nlniatiy* ihp diffinilry, whi>ro Tbc arrery 1:4 riwply plncv^, ci 
threading the needle wlien passed unarmed, as it «ometiinc£ 
advised. The sitb^litution of three strands for a Auifilc tigatuie 
diMrilmteA ihr ptrM«itTr cnrr e. lar^r arnoit and n ojrtftidcrcd 
more teriiiinly to effectt nfchisior. 

As to the OpenhtloD itself^ the strictest a^pnt muil be main- 
taiincd, the skin and instrumcnta l>cin£ thoroui^bly purilied pre- 
vioutdyn Thf? aitery must 1>e snlHutnnemuly rxainmed u!» nr na 
l4 pOMlble. io that a suitable portion may be elected for appl>-in9 
the ligature. An incision is made cleanly ard neatly thtoutfti the 
»kin and subcutaneous tissues* and of suRicicut hisc to aUow of 
the uecesaitiy mampulii1zun%. Tlie vartous sUiii:tures utei vilh 
on the way to the artery are T^cogniaed, ^ni] drawn, if need be, 10 
one or the other side, ^o ua to hiy bare the «bca1h of thtt vtsal. 

11 K moM import^it iLat Lbeso aiiatomJ<jil landmarks or nily^ 
poiHii should onci) Ixr "^nni or felt in ordrr, f'O (hat ibe operator 
may not he le<l astray or mit^s the vesceL Naturally it i« eaaer 
to had the aricry in the hvini; fubjeet Ituui in the dead, the 
pulsation l^cinj; of ihe grcateM assisLance. The sheath, having 
lietm exposed, must now lie opened oiTr the situation of the 





UCATVSB OF VESSBIS 



m 



I 



«iei7bya few 4<ticate Mrok«i of the knite; a portjcn ol the 
skaib shpQuUl be picked up between the bladcti ot the ioTcep», 

laUi^ cnr« 10 Veer the bcick of llie knife tuwanis the vt7«tel. 
1^ BKUicn shooUl be £ibo;it j inch m Ivnicth, and shuLtU cipeii net 
cefydac i;cncTAl» l>ii( ulao llic special, ^heaih of ihc /irtcry. if nuch 
tvfl. E'trh vide oif tbo itici^iui) in llie sht';ith i>LAy then Iv 
pffir4 vrlh calcb forceps, %o Ai I0 (^lefidy ir, w-biJsr the Ani^ur^rr 
BBode IK inuitcd unnnr>c<^i and ^Dlly mftnipulalcd up :Lnd 
teii.v> d^ to free ihe vessel aIJ r<tund, a cnAttci of nj i^rc^Li 
6ficiliy, if ihr ^h^-Aih tia* J>i>rii i^'trly (i|>rnf(l, :*nil Thi- wtiih- 
|linrD:nf: arltii.-il wall t-ufficicmly c>;pojiftd. The li^alure may 
tte l>e p^ks^ed ihrou^^h ibc eye f>f ihc neciik Jiud cirrifld rwind 
tfat \»3d. It is tied in a dirccltijn rxActly aX righl nnj^lei^ to the 
kflgi:iiciin«I 4xU. ^uid in lining; sn fh^ ^ricry mtisl nut Up dr;^^^«i 
nCif in ttbeatli. but tlic lifr-nturc fihould be lightened by the upt 
it}htit*tvhnffan mectirt: upon il (Imr- jg). The fcei-knoi is all 
ifaBi i» >etded f<^ iscctiiiEy ; more compllcalcit knots arc tuO liulkjr 
10 kt lecomrnendef!. 




fTlLLMAtfN*-) 

TV mleuEUAJly followed i&iopass the noadlej^^mi imp&rtanl tlriu- 
itansr mfjh Ai /if tftn. Imt r&nlly this is a matter of littJc impor itincc 
*ficfi the above directions have been c^^ircfkilly carried outi fuid 
t^CCully in M]|FT|ici^| ve^srls. Should the Vein be acci/tfittolfy 



the nenlle must be at once v»ilhdrawn. and the puncture 
ttw tcifi carefully Mcured by Jif:nlurc, whilM the fiitcry is tied 
■ Mt hi|;her Of loutcrr. In dcahnff, however, wit)] the smalki 
voiel^ whrfe the renat comitnK itte ir cEosc? <:ont:iiCt ivilh the 
«t«n\ no harm will a1t«nd their incluMon m the lii^nture. 

Uc ^avc already di»cuMcd the desirability of so cij;htcmnK Ihc 
li0U«ic as 10 divide the iuuer and middle luuU; it is pans^ble. 
boBevff, that in very Ur^e trunks like the Snn^^minnlc it is wiaei 
cfilyto Ct^mpJctely approKimaiv chi.' waJIs bv vomc thick animal 
fabrtaooc, web m lamgaroo tendon, and net to aEiempt any 
laptnre of tile intinia, 

« iiAweil kiKm-n fiwrt that all flricHpn arc maincainwl in the 
W/ more or lefic upon the stretch, n% evidenced l>y their n»trae- 
tioo irkltio tbc shcntb on complete division^ There must thera- 

i3 




ar* 



4 MANUAL OP SURGSaY 



fore a.h 



be 



certain amount of ton^it^idinal Icmaon 
part of an ancry lo which i\ UgAtuic haft bcci) applied in cb 
cnnlinuity, a condilioti which rtmy prrr«Lun!iMy prnfispcHc tu 
seoondary bEcmorrha^e. To oWiate lhi», it has t>c<ti tuij^ieiaFJ 
thnt a doulilc ligature should be applied, onii the veuci d)r 
tx:t\vreri thern. This plan :iiay lit? ii-ted with a<]vaiitai{c ni situotit 
wha« Ihe arltry ran be rtadily r<?achpd, liul is »car<Tply 6tiii1)je] 
Mme oJ the deeper operations; it i» probable that ili« 
thereby obtained are belter than whcnnnirtglf ligature i!teinp1o}wi' 

After 'Tnatment. — The? oidmury atilist^ulic: pm^aulujii^ ik 
laken in rcj^ard lo lh? wound, which should li« h^tlnl Afid sll 
stitchvG rerncnctl in t^if^^ht dnyt:^ : l>ut the pnueni must be kept it 
rest fur Hijnt^ liiiie iuu^^rr tu iiUovr thf? liuues tu coitsclidMi 
fispcfcWIy in drf^ding wilJi ih? larger vessels ami in eldrrly ptofje, 
\\ hon the main trunk to ont* of th« tvtTt'niiii»>fi ha*' been tuA, the 
linib should ho wrapped in ootton-wool and ^li^hily raii^od^ ftOif 
lo assist venous leluni wiihuul intcifcrinu ^'^'itn the Aftenil 
fiiipply. If \Y\rTf is any liWpUbood of ganer^nr, a\ in thr \t/m 
Umbs of fldorly people, \]\o cxtrfrniity should be Uiorout^h^ 
piitihcd, and wrapp&d in a^piic wool immodiAicty after the 
tion, In order to avoid scpiir complkAtions. 

Thi^rrT arr^ twci ^{Trsil duig«ni liable eo fallow the ligation oil 
artery in its continuity : 

1- Second^iT Bnaionrh*<t (c'i<i< p. 227). 

2. Oaocr^ne, winr.ti [ita\ nI^fc iictm a \'>ricty of 
{a) FroTii -iinptr Inw nf viTaliiy. (hr mniEinnini ammtnt ol 
traosrtntlrii hv ih*^ colbt::ral circulation tHiinfC inituflicieat 
ninintAjn in life the whole of the port supplied by the vcsmI' 
li^y-atpd, Thi^ tti p;ir!icuhirly the t^iisc wJiPti llie peni^ifial ii^euavb 
are in a condition <^f calcareoni dri;r?iirnktioii. 'I hff llsstaM wtiifh 
r^etve the £inati»t amount at blood die hr^l, f.^,, tlie fiti^«cf or 
10^, or Cht &utH;ortital ^hite ftutmtancc of iLr biain. A <«^ctc ba 
of blood afl<»r [hif operation, us fioni si^coudaiy h^-morihaj^e, I^aIv 
«ul^ci«ni \n some cas<*s to determine tissue n«cixniit, L'nijpr sudi 
oitcumMAiiccB it Alvtavb iikko? on 1h« dry fofm if in^ol^injf lti« 
tern^iiiHl ioiiitii t^f a liiiiU I^hiI in ujoic llt-shy p-xH^ U n^ay be 
moiM, (n) Interference wiih ihfl \^rnous r^rum, a* \vy injury to 
th& vuo during operation, such xt. inclusion in the lljcatufe, oc 
thmmho:^!! induced subsequently by r-cptic periphlebitis, is very 
likely to caii.v: j^i^icrrnr. and then it 15 of the moist typcr ; tbe in- 
junou*[iTPvtiircof ;i tight Ivtndnge, olMtruclinj; the vr-noiu circuU- 
tion. will have a similar eifcct, (f] Injudiciorus after- treatment, 
tiuch &a too fcrcat elevation of the limb, ttie appliculton of cold 
lotiuns, an kel^xg, or Imr foineulatiutiK during ihe period of 
dimEntvb^ vit:dity immediately foUowirg the opevation, or even 
aJ) attack of erysipelai^ may also brinf* about lh« d«;ilb of some of 
the tissues mvolvcdi 

Evc^ry prcrututiuu umal be lukea to pi^'cut tbe Qccuflreuce gl 






UGA7V8E OJf VESSHLS 



•75 



I 



e,a% indirnrivl ahrw^, and as fioon as there Is any sus. 
jm orf tit ootct the whole limb miisi li* thoroughly puiihed, 
tti (Tuinttuncd siibacqucnlly awptic. As ft g^cnuml rule, the 
fnunwtt of avrptic uftnijrcnr fdlowirie ligalure is cxpectaiil in 
dancier. Ihc pcirt^ ^win^' alEowtd to separate nntvirally. But if 
thtfe IE much pain, or any icadcncy to spread, or if tcptic 
(ti.'chHf is pfpsent. RivinK n»c to fever and general dlsr urbane c, 
i\ iS *u<i cilhcr to .imputiitr on -i kvel wilh ihe onginal wnumi, 
tf,W thi§ U ricar Ihe tnuik, ;ii in lijjuiuie of tUe femoral at thft 
MTL tji bcvpa'b In^ui^'lc, to ruinovc the limb well nbove the iinc 

TV hOTJaitt AitHT- u olreAdy aBudon^d (p^ 16?)^ bw ao* booQ ttod 
■t± <*£(«■ on Si HpAfvie ocuiiofu ogioTa tuuu of twwily-llve opvftlloiu, 
M^ t Mf IH A-nfidfaMil ibit A n^id iwp«» wiFl ■nabl* i^urgiinn* lo dnal whb 
iiK titm\ ia ths fun^rr wLih-mi ifip^ t^^rrilil'- izKn'iAlLiv thui hu hiiheno 
Ku^vHd ibr <jpvmiua. v-ipKla]l> if ibe carotid and vcriebiftl un aha 
u iht same bmc 

An IficUika b in*dt ^o^g iha lewer iHlrd «J the 4fli«rior boifdor el 
t^*n(»asttiuid,AAdi«f^Db^vil Jawvwsrdt i»twavpi:i«*rlKi«nppurBdK<'Cpf 
tetMBnuUnrtrh Thrpbryanih, tl-wmifvriiriitl.-imt d^np f^HT^r .imliviHKt, 
«t QiUivrioT jBculai vtin vcurnl if n«:«»iiy bpiviwn twu l^atuivi. the 
■BifrOittU L9 dnviii (jut^uJa, *Dd, if need b?. ir* miii^E' [citdiinijua AWca 
ttfritcd, wh4lii the ticrnu'btind uul -tbvruid mv>clc& nn: m-^etvl cLuac tu 
tkf ttrtam and dnwv inwAjJi Thcr tbcnth of ihc ccrnimuit aLn>tid artery ia 
ttm bud toiv ami nfwnrH it it« Inwrr p:kri, w> u In ^irvtui ihn vinvw! *nd 
mUth 30 be atnA. ind tn following thii doutHMnrflt ihr inrommu'? trunk u 
Mckd to VMOs CUHTi U il:>^> Mimllle iririlreik tu rc^iiluic jH>ilkElM tjf Ibc 
'Mum bkJ tnocr ««il o£ thij (iMidt. The riK^t "mtctttnl lu^ulni- And 
B«4 >vi&9li* loilwoQier qid«of tho va«ol, but if ma<rh rtiipotBrd may 
tfvvr the artery, lUid miui lliui be drawn uido by rcimcrorr. vrilsi lb< 
thjTioicl pieiu« niAV »iir«ff dlncEly in Iroflt ol the s'tocj, uid even 
iBbbe tfxumd Tn lim riuifrr nr ri^hi tldi Km pluml thi? ingus nnrv 
|4uiLid nc., and tbn» ciiifi Iw mrr-hdly sqnnLUu ffimi iIhi «rtery ^hilni 
u [Bniiid fmtit without inwudfl, and ttota bvHi^ ayvam \ 

j<e4 MicWriitb niwdk a^II probably be requirr*! io duel ihU A 

bud wMkU lip^titf* — * J . a Hrip o| oi aiuu or kflntfUMu tendon- *hou!d be 
'ftciM»^Hal Asmm niii« h^ flii«i fhnKiiighiy Mtunilin! to, und •v^ry 
kftir^wl tri mtitrr if^JinK hv Arfl ^nii<Tiii'>n 
Milmt Cli«nl»Uoa.-i>mu,>kjji4ir Vprtebnls And c«n:Udi in tiiclo <jf 

'•>«^.VAt4 . hnaKhcivti\v two ciicrBnl c«retld*iLcrcui mkldlc tine. 

ff«4 tme w^ilc viIarcckTjJ k«M miiMrnut mtarcAatid ul aubckviui; upp«f 
mtr UiCKficrAuSH tifi ihnn'ir l^ntrrhr^of ikiPnT>' and iniin-L-^i]0;<K itf irrnrn^l 
ttmoMij . dnp etni^atric and phicmic ixiiM tarmitial Jj^ iiuuiLa uf iiLEvrniil 



ThibeMU AlUlT mayli? ti>^ m our ci( tvio |iLru'«4, ridu-r uLkivii iir Ixtluw 
tfcy i< u vluUi ii ii cmsfd by- the ^loior belly of Iho pmr>'hv'<rid. a iKjint 
^VH^ondblf to the traut^nc proceoa of [he outh cerviml verubm (Cbav 
MtMc'i tebRilcj Th« Uae el Ihe vaaol it indkftted by ihiit drawn Imm iba 
Ma»<fai1atv ulniUtioa to a intni midway between ihe «ngl« of the Jaw 
vi lift flp rtf ih* BBtfnkl pmr^^v i^" bifnnrallnn halni; i^irimFril on A lEvel 
*ibibt mvr border ciftbe d]>rDid circib^ 

LvOfi *Wn Ott Ort^i^yif^- Tbii u^rMin^n u alwa^i t<:> b« ch^^vn if pnc 
■vK 1^ ^HtuR Lctng apuliE>l nc n 3f>oi curmpocid^nj in Icwl t<) lh« 
"**** '~n-*i>i Hi* paiHnt W ufK^n ilw tdck, ulta lh*':h]Ti nweduvl Ihe 

kS — a 



a76 



A MANUAL OF SURGERY 



madii 



head turned a little towards the opptsiie side. A 3-inch iadsioo b 
the line of the vessel, the centre on a level with the cricoid (Fig. 80, A) 
skin, platysma. and fasciae ar« divided, and the anterior edge of the 
maslmd defined as the first rallying-point. The deep fascia b Indacd 
inner border, so that il may be drawn aside by a retraftor , the t 
branch of the superior thyroLd artery may be divided at tbii sta^. and 1 
passing between the facial and anterior jugular may also need tobeliniari, 
On the inner side of the wound the omo-hyoid muFicle must now be Iduedfa; 



ik^\ 




Fig So — IncijiIovs for Various Opebations on H£ad aso Nick 

A, For ligature ol carotid , V, for ligature of vertebral artery : B. fo^^ff^ 
of subclavian , C, for li^.iture of the first part of the axillary: MniOf ■■ 
internal mammary : H. for the lingual ; E. flap incision used in ln|'iii*( 
for menin|<eal h^morrha^e : F, fiap incision for operations on thA nxa' 
the bfth nerve. 



trending forwards and upwards fmm under cover of the stemo-nustoU.^ 
the an^le formed by these Iwo atruciurea the pulsation of the *'*'>^ *2S 
be felt and the shoalh readily recognised, with the descendeoi tv^ 
nen-e upon il U is i>pened on ihc inner side, and the arterj- weU da*» 
The needle is passed Irom without inwards, and if the sheath bi> ti* 
efficiently opened, ihe va^us nerve will run no risk of Jieing inclndod ivV 
ligature 

Ltf^aturt hdoii- the Q}ni*-h\-ci\i . — The incision is made in a similar diiBCO** 
the above, but lower in ihe neck, reaching from the cricoid cartilage DeAil5 ' 



di cMVMlavtealftr |ol»i. The «ienv»-manoiif i« clrauifi cuiwBrd», and par- 
biplbejuilcrior Abm imy mvI to be dl tidal . the Kcrno-hvnlrl «nd 'Vhyrofrl 
DMclBttB ratnicuiJ in^wth or ^uitJAl. anil itt uiurj-h^oji) can bNuily ba 
dim wiud» TIh vboAlh i» ibiii vipuMiJ, Arid L7[KineJ un ihe bwfT vidf. 
AeMAbeiOftMiaioJvHtihc preiioug operation U mufli be rrfflffmbcfed 
MMitfiuriuu ^a^larvdai aKdiFMlcii lowudBtbo ri^htit*^ m the low«r 
(Ml Af ibair oemnr. »ftf! bwiCB (he Ufl vein it llkdy to lia tornewhai m froti: 

h 4bn h^dv or luatUfnl. 

TWi/nfi of licaluie (jf ibc UkTCPtiil upon the baaJji arc of cmi inicrcii afti 
ii f ^a x Sf<faitkn go u> prow ibM ifi «boiii a^ p«r cent, of the pftiLcnit 
iti w i oe owAu i lyttiptcnii miail«i tlwm»#t\'iH. w(har Immnliately ia thv 
iif»aJ i ^ Bf r yp {toib ott*4inl Ar:miik, nr in th^* rvinn^ nf a fi»u c!aj,4 fmm 
onU nteitiift, CMU^j; convulflotii conia. nJid cit-en fUmih A fȣ&l itaim 



KOiW fovtn of coDifDiLion at the lunvi iaWowt llnuure of inc caroild 
I « Inr lioan. pawUy dua to interference with the drculalion In tbo 



er tc imjfetvpTi i^rinjery to ih* vaf*Li>fir tTtnfAih*Hc4 it miy nm en 
iDVbmiLe ihlUminjiMcin, artd k b»r rvnertlnl l>y fm iilmuhrirn. or pven 



OiUmmI CIkhIbUod, —Imimnmuil Circli; iif Willi>- 

t M tmmi4t CamdtMiicuioOB fecroin tho middU line of bnnchu of the 
MVU cvDikk ■*! Tvrl«br«l« : inbrii^r tbjToid nitk ihv Buparior thirroiJ . 
pniulj-vt^Kli ntt pruiocfa anicifl al ocnjniBJ . viipc^rinrial ccrvirhl icnfM 
wKftn ^r ccdptiAl and vtrttbnl. 

lifnui af A* InUviAl Ikratld ii bm ^rcly iwadoci, bit hu beea conpbjrvd 
fcrhiaiiiilm^imJ iniflrQAticaDctiriun* \ny pan oti\uf vn*«l irsybt iwd, 
l>LWtivle. 1^ ll^on Ji f>ia«al juui Abo^'e the bihjrviiion TheopenlLon 
apiMlcillr tbm Kttnm am Inr vHurinpr i1i# coininrin curoiid. but At ahLaher 
«a Aatavltioa U marie »lan|£ the nutehcr bordrr of Ihtr ^inrnii-muldil. lla 



UuBDculj iHjpusliit? the fraftt comu of the hjoid Lune. ihvtauKlsw 
Md*ellWkta4Kr>. .uhJ [be ulerlur betlv of ihc d^icutrig ta do* bcci and 
•■m ap Thtf *.ilcrnjJ caroiid pre:icnt> itwK anJ 1* c(L«fiilly diipli^ced 
^oA. wd ih'E ihr ittiemaJ cwtid in ti« thoiEh 3p|>«tn ThU 1i opened. 
Wf At wr«fn n-v«11p p(i«fd from Ihr jugular vnn — Ji tn>m wlrhnul 

Tht BBllataral Circ«Ulioa hJ the tjri^i; i» iiiAiriUU:>cJ l>y ibe circle of Willie 

f^iAlv tt tke btenal Cuoiid ia occuioiully ciUled fot. the aile of eLeC- 
■■le tppivmc the hcanirr Uin^ beiwecA Ihe lupnicirr thvroir) aod lAigual 
^■thH An inadon hi made AliMifltheamierlar boniaraf inB«ierTio-RittMt^. 

wr ^ >bc JiMtnc vuKht br Above, ifao hypopiloaad non^ lyin* Jiui belotv 
' Thaabtain k nov optfned betov the lip of the grav coma cf Iha bvoid- 
iidfl»MadkpoMed Ir^m uithout LcwArdt llic oparation may 1« nnprrta 
uAu Ij dUucolt by tbo f p -n MnftftiiAfifWl ijlAndi or ivin*. espccUUjr tha 
NtvLktal bdJ ediicnjr thyrvM. whicli tjftten lit; diiccily in vont « Iba 
*^r1 Ibe eiipcnur laryiveAl nenc b plA&eJ imcainlUUly baWnd U, hod 
vwaaeKonly baaitdded 
IKhiary Cirwlatlpai - Vtdi Lufaiare ol common caroild fwiracrmnUl 

HffW ra af Ihe tUgaal Aiterj ii chieRj imdod in maliirnn"! ^ISsouc of (hu 
>i^f^.cithir wiih :« *-K^ (c» lUieii lUc growth, or lo toniM hAmiifihW- *^r 
■ * l^vlimiJUJ^' la rcfix^al ai ilic urjCAn . it ^ oLki occuKmnlK cmployvl 
• Vuauiir: caan Tha t^uel can br *#cur*j eiilitr time tn iis origin trrm 
thr Ctfar&al carocld^ cv in ihr lubmnxdUn Lnaiif;^: umler cover of ibc 



»T« 



A UAHVAL OF SVBtiBHt 



hythvlosHUt nuKcle Tfa« l&ttsr t^nlJon \% murr cvmniunly perfcvnKdj bd 
iut former i> tlie beiler procoodlojc. iiuwDUch u tb« itornAl bnDcba«W| 
Uiira ihc veud u( the poaiorJor border of ihe hyo'Rlo«*u« an ftW indbWi )■ 

r^ fA' .s~if/i«diiifiJ>>' rruiHfif (siie □« el«cl^on) — Tlw rMletii IIh on ike tacL 
\«trh ihf nhntjUlf-n riti«?1, arifl ilif* hvail titondvd iMcnvjirdt ftnd turftedHik 
D|.i|u»itCT ^icltf A cit^pniic indiion commondcuc ibinil i inch brlov 
GAVcetuJ lo [be ivniphf-aia menti, uid iWinirw Ui«fttiglD of llie J4v. m wk 
tha emirv oppoule lbs gruc cumu of fhr hyold bOM (Fif. Ho. tij T^ 
lB(s||UTnu1ii and pLaiwn& rirv aividad, nnd tba U>4«r bordtr of ih« s^ 
mniilliiTy trl.ifii! rlcfincJ, aiv4 iling ir t>ii< iWp^tviit t4 inrJwri Tte |lvM B 
now cimwn upw^nJi. juid held mer ifae tnui,-L[i uf tlie jaw witti » mncH 
ft-lK Bi. Gi> On ihuruu*;l»lv u|wmoK up lb< vognd ihe i«o btUwBofil* 
di|[utnc mu^lc {Af trv] nrc wen cunvr^Dg to tbe hyi>ld boar (ZK Af 




The ibbmftxiltary xtuid (Ci| bu bun dnwn nvrr ibo 4uJc of ibc lain mt!^ « 
hook; 2. hyoid bona; i. ritcmBl cwoiij; i. tnicrDkl jviir^id^f : r laipiil 
ftTiery; 4. r&nlrtc bruicfa 1^ tfiicb] ; 5. hyptvloaAl Q«rvc ftf In iTn—hr 
Af (TW- ?3rvl»tiyrUd : M HvyAp, mylO'hyaid , M fiy^. bywtoiEni Tlw 
I>1acc ssbtcF i!ii- jiiirfy U lE«d U Imllcsw liy A uhiniluTji in ibt bjofkMiCdt 
Ihrwunh uhidt il can w: »wp. 

uterioi- belly povlnc tuperfidql to the Qbm of ilic infW'b^olil noMle 
(Jlf myhn], ^Mvi courac nearly imnivcnely \o ibci mandible The dirtiDk 
teodon mAy b9 dravn d<jwn vrtib a blunt boob, and m (h« vpacv thut ct »m »J 
thr hyO'^To«sii4 mfCAcIf (M kytui ] hv^nmrn rvi(1'*(ii. wtfh ttv &br«« pwrint 
tiTLiiiilly ijp\*^,nlii. iinrl rr'ttlnit up^n li ihp b>7V.«]oAnl nrrve (51. cooniif 
brvkarJ!> Id ucI undn coici oE ilic iny]i>hyuUI. widl n litl]« hiwrr the racdm 
I'cia Tbc fibm of the hyu-xlijuuk are fioA dividoil tranivcrtclv midva^ 
befween the ni/tv^ and thn hy^id bonv. an<1 in tho opvnii^ madq bv ibdr 
rtrrufCfon it fc'mi thKarlary {j^, which C4i) I* rHdlly«Karfd Should li no* 
tir fijuml ki thm HliiuilDn. ihr IncHnn in the h^r-^lcaiiu ihoiild he«ifn.1H 
bncliwanlti. ijiti ihe vnirl y*i\\ then u&LiAlly oame In ultfhl' 

In iki tlttk ihit fij thOt'Ktt -Alt iiiuMun ia moi^v iJcnut tb* waivrfar livid« 
of rhe iIcnio-moiitOLrl nimTlar lo thnc not<lod for lig^tura of iht «M*rnaJ catotid, 
Tb« intarior bortltr of th* mutcl* iG drawn oiit^n/*1i, and ibc rtui ooniy fif 






UMTVaS OF i^gs&sis 



hnmaotm and dw pcoieHor UIIt cj the diea&irk. In which the Ulcrv oui 
h M notiag apOB u« Kiddle cooatricte-r. and iccLiml juiE ft* il rl«« Eram 
te rdvnal Cttnild Tba aper^ion iH b); si> fmunn «u timple u Ih* Ibrmar 

TWjMtel Ait«7 nu^ be txpcoed ^od EioJ ihtuu^h 4 hofiuDtftl ind«ion. 
I ■dbio iMgth. awk dtracily owr th« vomcJ uit crowed tbA lover twrrterof 
tejivlmoadUlBlT In frfiAl af tha muutfv Th* flat yvma will n*«l clivimrm^ 

TW1t«v«ml Arcvfj i* ttaeh^A in fronL vC Ch* lurlltory mmiui. Mid M II 
CMasibf ijifoma. Ihrnnf^ a t^rtinf inriwnn Ie it miv^Zy rnv^rti^ by nbln 
irilnKk.b«l DOti becmrully iulaiM from ihe auritulci Temporal nirnv 

TWMilvriH AitoiT hu been littd in cACh pan of iu ci^unt. t>u( mc»l 
tepMly m tiM third- Ltcsmuv ol the 5n( put ha* bwn *n iri^-inii.f»ry lir^i 
atuvTtttWtiiailAUUlrtngllSAU!! uDjuaiiflnMe profudtniE.in'l be nee we 
Ai3Kt4««Hh»H Th« tecondnn m»y t« »cuTcrl wUlioui much nak. tbe 
ifB^bas VTJnr merclr a moiMcatioo « tho ubu&I pnxceJtcu, and only 
■niwtbviotleaaiu^tlcuA i^ he carefully dnuti aside. ipedalhvAlbcinii 
vmtftht bbrenie oerve- 

IfWf e/ U# (Airrf flit hu beea perfotcua for ulllarv uiPim-un, ar 

lna^h^•, AA A (Haial (ip«nhrm fiv nnrtlr nr Innfjmtnitli? jkneurlEEin. ind 

■tt^Ofttta pretimbiao lo ampuiaiion uf thp ujipei «iir«riiily. Tficpalieiil 

h^mdonthe tuck, dose L{> UiecdftevJ the ubie, tbo ann is well dcprcveJ. 

m At b«d toreod lo the opposite >£i9e- The 9kui U now drawn down hy Iha 

Uhui^MdaalfkcllIn joriioehMlonr ri]Adeovertheclavicl«(]*^E "(i- If} 

<h RfcHiQf ibe ikid it rMnctt upuamt, vt thai ih> utound Dcjrnpt lo be 

^■M ibMt I Inch fthorte ihp divide, and tbuti lb'- ctl*ni4l jugular vctn b 

•ntAwnly pmtectod Tbc WDUeaflbclnciibn should b« plitcrd atvji 

T«cb k* ihc iBaar WJB «l the ontfc of the davitle. and ihould upoH thfl 

■pBtenMn dae Mer»>-ini9*l(nd uid trapeaiim rnu»clc4. Ibf^ libr«i o( whidi 

■Vtfvidfd 10 a HLilahlf e*r*m il ihey abnormally rncri^ich tipcnt rh» b&n*, 

IWikiv tnptfftftaJ laKiA an^l nrrM-t. uuh ibe pliT\'fmB. irr fKuirlnd nlong 

lh«MeM«tborthe|flf:Lition. juj-Iui fheilenp bucSa. Tbe Fit?mal jutruUr 

^oAa eoB* ptrvr tiTmi; InX*} vkw. cifteti tuitmiiuUm 4 {jlehuv whjth may 

^tttmipeon snidQ lroaU« , ubm [-owblo, lli«y »h(>ijlil Ix ^eat]y drikva 

vtdlba vAy by mnmsol blunt hr>okt. boi if orc«aary they mum be divided 

Neii« tigMim The cetMor E)uue is then Inflber incifed in Tbir lLn» fif 

■^ wnair cam h«ot laUn lo «t«ld ihe trvii«-eFK «n1cal and vimm- 

•Qpekr enaif«, ih« vnosr of mhich U abovv Ebe iJur uf operoiiuD. >^blkl 

^hltntohiddrabtfhLDdihedavide. and should nut avi>»Lt TlicpuMn^or 

M7 tf the Ci»o-hyc^ li cTe^rly d^/incd, uid. o^iitti l\ ai a i{LtkL«, tbo finder 

(U l«m^adlA«wdi lo tht bekleniia :iiHiciiH, And ibon» downuardii i" tht 

' rt l— tabercle ens the 6m rtb. The imbchi>Tan vdn is situated in frnnt rrf 

^ fenfcr. but an a Irmvr l*it<1. whikr ilv artery ilM'H caji be dcieaifd 

MMSng anderibeiTulpor ibn Ani-i-r Utuvenii and ih« ril. On UoariOK the 

■MdabitleLiketordiorihebrvhjalpleiat wUl be K«n above asd umeiuJ 

fe t Ihe lower cord pua^iXK down behind. The needle U iatinnated fnnm 

vQta aotfwas^ and tnan be kept very clout to Ibe »ft#ry lo pnpv#Tii all pi*- 

4tty orf Ibchvlinff ihi* Icweat e<>rd o( ibe pleiui The operanon m a Ihin 



IHCM t&ay bv^mrifiefTy v^^V- ^^^ ^''^ ^ ?<1'^iit ■cLibjrci, wiib a iborlibkL necii 
Ml hii^ [Laiick, ibe Knuieat diniLZahy may bp oreririitiil in findinji the 
•Md The chief dM^fcrt ATiic from ^AuufuliA^t ihe^neuhimal eu. thu pleumt 
qwir, *f tb» nMt^elal *eiat, whilwt tbg pmiirmly of ibe Cardaof Lb* hrvhial 
to< t>e iantonm 



OM beferpolE 

DUwnl rti—lattna T*»'ii ir »r hrsincbr^i oi ihn aortic iTViercoiOtb And 
h«nd fMmtwiT >trJh ihcndr brancbes o! aaitlary 

fu Sh^ >fi ■ S«pn>captilaf a^iJ pij^iniiq «uipular MfA subKuptilaf nad Ita 
teuii bf«Dcb in tbe tecicr <jt on tbr; ^Itnain of ecApuU 

4/$9miUS ui: Sufweapclar ififA ncromi^ thoradC- 



38o A MAJiVAL OF SURGERY 



The InUnud VunauirT krtvj (Fig. So, M) may be exposed and tail 
dividing the iDtercostil aponeurosb and muscles about a finger's braddi 
the oulei' edge of the aiemum. If [he vessel has been di\-ided, aod \^i 
have retracted, it may be necessary to excise a portion of costaJ 
order to secure both ends — a moat necessaryproceeding» owing to the i 
the collateiaL circulation and the consequent liability to continued 

Liffttfire of tha TBrtebnJ Artflrr bas been nndenaken for woand^ 
secondary haemorrhage after ligature of the innominate, and in the 
of tipilepsy, but without much permanent benefit in the last cue The 
tion, though by no means easy, is usually succesahil as Ear as the i 
surgical procedure is concerned. An incision is made along the lovtr 
the posterior border of the stemo-mastoid (Fig. Bo. V), the platysmaand 
fascia divided, a feu of the posterior fibres of the muscle itself inci«d if 
be, and its belly drawn well forwards. The scalenus anticus muscle it 
defined, together with the phrenic nerve. The interval betwcd il wd 
longus colli muscle can now be demonstrated, with the ascenduig 
artery l>'ing upon it. The anterior transverse process of the siith 
vertebra muat be made out. Just below this the vertebi^ vessels ifC 
entering the canal in the transverse proccssn and the vein, which is 
anteriorly, is drawn outwards to allow the needle to be passed from 
inwards As a rule, a few sympathetic twigs are included in the ligatoit. 
the resulting contraction of the pupil may {according to MacCoRU^ I 
looked upon a& sati^^tory evidence that the vertebral has been in ratKf 
secured. 

LigHtnr* of the Thyroid TeneU is sometimes used as a means of imsiiq 
Ihe growth of a j;oitre 

The iiiprrior thytoid arttry is tied by an operation eKactly similar to ibit b 
(he external carotid. The incision along the anterior margin of the stoi^ 
mastoid has its centre opposite the upper border of the thyroid cartilip^ 
the external carotid is dehned, and the superior thyroid secured as it liM 
from it 

The iiifrttor thyrosd attery i$ reached by an incision along the inner bcrdK** 
the sterno- mastoid. eMending upwards from the clavicle for 3 incba. Tli. 
Tnur^cle and Ihe buhjaceiu carotid sheath are drawn outwards^ the stemo-li^ 
and -thyroid usually needing to be divided The transverse process of the *u4 
cervical vertebra is sought for, and the vessel found pasung in wards just bdof, 
il. It is tied close tcj the carotid, and as far from the recurrent aetft0. 
possible. 

The AiilUry Artery but rarely needs to be tied, except for punclurtdwottik 
and possibly secondary hemorrhage from the brachial. For aneuriso of ^ 
brachial, one \^-ouId no^^'a-lays prefer the operation of extirpation if comp* 
sion fails. Two classical operations are described and practised in clivBB 
operative surRery. 

I Ligature of the ^nt part ff the i'fsjr/ is undertaken through a curved iaciai^ 
wiih its concavity upwards, extending from the coracoid process to -^fdi^ 
] inch of the slemo-clavicular joint, and ^ mch below the clavicle (Fig. 80, Q 
The clavicular orif^in of the pecioralis major is divided, and the c*<* 
coracoid membrane exposed, reachinc from the upper border of the peclcnji 
minor to the clavicle Sundrs- branches of the acromio-thoradc axisipay^ 
divided in this proceeding, and lieil. and the trunks are then carefully k™ 
backwards with a iJireclor and forceps to the main vessels, keeping u far fl 
possible to the lo\ver bonier of the subcEavius The vein lies within and bek*< 
and theconlsof the brachial ple\us ahove and to the outer side. ThciHedlfb 
pa-vsed from below upwards The divided muscular fibres should be snte 
quently sutured together 

Guthrie recommended that the vessel should be tied through an inddctt >< 



LtGATCRE OF VESSELS 



twirtt vt the tntry dfcrtdinjE ib* pcciomlU taa\at» vtd «efL*Ialy foi m 
MBtod ^#oiin4 llila lh« most d«nr«blo proeMdiag. as nay port of the 

I Liftnmi tfihi MM ftirf «/ thf ttifty m pwdr-rmfd (mm tlifi ^viJIa Tht 
nbhtfyabiacBad, inn the virEfcin «ia^d» beiwwn 11 inr) chp bodv An 
ia3iios « ^aik in the oourw of the h«»] ai the junciitrd of the zuiicrlur adiI 
»Uk lMn±a of ifac vpikc? Wtwren die ^iicri^ir anil ficrfl[mi>L- flHJlliiry fijM* 

2%i^ -W Tlir mcBr UoTiJcrDl lbccnrAcrvtir3j:hiali>i(nii»chiKdrair]yfl«&n«d, 

toitti Ihm (ftwttnlf. the uter>' ^[idr It sku wiih ihi^ vein 10 (he Ulner 

Mrttnl CSn«]atiai If nbovtf ibv acrMnio ihoracic. (b« tam* m for ih* 
iMmn v4 the fubeUvlan (y r \ 

II ak«e (he ^ulHCJipuliir cluiI rirf iimrlf-.T ' |./Kig (honflr^ UKt laWfCMUJii 

*» lopiiv bnmbn of wl«i;apuUr . »upnv:apulai dnd jtCTunii'T^lhcvack 
«* Hnrior ctonnflei tt iheddtdd. 
HUfw tb*dmiinfl«9c, unw u for Iti^^aiucv of brmchliLl abov« (ho luportor 
'./-* poM«rtar orcmnticjt «'rM ■uporior praluoilA id tha deltoid 




1. Tbd twii of tlw &Ulkry . B. linchbl h C. brachial at tbti IkuJ ^t lbs 
4*«. D. *p|Mr ihinJ oC r^lia] , G, mldJk tbiid or ulnar; C and P. 
bw Eiank of ndlAl Md ulruir 

Tkftnatiu Arwry n^jr thai tn Iw lii^sniiwl br hjrntfirfhA^u from ihe 
pnr udtoi, or from a tfti^iind in ih'' fnmrm nr h?^iii ibii i-fFv^w. fnr 
^■anfei, or f6r iifi«ri(^^TDiLcai9 vMjunda al ihe ben J of tlieelbuA li inay Iw 
W b cm of Cvn> places . 

' J'ijf MUdk of Hu Uf^ Arm - The arm h hoM ft**iiy from ibi? ndc ai a 

■VltC^- ^Ib Ibeb&ad *iipia*. but wtrh iv> tupport btndVb it Tliv luryooa 

■4Kf pljK*d h«lw«AElbii irmaml rht* iniiik, or rnay tianHahovi'ihi'AFrnnrxil 

^^iT it I0«ptni< Aei jncMon ; Inchet lone If madv In (far tiiYc of lliti 

■^tia^E *• "•"»' l>jrdcf uf itip [ii(.tp lutjitk (Fm Hj. IS), .ind Oie ihln 

«ttd mv«MDlQni of tb; limb ditidorl Th* inner ocIk? i^f (hi:: i[iii!*ck mdwitly 

cip'Md^ Vbd by flrawifi^ ji tlijhtly ^c^rarHn ib« meiliAn ntn-ii in bicuf^hl in(o 

*■« ao4 ndnp> thA barilk vnn The n^rvi-, ithtch i« aE tbii ap-ii crnnintf 

*iFVry femn wltboul mwardt, i« druwn nslJe, jvhd thr ^hMih of ihr v^wi*! 

Nndbcgimh »J The an«ry It wparpitol from lo vcn* cuinUui, and the 

%aan |«aKd and tktl 

liauMdon li by 04 miuii aJm^t nn «a«y on*, aa tborv tm mnnv inpj 
Monefa Iha basl»TmaT fall Thai xhc n^vdian nerve may crott IwhmJ 
4ei^«| iBilMd of in frwii of 11 . Ibn buiTto vein mny he over lEt viiiniion. 
wdW oinafeeQ far n : oribfrrtnayht ahi^hiHsWon, anfftwoinjuk*, iwuilly 
||tt(_diaefQiCTtbcr.uiu'>( Ihin Ijc bk^ujib t for ittticaU of ijiitr TIlc nii»L ci^miiiL}^! 
■n nt>t rfcocmsinit <li^ bkepi raoKlc. and in -infkin^ im (he 
kft prop*r ntoation 




a8a 



A MANUAL OP SVRORBY 




3. At fAf Biiid nf tkt £lftoir.— An oblirroE inciuoia U mfedct, ftboal t 
loniE. pa»ll«1 t*f tM inner Itorder ol Ih* biotp* ivmlon. aad ite tmbln 
KBpondinff fothft feMvf (hf* pOrvw (i-Tjt hj. C| 11i« ■ouwt«hMikl b* '^ 
ftl ibouf nn u^leof tOTly-fivr 'I^'jirnv^ in iTiPOiliof II]eUmb.U]d (ttthe^ 
ai. juid nuflv pAralkl lo, i^ir mcillAn liauUc vdn, Hbkb, If Mca. Qtufl l)tf dm* 
inward» Tli^ biopilal r>Aci> ii nuw irdaed. and ilw «rtcry wilb *(» i«» 
comiles ripowd in tbo lo»c fal. Ibp nnttUftQ Q«n« bvng iweJl «»») oa ■• 
litfl«rfld« Tfti' ni?«vl|c IB puHd from vrlihm dutu«rd« 

OfOUtfTLl <nnalacl«S,— If Bbov« iht origin cf the ■apcrior prafiibd«7» 
trrior dTT-iunild) m ilrttoLrl nritt Mcniltn^ lirandw Of aopBrtor j voAinli 

If IkIuv ihc origin or ibo Inferior i;(ufbn<J4. iht aniiilninfn wimS Af 
«1bow-Jom( 

Th« DUfcr ArUry rftrdy nmtU liAiure uccpi lor palnuLT luFmc«Tbutv 

thr vriv. in rfa« latiifT caw by pnUrftng the ortetiuJ wouad^ Tbalodloiilv 
bKrvoi>p«loueraiIons aivdeHrlbed, but uc oicrvofica aoca to Ihsntfii*^ 
iloQroDrnocdDAil'huiJKihws in th« opcnutng duMre. liifaouU bcbmn 
mind Ihat the linir vi ihn utflrv ii froin Iha coaire of A* bend <d tkr *n»* It 
the riidiBl vldeol (hi* pimfrkrinlmui 

r At iMw K'nil^An mri'cifkn >rxHii i icirhin Ipnfpih u nuile diivrtlyiipvvih 
injm the flaim of the 4ti»i ni the line t>t the \i!ucl tl-la St F) Tw dor 
IucIa U opened, l]^ itinJuti iif the flcnuj uu^ji tiliitvit drA-mtlulM inner i4« 
jind the vcwiub fine then noea, acc«impiuii&i hj ihc nerve ^hidi lice lo 4* 
ulnar itda oJ the irli^ry II posvible. Lh* vsn9 coniitM chnuM Imi ic^rUflA 
iml nor rnirliirjiyi in iht lljjfctiire TheanporiHn nwdlfl miypprhip* \wTami 
from \wjtb>n outwnrflv bur tbln Is 1 ni«l«r of no cpefifll Imporunct In MttC 
miih hucb II lUprrfitLAl vc^mcI. 

J ^1 fhtMtiiiilt ofiht F^mrin.—Ka induont» tn^e alonxm lins dni*« IP* 
ihc uiifdnK v^^tiv oi [h« [ipof itic Inner condy]e lo the rMAl«>deaft:k>|*^ 
tofm IxjTLC (Kig Si. (^1 The whJtD Un« Indicetina Lbe tnf muo elaf itfUt 
b&Ewrtn the (1e>OT »rpi ulrmrik eiAd Havtir <tJbUinit ili^jtiorufn H then foa|M 
Eor hiirl onitfiiid np, It ih i^fti-n v;^ •ilij^hily mafV««^ and mity be diftruk |» 
diitiaKulin If th? concci Intenpnn! hu bn;i opF()«1. th? nimun n dbc«l 
;oiiiLrd> ihe u1ji«, 4Jid ruiJIlv (tUM xtic «nacl> uriilei fov« of liie fleierOifl 
olAftfiip w&ib the nvrvv Ivtnii n little ^ay (o Ibe inoer ftide^ The moet 
mlfltale conkiuFt tn uvilin^ loolitr io therudieJ ^d^ ead in e*pu«tiBf 
ponlAnu or ihv flc^Eir iiitihm»^ or in fouinf beturen it ud Ibe 
umifif" CkT-ttlonAllv, Ftrfi uhrn ihrr forrvci inEenpac hu lieen uiewii> ■ 
bnr<Jiuei (nay p^n [jcyurul ^he visihcU, ukI find falmself bctAvm the Cvtf 
Cari>i uinufii aih} iht rierxiii' puifiimluii 

The attmnLD iippcr limii f>f chc uln«r Aritiry <ui alto be rieched itmufh tf 
ol>lujiiii mdainn Miendinv aJon^E ihe upw border of the nroa»t« Mm, llu 
finfnm^ up the ipa«e in nroni ol the eJbow (uite^cubhal rirnj and etpodai 
the bifurcation aTthn bracblkl 

The BftlUl Artery will require Uaiucc ander aiiniUr drcunucvxaailbi 
ulnar. The line ol the veatl »«iendalrom the middle of the bend of tbe e lber 
to ih« mtenrpece at the wrtet btlvean the flnor carpi radialii aad ilf 
tdpinator lDnBn« It ihen mmsoniwkJdi, And mav befell Dettiog ic ibrifM* 
dscilbed bv Trench anatombira lu'It titl)fttilte (or MnlT-buij. bdvoa dff 
lendoni of tW uienior prlnii a»J becaudi inCenicidu mudee. 

A I theUdi^ j/fAf M>rAftbo\«*aelniii> be KCored by openingc un the abowr 
maniion^ )n(fr1?nrJiDou( hollow, where tha kficry b fbood <oUnfu ««wwk 
tft Ibe bue oi Fh« tint initfcdeoiit ipnce. As obliii«incWoB U oiade liMieV 
the tendoTie, titmdlng irttiu ihc iinr\ nf ib» tfylolH praceiM<tf the nuOSia idA> 
baee vf the AmL Jiii3Umri>a) iH^nri Thr radial i^n U found iiniiifVriilj 
beneath the tkin, and a. few L^it;^ uf ihc r«dUI <3cr^'c A ikcpei Uy^of EMOft 
» than divided, pudag bclvfcen the lendtma* ajul beneath it ihe artflfj b 



uicj retracted The s'p^h^hcljh are found undtr ci>ver ut [hi'% siruc- 
:ie r^ial nerve lo ihe ouler aide, though sep:irated by an interval 

nt thfl AMomiDiJ Aorti has \ieen unilerinkei] jn deven insiances for 
ia.r\- or wcondary haemorrhage, or for ditTiise inguinal or ihac 
xben no other method uf treatment was practicable. All these 
proved fataJ. thougb one patient operated on by Monteiro in 
rica survived till the tenth daV' Ti has not been performed since 
::(ioD of itnct anlisepus ; and inasmuch as the fatal issue was in 
ncea evidenlly due lo seplic contamination of the wound and 
izmoirhage. and as ihe opeialion has certainly been succ«afii] in 
is pOHsibw that we may yet be able to chronicle a salisfaclory 
Tiumpb of oiodem aurgery. 

LDct |idaiu of operation have been followed, viz.. Ihetrans-periloneal, 
ra- or i«tra-periioneaI. The latter method^ performed through a 
Jon on the left side, reaching from the tip of the tenth rib down- 
involving the stripping forward of the peritoneum and its contents, 
cull and dangero-ss ; and inaamnch as we need not fear opening the 
^vity, there now remains no occasion for such a complicated dis- 
ic 'rBH&-/frT'aiua/ operation cf^nsiata m opening the abdomen through 
slightly lo the lelt of the middle Hoc. hsiving the nmbilicua on a 
its centre. The intestines are retracted on either side, and the 
yer of tbe serous membrane covering the aorta carefully divided : 
sn no difficulty in passing a ligature around tbe vessel Possibly 
:n:aution lo prevent excessive backflow of blood would be advisable 
the inDominate, viz.^ to secure one or more of ihe common iliac 
Iditioo : sncb woald in no way interfere with the establishment of 
aJ circnlation. 

■am niAO ArUfT entenda for a distance of a inches from the hLfurca- 
lortaoppooile tbe left side of the body of (he fourth lumbar vertebra 
of the ucro-iliac synchondrosis. It may be reached, as ihe aorta. 
hods, tbe trans- and the redo-peritoneal. 

tFo-ptriltnual operation (Mott's method) a curved incision i$ made 
i abdotniiia|parieie3 similar to that tor ligaiuring the external iliac, 
□g higher (Fig. 83. A}. The muscles and fascia tranaversalis ara 
vided, and the peritoneum with its contents stripped up and held 
vav with a broaa ntractor. The ureter wbicb crosses the artery is 



a* 



A VAlfUAL OF SUXOBaV 



Thf lyfiii-f*M7C"val DUn bAi ftlTMdj* b««n urvtcmldA «rt!> mcmh nam 
cue&, uif] will (ir^jtijilily rjillrthr tiipfrttdn ftll nih^r mnitmlt As ikmcbb 
luwici iiL lIlc Liicdiati line frvni Lu« brmphyiiB lo ibo uintiiUcva iFtC- A^ C|, fc 
ptricoDvufli o|MD«d, the inccBiiiin irtracitd. the vond vWbt tot tadt^imi 
hy%n Icict^oti Ibroa^fh tho uatcrior U>«r of Uic pvJciNJ pcriloacuL ad « 
flf-arure putcd ^nd iled Tha operftEkm noocl not b* A^IOeaJl oM.haAl 
iXTtibt \vhii:h frotuh Eho irtary jiitl kbov* Ih* bilunstioa nun hmtm^^ 
nv tiller- J 

OvIUtn-Jkl Olrvtklfttioa tfXmt Uiston of dmunaa IUbc Aftviy — QAtOd 
ihf rnt"\>i! i!'\t, and Ll4 liraiiLZir^ ttv uir^Am u( lIic iuuilomt^ra %d iJk 
ancnn avM ifce critiuniflti iliac, *aJ ol the superior cpt|:v»irx. Idmltf\a 
intrFK4tiil4 u<M tba qu|Hirf]':i4] 3iif] rf«*ji *pi^3iHtrtc Tht tm/nMJ Ua- «jd 
r^Fxni'ht'H in utipiiliMl hy ihr iini'in tif |iTt The Inmhar bruicliei iW ttt I 
Uiml.vir |V') the middle lacral t.^rA thr laiPUU lacnl , (f) ilie rvtPcvpQblCMi 




FlO. Aj-*-]HCOlO!n PC* OrttnATiONs ow LowcR Pajii or A 

AND TlllCUB. 

A, Mott'i lociiiop (or tyind comnioo ili«ari*rji : It. MarMlhn l»fiiiil>»ic«» 
for fhe nnr . L~. Infl^on lor irani-pFntociraJ h^lum ol ilac WM. 
D, inclnlfir itir findRiun u£ h|p1>y ihe uiierloi nwitiod; C, b^nd*^ '^ 
lomy H F. Abortittliy^H tntdihad upentinn (or UfAlurc of ctierail iM^ 
Gh Ait]«v Coopfir't inti^ii^ri [t4 vun4 . H. li^iuca oE Inoval aiV^f^ 
ftpOfc of Scarpa 9 inuiple, K, iLRiturv of tvcnorftl arlviy u 1 JunMf'i <tti^ 

LoQQWB of ih* rwc> ohluntor arlirin : and {^J tlu catDfntjnlaillDiu of «h# 




rlu|;e tnmi. <ir Armriatn o1, oub of lit branches, (he clul**! b«um lhi« 
r:i>mm'?rLli, nflbcied. mm! loulj- has twni r*O0MTB«adad Jtf A n««aA of 
m^ the Vjjv nf AH vnUrgiift prnvUlv TTia Imnl U n thort OW; al 
1^ in^hn in Irnfrilf, itiil K tmi rrarhrd tiy npenlns ih« slidunivti Ifi ihvnMfc 
Tine tcb^iA the timUlkui. i>ijUilii|r >uidc (he miniiasi. uul soMchitttf fc* tte 
rrifuELHiiiiJi uf tlic Luinmuri ilUc Tlicpovicnor Li^cr o1 iLe fJvc1<oi)e]jiMii<~ 
r4^fii1Iv ilicIhctI, the ureter avDidhl, and MA urmcil ancunotn iwcdle pi 

The €oUt(4niI ClrcdlttlAS k Thv iafni> u ihat fjvm for dm iriVnuJ iUv 

dlvUkjii 0f lhcc::>mmon \tiac 



LIGATURE OF VESSELS 285 



tttTj occasionally needs lo be secured at its point of emergence 
ihrough the upper part of the great sacro-sciatic foramen. 
aied by the junclioii of ihe inner and middle thirds of a line 
o&terior superior iliac spine to the top of the K^eat trochanter 
ade in Ihe direction of^ Ibis line, i.e. along the Bhrea of Ihe 
, which are separated and held apart. The deep fascia 
scle i$ then opened up, and the space between the gluteus 
□rmis de&ned. Through ihis the upper margin of the sacro- 
be delected, as also the pulsation of the arter\- The vessel 
as deeply as possible on account of its early division. It in 
ufne dissection, and possibly in most coses it \%'Ould be wiser 
ilk of the intemal iliac. 

d Fndie ArttiiBi seldom require to be tied, but may be reached 
dal spine, at ibe junction of the middle and lower thirds of a 
I the posterior superior iliac spine to the tuber ischii An 
' over ibis spot about 5 inches in length, corresponding in 
fibres of the gluteus maximus, which are separated and well 
5<pine of the ischium and lower border of the pyriformjs should 
?d, and the vessels and ner^'cs seen emerging from the foramen. 
J lies [o the inner side of the sciatic . the ligature is passed an 



Iliac ArUry is probably more commonly tied than any other 
agnitude in the body, and if proper precautions are taken, a 
: may be confidently anticipated. The trunk of ihe vessel 
i\ to'4 inches in length: it nas but few branches, and those 
.'Ti. ^vhilst it is easily accessible in any part of its course. Its 
ited bv the lower r\\'o-thirda of a line drawn from the bifurca- 
ta to midway between the anterior superior ispine and the 
>. r r.. to a point a little internal to the middlrf of Poupart's 

ions as to the best means of reaching the artery have been 
tran!^- and extra- peritoneal methods have been adopted It is 
3d, however, by the latter thai it seems unnecessary loopen the 
here are two chief forma of eKtra-pentoneal operation : 

OperatMH —An incision is made parallel to the outer half of 
ent, commencing a little to the mner aide of its centre, and 
r t , o\ei the internal abdominaJ ring, and extending upwards 

about J inch internal to the anterior supefior spine (Fig 83, GJ 
ilique apofieurosis is divided along this line, and the exposed 
f the internal oblique and transvetsalis muscles arching over 
al are drawn upwards by retractors. The transveraalis fascia 
ritoneal fat are now opened with forceps and director, and the 
sating immediately under (he Anger. It is very important nut 
Tthe epigastric or circumflex iliac arteries during this manipu- 
y are most euenltal faclon in establishing the coUaieral circu- 
e circumflex iliac vein crossing the main trunk from without 
90 be avoided. The needle is passed from within ouiwards. 
. and Ihe divided muscular and aponeurotic structures brought 
her by buried sutures. 

'ttdifird Oferalian is that more commonly performed The 
i inches m length, etlends from a point i) inches within and 
joT supeHor iliac spine to just external to, and ^ inch above, the 
art's Ligament (Fig. 83, F). Through this the apuneurosis of 
ique ift divided along the course of its fibres, as al'^ the internal 
taverialis. The trajisversalis fascia is now carefully incisetl . 
sely in thickness, being sometimea well developed, but i^ occa- 
tinaied as lo be scarcely recognisable, and in uuch cases Ihe 



186 



A MANUAL CP SUli(iERy 



peritoneum nuy unLnit-ntiaonlly be <vpi7<iDd In llw pnoeot d»y ibit b m 
Acciilcni ufitljclx iin^it4Jici7. lLg wuunil Udn^ rcadf[y dosed brvcoaiaMM 
vururc, juieI no hnnriH «> n rvil?. r«uliiiig The fific«f>AfV now btrvdWid tttV 
tha U'outirU Ar<] the perilr4iei]tn aail ju cnntentu vtriAvc! troifi lb* lUu taa 
Aiirl (intiin jnu'AnL^ »ml T'>rwar<K tvhirrv lh«y xt9 \f^| <i(ir r4 ih# ^nj hji 
bfoad inaml.! Ln ihr ijm^r ihu^ m^nnl W can w i^v ihMa* V4tfb 
covcrcil UY Ilk fjitc^a, ind iv iu innrrr liJc the ruuadbJ uuilint of ib* nk 
Tlif vchcIa He lu ibc lEiiicr bon-lcr uf Ibis, ArJ cAii taudJfy be nAdily liul 
(invotri^Hiil in a tAJ<iii] iifinAth, wrib tlni {^niEo-cranJ onN* courHn^ utqF U.mI 
^■•■h-'kpt torn* lymphj^rir ulnrnW npin il Thj» art*^ it wpant*d fntfQ te 
tftm wbirh lie* to rhr inn*'r iwl#'. ajid rhp riMrJIc |i.'vgw^ fmm wiiliir nariAfii 
[f ihc irantvcruiliii fAscLa hju noi haen proptrly apenoi. U li ijiilie poulUiM 
\Uii' II mj LiiKdl'itrr vfilU iht tjcirluiicuiu. aud cjuiy ihc voddi lutwHrib«tf 
it, Hrlim tUcy mAy be found ander cover of tbe apfttuU 

Oa tfomportniE ^bv Iwl> opwratinnt. w* ar* v«ry dinimdljr in bvoor d lh» 
lalicr plan Ify C->::ipQr't n^rlhi^i ih# »n«iy i« Unl ivry dow in 
coMAtr^rdl bruichpi, wT^ikT hiiT n tmatl poriicm ol tbr trnnk UFtpiwil.~it 
if (hat is lUttiihnl unit uTihLEldtbli; loi the jLppllcAiiaa of a I^tuurr lu Ar4« 
thuLr in |Hi*nni1fT In .MuTirirLlai >, lju ibc othET hAod^ the vb««(1 u lleJ «vl 
flway Trom zollnicTa] brsntl^ri, and if iho «kpcif*i1 nonion rrf ih* -rual a 
dlMoied, the common ilist.il cui b? nochcd uttd HCDndv^thrU'' 
by vittiidtn;{ the inciKioc upw^irdt Ai io Th« gn«T«r iEf> 
*M1M (lifliiii h\ ihit nwrh«i1, Thl* may h*v« bwn the caiem pcu^i'iij*;!^ 
ilAyi. ubvH lim mu^doi wtm nut vutumL Foi favcfrftviunjc «cpiB;d>Hha/^. 
bm cnrtfMl iicpMi, ihr uif of buried BUtum. and the ponftrility d 6eit( 
wiiliuui drfiinA^o inbH should render ^Dch & >e^iie]B im|>nHMh1« 

Collltar*! ClVOOlftOra — .f -Vftiv iit. Sup«riar c-pl^^rkf of inMm*t tttmnT> 
lumbar, ind lu^ur InUrt^uvlalk v"A Aiiperfidal and d^rp «(4gMlf1C Ui fb<rtrf 

IQClU* 

iVifmor 3i'- , Glutcul au^ sUAtic v/Hh iownuJ vtd ir*tmmi dnwilciM 
Gmi ^rcrfurniiiiK of |tru(iind« ai back of cre«i irodiADl«r (<rud*l atma/tomBi^ 

E^iiinjl uf llio-lumlur iIiieI gluMM vrtk dMp ai3d *npvritc4il dfteste 
ihv? »nd aiic«ndm^ branch ni «xi*mal circomflix 

tmWiHSi t/t (.>biimTnr nt/A miomAl rirrimflfri ancl lormlnaJ diiliMifit 
Intenml pudic lJ/A auprrHciAl and deep extern^ pudic 



THc Oofluaoa F«iwra] Anen in biii nmly IJniured. ciECTpf at a p^l ^Wiff ■ 

lii|vj<iini, unc* (ha numbercf hy mi liw tflMr 



tnvatur* iti .imE'kti.'itmfi nt liwii 




Cblhns lorthK cprnulnn it T« hntcr pn^iknloTlr Ibt MiprruLl illu Unff 
be rc^bcd |jy a verilcjl inculoji over the line of the vcud- eiusndw b*!^ 
Iittlt fllMive 413d hzUiw ruuput'H lupMiaent. The W|xibc^UL tyiaphiW* a 
^rint muHt hfl r.a»fn]ly avnidtd. w critirifDnn iancU diodArl. die ikn^ 
c\E-:*'*l flriii npf^nM, nVniJ (he 1ij(»l"'* p«ed frofli lb- iJiner sd* 

ColJatvrtI OiTontatloD /uI/ivjI t^ . Ubnurafor t^rJt intprfvat ^inmnilln. am 
imcfrifll pudlc i/rA ntfrrnnl ^iinllc 

Av^^rKT Iff r Cflutckl And pcinik a^ifi inTcrnid ajid ctterniil circuiala- tm 
Antl ptrfiraiinx ; comK norvi ifchiidici t^J^ pvrforaiiiii^ of lb* pvctevAt ^ 

motcular of popliml 

Tbr flapfliUclHl Fofflcral Arterr l» indJuAied by a Unt dnuu Ipos rnUnf 
|>cLkt«--iiibc AiiEcHi-ir ^Li^irrLui >pui«And Lhni-mphTHt pubih. aod Ihelttbcto^ 
tff the innmul comhln rh^' hmb bcinx A«ic^, abducini, and a bulo *v«rlB 
II may bo tiviirKt m ' t]i4> •-Hf M <<liKr[ion.' * r , a( Ihe apn cif Scarpa^! tniB^ 
uT In HiinrcT « canal 

/.f^4'i»rr III lA* .^Pfi cf .S;j«*j 1 r'l4uifjr — A ^-Inch lndili:>n ii in*de la ik 
but: (if the aiLcj). tlw ttiurc beiijtf aUjui 4 uicbcH (ur a liaikl'k braadlM beb* 
TVup^ri ■ licimtni jPijc, 4j< If) The int^atncot auj binr m djiiocd. ih> 



e arlerv m the middle uf the ihiyh (I-^ij^ fij. K| Tht internal 
ncYW and long saphena vein, it -^cen, should be drawn ariidc Th« 
s e\postd bv divisinn ol (he fa-^ia bt^, ils fibres rannin^ duwn- 
I in\\arJi H the upper pun "( [hi- vt-isol i^ lo be lieil. thr' iriner 
luld I'e looked for, and the mu^de ii'.eh drawn outi^ard^ , whilst if 
ton L^ directed lo the lower half, the outer border ^uuld be defined, 
nuaclc retracted inwards The aponeurotic covering of Hunter's 
low in view, strelching between the adductor longus and vastus 
il ifi incised, and the sheaib of the vessel fourid below it. with the 
he vastus inteniu^ lying to its outer aide, :he Long saphenous nerve 
: from without inwards, and the vein passing behind it, to become 
iwerdown. The needle may be passed in either direction, and the 
ui]ld not be platted too low on account of the contiguity of the anau- 
DugPA- A common mistake made by aiudenls in tying^ this artery 
ul subject is to burrow down along the vastus intemus on the outer 
i vBsels : this is to be avoided by always keeping clone to the under 
the sartorius until Hunter's aponeurosis is clearly visible 
al CirBnlAtiail is maintained through the profunda and its branches. 

>lit— 1 Artaiy may be tied either above, just after it has passed 
tie adductor opening, or below, in the depths of the popliteal space, 
ably in the former situation. Neither operation is often required. 
^rr part is reached by an incision on the inner side made when the leg 
iducted and e^ertcdparallel to and just behind the tendon of the 
tnagnus (Figr S4). The internal saphenous vein and sartorius muscle 
rawn backwards, and on opening the deep fascia the adductor tendon 
id hooked forwards, whilst the semimembranosus which lies pos- 

kept OEit of the way by a suitable retractor The artery is found 
e to the bone, and auirnunded with a good deal of loose connective 
nediately behind the adductor tendon. The vein is usually seen on 

Side, aod ia here very thick and den$e, so that it can in the dead 
■ readily mistaken for tbe aiter^', 

it fart is tied through an incision in the middle line of the popliteal 
iding the deep fascia, and drawing out of the way the heads of the 
mills muscle, and the internal popliteal nerve. The vein is superficial 
cry, and is fennd by following the short saphenous trunk The needle 
from tbe iAser side, 
■ftl Oinalfttisa is maintained by the anastomoses around the knee- 



tSS 



A MANUAL OF SURGERY 



border of ihe libia (Fig. 84). dii-idiog the skin OAd aubcutancoia ta 

loog aaphena vein and Der\-e beiog drawn aside if neceaaxy. Tbeljl 
oS the soleu? i? ihus exposed, and inciaed diicctly Icrwards the tibi^ 
fibrous apoacuroais on its deeper sur^ce is met with. This hanof b| 
Jhrough, the miiacle is drawn backwards «iih the idiatctor, tod ^ 
ensheathed in a deep layer of fascia, are seen tying on the flan 
digiiorum. and u-ith the posterior tibial nerve to the ouier vdt. Tk 
comites arc separated, if possible, and [h« 1igaiur« pus«d from Iha 
Sometimes the above-mentioned aponenrosis is in the substance of tbij| 
and a thin layer of muscular fibres exists on its inner aspccL 

2 In the Lower Third of the Lee.^^n incision is mue midway betvtf 
lendo Achillis and inner border of the tibia. The skin and ttscut. ia4 
the upper part of the internal anaular ligament, are divided, and Ifaftl 




I'l'i. WiJ.^IsCJMOS^ FOR LlGATL^HE OF THE POPLrTEAL AND PoSttl 
TlHUL ARTEKIEti 



seen lyinii on the flc\or longus difiitorum, with the ner\« behind and 
nuter side 

3 lithimf /he MaUet/hn - An incbion is made about a fingers br^dd 
the mallftitua. cutrinE round its lower border. The deep lascia (or. ■ 
here lermed. the internal annular ligament) is divided over the vessels bi 
the tendons uf the flexor luneus digitorum and AeKor proprius pollicis, a 
arierv is then readily cleared and ligatured The sheaths of the u 
tthoEfkl not l>e opened 

The Anterior Tibial Artery is found along a line stretching from 9 
midway liet ween the tubercle of the lihiaand the head of the fibula above 
central point iM-t^'ecn the two malleoli below It maybe tied in throe silo 

I /fl the Uf'f-er Thinl of rlit Lis - An incision is maaeenactly in the line 
nrlery {ri^ S5J, and ihe tlwp fascia incised The intennuscularsjaceb 



LIGATURE OF VESSELS 



389 



% anticus and the eileiuor communis digitorum b opened. The 
between theac musdes upon the iaterosaeous mcmbnne. the anterior 
e being to the outer aide. 
It MiddU oj tkt L^.—Th^ same inter- 
space is opened, being indicated here by 
white line. The vessels l^e between the 
iiicua and the deeply placed extensor 
poUicis, the nerve usually lying on |he 
i needing Id be diawn aside. 
t Loirer ThinI of the Leg. — An iaciaion is 
he line o( (he artery, reaching upwards 
inches from a point juat above the ankle. 
fucia and upper port of (he annular 
are di^'ided, and the vessel is found en- 
tn a mass of &tty dssne between the 
f the tibialis amicus and of (he eiiiensor 
pollicis. the nerve lyicg to the outer 



■nalii 7>dla Art*r7 extends from the 
ihc line between the |wo maJleoli to 
k'al between the bases of the first two 
J bones. Anincisioii 19 modern thisdirec- 
S5). the deep fascia opened, and the vessel 
ccd deeply between the eiteosor proprius 
id tbe innermost slip of the extensor brcvis 
1 It IS by no means eajy to find, and for 

rjrposcs the best plan would be to divide 
bv an incision extending to the bones, 
pick up and lie the bleeding end*. 

nuiBAl ArtttT can be reached through an _. _ _ 

dong the pciterior border of the «ntre ^'? By-lNCisiONS por 

lula. ihe leg bemg laid on its inner side. 

r edge of ibe soleus is defined and drawn 

the lower fibies of attachment to the 

dn^ divided if necessary. The flexor 

llicis is thereby expowd, and incised in such a manner as to allow 

on 10 reach the postero-intemal border of the fibula ; rhe artery in 

ily found lying Ui an osseo-aponcurotic canal- 




LlGATUKE OF ANTKKIOH 
Tibial and DoitsaLIs 



19 



CHAPTER X. 



VElNtL 



be 



Wb 



ThiomlKwii- 

By TbrombosU is meant iDt^a^'ascuEa^ coagulation in an 
the circulatory system. Normally the btood remains id a 
dition, owing to some interaction between it and the vessel 
the character of which is not yet fully estabbshed* Any 
producing a disturbance of this normal equilibrium ma^ 
thrombosis, and any part of the vascular tract may 
by it, whether the heart, arteries, veins, or capillaries. 
discussed already some of the conditions associated with 
or arterial thrombosis ; what follows, whilst referring 
venous thrombosis^ is also in a measure true of the other 

The Cfttmea of venous thrombosis may be arranged under 
headings : 

(i) Changes in the vfsul waUs, as a result of which the 
of the endothelium is disturbed — f.g., injury (either diviskn, 
ture, puncture, or contusion)t inflammalion, or degencfatiA 
in varicose veins). 

(2) Changes in ihe constitution of the biood, whereby its 
bility is incre^tsed. Excess of excretives, as after 
during removal of the uterine walls, may have this effect, or 
presence of toxines or ptomaines arising from bacterial 
Hence septic diseases are commonly associated with throoi 
Great loss of blood up to a half of the whole amount in the 
also increases its coagulability, but excess of leucocytes, 
leukemia, has the opposite effect. A. E. Wnght has ^own 
the percentage of calcium chloride in the blood is an i 
factor. If o'6 per cent, of this salt is present, coagulatks 
hastened, and he has proposed to reduce the loss of blood 
operations to a minimum by injecting into the rectum 
hour previously a pint of warm water containing in 
2 o-£. of this salt. In one or two cases in which we have 
used, it appears to ha^e been efficacious, but whether it 



hatf! 



win 



■bbpUa' jtpf>!iciMef ts t^oubllul, since it might also lead tc coagii' 
Hfib unwishE(]-for IocaIiuc^, 

r K Dmim\kni fait af tki httwd iirram v^'il] teiul to prutUicr Ihram- 

ItnsK if u>a\* olh«r condition i^ 'aIho pre&cnt 1o diHcrmme it. 

ILdcr (bowed ytxob t^o linit blood can rcnmin fluid for a Jong 

I list tf kept IB Aiot'tube fuiLiicrtl fjf 4 ^ujuUe length of a voin 

lull; tvi when dthdrr of the pr^x^iii^ fkctofs ik prt-sent. a rt-- 

FtvdaLioc of the blood Mr«am wotild niatertftlly assist in c^tising 

tcarilMEon. TTjus, when a vein becomes prcavcil upon by a 

huDQnr. Ihc obftTucltun lo (he IrlLud tlt;w produces & cloi aI the 

wx »hrre ihr inta^iry of ihr «-nU is mterfcred withn Aftpr 

lEvm. cucb A£ typhoid or rhoumntic, ^vhere th« ch;iractfrr of th« 

Iib«d i» sortMwIut altered and tiic Action of ihe hc^rl is weakened 

M dttuges in the musfaihir 6lrrc^» the drfcctive vts-a^Ur^o cmiikcs 

■ nfimbition of thp flow in th<? vdn*, as a Tesiilt of which the 

'bCRVYnCHM pr«i»uro i« ditninishcd, and the vnlves arc only 

|«li«]tr pomctl Imck, 3p£LCe» l>dnfi left l>ehLnd ihcm in which the 

iiwd st^miU^- CoogiLLiLloii is jmihalily drt*?(raiiicd by sonic 

^hi injtity or prt-s*iire which i& not noticed by the patien!, or by 

iOBW l«H«ae<l Mtalily i>f the wall of the vein, or by disintcftrj^tioii 

d ti)c Itticocyte* Olid setting free of fibrin ferment owing to iho 

Maivc rirciilAtioii. Tlif^ clots Thti^ fornit^d Iwhind iht- valvea 

gmteJIy incrciLM in wie xintvl the wtiule laitmn of lliv ve46«] la 

«tKliuct«d. The irA*/^ //^ cif preRPancy is aomrtimei induced in 

tiK ttmr w;«y, dllliou^li it i^ Lrubjible that m many uue^ the 

<aj£DlL.rT: P*ir-!i.U kJ thf ff-iiicr;il vein from th* uti^rine [j1pxti*i^s. 

iM O&AnbcUr of the ctot v&ne« riccordrng to whether it is 
4epMilcd «lowly or is due to a nipid oja^uUtion uf llic blood. In 

thoMoct CA5C ihc Mf-^^llrd WkiM Throin1>aa is met with, which 

(nml upon, ^th\ adhf*rcft to. the vcvwl wall^ and ffrnrlnjilly 
hy fresh deposit of librin unlil it cnliroly blocks the 
of Ac vcMcL As to lh« mcihod of formAiion of this 
ln]<i nuuiy difTcfcrl opininn^ lt.\vc been ^vcn, ^Jihn, by 
apmrnrnLitly irriEatinK ihr mns c£ the mcfientery or lon^ie 

'i ffOK, !taw th« ihrombuft formed from what he imnf^ined w*is 
lUcdion of kuoocytea, which iidhcred lo the injured ^pot, 
MSiei .i tiinc toMni; their dcfiiiitiaii And i>orliti«> Wfie diAii^il 

In I ^briivoii^ man. Later rf^*o:irchet, bfiwevtr. iecni To mdi- 
that Iho fomutive elements m a whitv thtombus iire not 
kacoarXe^, but ihe jo-caUcJ livmatobWu of ll.tyt-in. or the 
'ffaod p1aia>« of Bi/M/cro/ thos<? minute oiloiidcvs eJnrienl^ of 
A^Uood which only become App:treiU on special preparation. If 
«c«r1ain nufntwrr of led corpuacka ^trc miUngkd m the mesheft of 
bcckM, it i« icrfnc<l a lUscd TKrembtu; the more fupid iU for- 
I, the grrsiti?r ih^ nnmlwr of rr-d rorpii«'lr*<i pr«rni, Shoiikl 
tlttUood coagulAte fii mayu in n vnm, ;le !itl<ir iu totAi division or 
:, A/i ofdionry K«d TliromhUB i'^ proiluccdi which At hr^t i& 
It to tbe waII. biK bc<:omc5 Kf later on. especially At its 



i?ud|] 




a9a 



A MANUAL OF SURGERY 



base- A similar type of clot is usually found post-mortenit 
any white clot which has formed previously. 

The SffecU of thrombosis may be coiisidered as locaJ, distilfi 
proximal, 

LocaJl7, the following conditions may obtain : (a) The 
may be organized into connective tissue, a fibrous cord 
the vessel in the same way as was described for 
thrombosis in a previous chapter (p, 213). (h) The lumen of 
vein may be re- established by canalisation of the clot, or of 
fibrous cicatrix replacing it owing to the dilatation of the 
contained within, or by cleavage and shrinking of the tbrombiBl 

one side of the vein wall, (fl Thei 
may soften^ disintegrate, and ne 
away in minute particles into the 
culation. If this is unattended 
sepsis, no barm need follow ; b 
septic in origin, an abscess may 
locally, and from this septic pi 
may spread along the vein and give 1 
to diffuse suppuration, together 
general pyemia- (i) The dot 
shrink or become loosened in an 1 
of a varicose vein, forming a 
mass which may subsequently be ■ 
trated with calcareous partidtt, 
stituting a vein stone or PkUMitk, 

Distallyi congestion of the 
veins is caused by the obstructrai 
the circulation, and if a main trunk 
affected, cedema of the limb fell 
and possibly ulceration or 
In favourable cases the collateral 
culation is soon established by the 
ing up and dilatation of other 
channels, which after a time 
somewhat varicose, and if at 
superficially are often very 
and obvious. Thus, if the common femoral or external 
is occluded a1>ove Poupart's ligament, the internal saphenous 
superficial epigastric \-G\ns become distended and varicose, 
the latter is seen coursin^if up the abdominal wall towards 
umbilicus, and uniting with the same branch on the oppo^te 
to find its way to the saphena vein of that limb. 

Frozlmally, the process may gradually extend upwards, 
finally involve larger and more important trunks than tb* 
which it originated. Moreover, a portion of a thrombus mftjf 
detached as an Emholm (Fig. 86, 6). If the clot is undergoi^' 
molecular disintegration and only minute portions are set free,tb9 




FtG. 86. — THROMIIL-Ji AND 

EMBDLL'e;. (Keen and 
Whitk.) 

A, Thrombus in siiu ; B, crn- 
bolus detached from the 
same 



V££SS 



AM 



wflUftd off W Xhi iun^^A Of kidneys, and no Symptom* BMd bt 
4iMd. If, bovk'ovi'r, a lar^'c poition ia detftchfidi uf^^Ot 4)Paw- 
IBM of dflpau'a uml cvt^ii ilrnEli (kciii fium r>1hbttuc:lioTi (o Inc? 

pdncnary vmwK If th« clot bcLomes fie|>nc an<l fra-^menU 
aanym^ or^aaismt aic c&rruKl inti> the circul^tioni pyn^mm is 
tkmuiit betn^, tiuwcvei. prececM m the portal urtA t^y pylc- 
lebitifr— lU^ mppurAiivc phlebhis of tite portal ij-oiik» in the 



t 



The {AiaicAl &l«iu ^ad Treatment of vctious thrombosis are lbs 

AS for phlfhiiis {iiA'4- 

As JEmMu iK the term appliod to nny Foreign body which 
tEtncb for A f^cAlCT or less disUuicc in the hlnoilvessc^U until Jt 
btCDmalodsoilviithu] thcniuiKlcfiikst'stilisirttctmn. Tlit^c .irc foLir 
iuintvieiv-i of rmTNitu^ met with in prnc^tice - {a) Simple Bmholl, 
'/., hlooddc^i cninuliLlioas or fbrinous vegetations from ihe 
viiic vaJves after acute endocarditis, athcrh^iiTintout^ pktc?. hat- 
M4lo (ji. 25;^}, &tt ifliilnilrH (p. 3^3). rlc. j6] Infective EmlKill 
avail \J either looglceu muMrt of lucteria or disi[iErgr;iEe^] 
^xim^ of blood clot carrymf' micro organisms and un^natm^ 
» pr«nkic abKe48 wherever utey tod^e. (t^) Hallcavit Bsibcll 
j;c farmed by portiijnsof some maliynazU ^rf)wllr, fruni \^hi('li [hi' 
nroifi secoridary deposits originate; £uch are met with more 
frc^iMntJy it> tlw ^rcoiiialsi than in tlic curdnotiuita. (1^) P«ruitSc 
Mali iilao occur, fmch as the? ov;i ;ind sc-ulices ot the Tmui 
»iw«fv. Riid The FHfitui utn^ainii Jt^miiiii. 

Eaholi may he dptiv^'h^d fioni thv heiirtj veins, or art^nts, 
lUlouflti ncce:iMLrdy they nro iic\ci iifrcstc-d in a systemic vcirtt 
kl M> in the arteries ii[ poilal vein. Th('> art: of aW iucs^ 
tfd the ch^tmctcr of the remihin^ symptoms depends much on 
4k. a Urfic cmboluj* iitarlcd vn a peripheral sein iisutklly lodge!* 
■ «e of the brAttchcft of the pidmooAry aitcry, and may cjiu-tt^ 
Qduil fleat^ ; a Mnallcr mii; is .tircMvd in one of th« terminal 
npricAn of iht- lung, whiUl mtnnic onofi will very possibly i>jis* 
Ui^u^h the puinKXSiry capdlarieSf and become impacted m the 
^tleEEiic \'caacls. 

Ifbci» of AH £taboliu-— Tilt? Local r^fTpciH of the lad^ineiit of 
luaple «Tfibijtii4 T'^Msi^t, t]r!il]y. iti (he depo«il of fibrin tiooTt ii, 
MdiriAi; th« oh«cruclion complete as im a& the lir^ coflatcr^ 
tncich; ori^anizAtion of the tliiuinbua ui^ually follows, although 
Kanonally it may diMnie^ii^tt^ and dlsjipptT^tr. Undei these 
C3mnstanc4Tit a weak t^pnt m^y be left ir the Arterial waII, from 
^kchon atMurum ti> ^ubwquvntljr developed. T\^K local eficcis 
<ifiofcc(i^'c« maliifnant, and poioAilic cnibuii arc dealt with elae- 

TW DUtol effects cf embolic ob^trucnon depend entirely on tlie 
ntoiOQ of the vessel blocked to the surrounding circulation. 




394 ^ MANUAL OF SURGERY 



(i) Should the embolus be lodged in an artery which gircsi 
anastomotic branches between the point of obstruction and 
6nal capillary circulation, a tnD«i«nt Ul»mSa is all thit 
occur in most cases. If the artery is small, or goes to unim] 
structures, no symptoms need arise from this ; but if the \tasA\ 
large, or supplies delicate and important tissues, serious 
may follow even a temporary arrest of the circulation; 
embolus of the central artery of the retina always causes 
manent blindness, although the retina still lives. 

(2) Should the embolus block what Cohnheim csl b a ' 
minal artery ' (1.^.^ one with no anastomosis between the 
and the terminal capillaries}^ or a vessel with insufRcicnt 
circulation, and should the veins from the part be vatved so 
prevent reflux of blood, the obstruction will lead to d«t 
at any rate, a portion of the anaemic region — t.g,, gangrene Jt\ 
limb, or white or yellow softening in the brain. 

(3) Should a terminal artery be blocked and venous reflux 
possible, the temporary anxmic area soon becomes 
with blood to such an extent as to lead to extravasation. 
firm solid patch of a dark red colour, wedge-shaped, and 
its apex towards the embolus, known as a luunorrliAcic 
results. Tn soft tissues, such as the brain, venous regurgitatkni 
this type results in destruction of Che affected part, which 
to resemble an apoplectic clot ; but in firmer structures the 
forms a solid mass undergoing various reparative changes. 
result in the formation of a depressed cicatrix containing a 
h?ematoidin crystals. The conditions necessary for the prodi 
of an infarct are Tnet with in the spleen, kidney, brain, and 
branches of the pulmonary artery ; in the liver the anastomosii i 
generally too free to allow of its formation, although it has 
known to occur, 

EffeetB of the Lodgment of Emboli on Vaiioiu OrgMif. 

In Ihe Br»ln, Ihe middle cerebral artery ia mml commonly blocked. feioWifj 
in immediate hemiplegia, which may be almoat eDtireLy recovered fnjm»l 
commonly leiive^ some impairmeni of fuQction In children ibe symFrtDmn 
less marked, but ancarism of Ihe affected vessel occasJonaJly foLlowi. In 1 
Cflntrkl Artfliy of ths Betiiu, sudden loial and irremediable bliodnas ii p^ 
duced : the branches ol the vessels are seen to be almost empty, ibe 
becomes u-dematous, the m.icul^ alune retaining its normal colour, being 
as a cherry-reel sp<H, contra'^linE marhedly with the pallid {Edematous 
around. Vision is never restored In the Long, fatal dyspncca raulti bM 
obstruciion to a lar^e levsel: whilst, if a smalLer one i» Blocked. * certrii 
amount of pain and dyspmi-a is produced, followed by the tormatioQ of tf 
infarct, aa indicated by dulness, iirunchial breaihingn and bronchophoay- b 
the Liir«r. an embolus of the hepatic artery causes sudden hypocboodmc 
pain, and perhaps a passing ^lycoiiuria The portal vein is also aometiinei Ai 
site of an embolus, which h, however, usually of a septic nature, and givtirt* 
10 pyf mic symptoms {pylephlebitis). In the SplMQ, a sudden pain in tbehft 
hvpochondrium it n£>liced, the orpan becomes enlarged, and a considerAble lis 
fii temperature may follow. In the Kidney, sudden pain in the loin and I ttfh 



VEINS 



^95 



izmatuiim coostilute tlie main Bff«cta. In the IntMtlBi locaLizod 
n nr eiteosive ^^angrene ia likely to follow, according io the size of the 
alructed. In the limb*, (he emboli usually lodge at the bifurcations 
teasels, often laddliit^ acrora the ^rk. and obstructing both branches. 
pain may be fell at the spot, (booting downwarfs, and either recovery 
ene ensnei (p. 68). 

bills, or inflammation of the vein wall, may arise from a 

of causes, and is not uncommon in surgical practice. The 
ig fonns'may be described : 

nuile FlilaUtlBf in which a more or less iccalufd inflam- 

of the wall of a vein is attended by thromljosis^ it 

i for a variable distance up and down the vessel, but 

Dot further than the next patent branches, {a) It may 

'om injtiry, either subcutaneous or open^ or from the con- 

initatioD of a tumour or aneurism ; (b) it may be idiopathic 
rCt and then usually attacks the larger veins of the lower 
ity, or vessels which have been long subject to varix, 
ily in gouty individuals. The blood usually clots first in 

the pouches or ampulla?, or behind a valve, (c) It may 
low as a sequela of primary thrombosis ; or (d) it may be 
1 by an inflammation of the tissues around the vein (peri- 
(), usually of septic origin. 

iftetiTe FUebltu is a much more serious condition, inas- 
15 the thrombus resulting therefrom is always invaded by 
organisms, and the disease is often of a spreading type. It 
is form of phlebitis which in the old days so commonly 
d operations, and made surgeons fear any interference with 
it has now been almost banished as a sequela of 
J operations by antisepsis, and there is no more fear of 
; with veins than with any other tissue of the body. It may. 
n-, arise (a) in traumatic cases where asepsis has not been 
^ to or has failed, the organisms invading the clot which 

the open mouth of the vein \ or {b) as a result of septic 
ebitis, as in wotmds, or more commonly in septic inflam- 
. of bones, such as when a septic mastoiditis leads to 
: of the mastoid emissary vein and of the lateral sinus. 
»ia] results are localized or spreading suppuration in the 
td and around the vein, and general pyaemia, (c) It 
Jso be induced by auto- infection of the clot present in 

phlebitis. 

ICorbid Anatomy of phlebitis shows nothing unusual ; 
dls of the vein are congested and thickened, and the 
elial lining hypertrophied ; the thrombus contained in the 

is in one of the conditions described under thrombosis. 
cled, the clot becomes soft and disintegrated, resembling 
>oking pus ; a localized abscess may form, and the suppu- 
extends for some distance along and around the \tin. In 



396 A MANUAL OF SUXGERY 

the more favourable cases the spread of the infection imjl 
limited by the termmai portions of the clot remaming finn 
unaffected. 

The Byinptoiiis of inflantmatioo of a rapwflcUl veia m 
cienlly obvious. The vessel becomes swollen, hard, aitd 
with locahzed enlargements or knobfi corresponding to tbc 
or to the pouches in varicose veins. The skin over them 
dusky and congested, and there may be some oedema 
region from which the blood flowing in the vein is 
this, however, rarely amounts to much, as collaternl di 
always abundant. If suppuration occurs, the signs of a 
abscess are noted ; on opening this, care must be 
maintaining the part aseptic in order to prevent, as bv~ 
possible, the occurrence of spreading inflammation and p] 

When the dwpar veins are involved, it may be im] 
detect them on palpation, but the acute deeply-seated poii 
marked cedema are characteristic evidences of what has 
The cedema is of a more or less solid character, amilar to 
seen in ' white leg,' in which probably lymphatic obstruction 
a part. Occasionally there is marked swelling of the whole 
but without subcutaneous cedema. Obliteration of the 
and any of the local, distal, or general processes detailed 
thrombosis (p. 292) may result. 

The onset of 8«ptic Bpreadlng PhlebitU is marked b; Eevcii 
rigors, whilst the local signs are more severe, and the 
more extensive, and more rapid in its onset. 

Treatment of Simple FhlebitiB.^The limb must be kept 
lutely at rest to limit the inflammation, and to prevtnt 
detachment of emboli, and also elevated to assist venous 
Locally hot belladonna fomentations may be appliedi or 
parts may be painted with glycerine and extract of bell 
swathed in a thick layer of cotton-wool, and lightly 
The patient should be kept on an unstimulatmg, 
nutritious, diet, and the general health attended to. 
every sign of inflammation has subsided, and sufficient M 
has been allowe<l for the absorption or organization of tbec* 
(six to eight weeks), massage may be commenced^ to asn4 1 
the remo\-al of cedema and local thickening, and an eltfi 
bandage may be serviceable in restoring the circulation, ■ 
abscesses form, they nmst i)e dealt with antiseptically- 

Symptoms (jf Spreading Septic Phlfthltis should be trette^^ 
possible, by placing a ligature between the disintegrating clot» 
the heart, and scraping or washing out the septic mass ; thui ■ 
septic thrombosis of the lateral sinus, following suppuration 1 
the middle ear, the internal jugular vein should be ligaturedifl 
lateral sinus opened, and the clot removed. Of course, 9* 
treatment is only feasible in cases where a single trunk is aflectt 



VXINS 



w 



H TftrlcoM Tvlnt, or Tarix- 

H^ A \m >« Mud to be vuicoM;. or in a condition of vunx» when it 
Hki boccoic pemmncDtly ililaioJ, wiLli tlikkciiinc Atid more ur Iras 
^■onuositv olits Yk-Als. TYiv sMiJeidti'iiil vein^ of Ihe lay. <f^pf^ciA]1y 
^Ubl«n)a) and ext4TraalMptoui,are tfao^eperhupb mogt commonly 
liKtod; tb« apennatic vtan» are oflo^ m a similuf coit<tilion, 
MUtilutui^ what li, kiiuwu a^ a vjie KOLcltr (Clia^in XXXVU.), 
tUcr piln^ arc prim^nlv tlu* to variroiiiy cf (he inferinr h^mcir- 
AcililvoiAS (ChApL«r XXXLIl,), VV« ^hall Ijure only d«%L with 
tk tet of these mrec mauifc^EAlIons. 

QuM& — Vfirix ifc indLiccd by any condiltan whicli ImuIn Io u 
frenratlyrept^ted or more or 1«£« »rmfiiient distension of a vedn, 
ucb A* praloncrod Ktiindinfj, a^ tn tliot^r ^eiv'inf^ l^ehind countcn ; 
the pnasurc oi lijcbt c'Lrtcn, c»pvciAlJy tf nom below the knee ; 
pndonged or fmdbk rxeitiaii of ihr Hmli, a> prasiMy iu i^clist^ 
vbfrefy ih« blood is driven from the deeper into Ibe more iuper- 
t6i\ v«sn»; the preosiuc ot a prcKTUuit or di!:pbc<!d uterus, or oif 
i pcJm tuoKMr; d« obttruciion to and occlunian oi the dccpt^r 
«0tA. A&y aIjcioiiiia] connnuniiinliiiE] ln^twrii^i] an artety itnil il 
>nt3t]so cauMfS v^iricoeity, from the in;il»Uty of th<^ Lxiter to with- 
Hibd tb« ail^rial bJood pr«»»urc! (cide An(^uri3i»:il Varix, p> 2^8), 
Uttcovtr, chioiui; condtipfLti<JU ofldi liimlcis tbc ictuni ot blood 
fcom tbe iowci liii'.ln, vrhiisl inhvnted wp^iknrsis, or the i^Imx^llIom 
rf yiem due lo ft«dcnUry habitH, mukt abttj ht- looked on as 
iriiMpuOin^ Cflu3CS. The tendency to xmtx inct:cAsc-i with a^c 
tilt lb« middle period uf life ia reached. 

Whrn A vTin has hecome varico^itf, and its wftlls ihirlcmipd, thn 
>ilv«i hecom« Lioonw«tonl. j&iid Ihv whol« 6ijpv«nncumb«ni 
«iii;bt oE tbc blood tc&ds in the lovvcr cKtrutiiily, by the force of 
ruity. Ui still fuiiber tncfirasc the mischipf. 

Marttd ATfVTT — To the naked eye a varicose vein In An 

cuff ttuft^ oppcan Ihickencdi <itstended, And tortuous; n^ a. rule* 

tti villa ore no thk;k that tbc ^cin when ciit across i\oc^ not 

[Olbpae, Imt pn^sc'iils n gaping mnuth : tbe valves shrink ;iiiil 

ly, thui l^etotning functionally o^^less- After a time the 

b«como further stretcJictl und irre^nrly cxp^nnded. lonning 

'pooch'lilte dilatatioo». whieh Itecomc v^cry ob\ioii5 undti the 

tll^udled skiD, (u wbieh Ihey 411? cflen juIhetenL. In m^uiy uf 

U» eA(«& lh« vk-HiU of the di^Evnded veins 1wcom« exceedingly 

^nuui eft&ily rupture. MjcrotBC^jpicsLlIy. th<i cliango conaisis in 

i tramfornuitioo of tbc iiunnal struaurcs uf the vein wall into 

ibroMScairicLU lisfrde. The [iirtica irji.'tli*i is mainly sfTrictcd, moM 

<4 ikm moKculor JibroE diuLppoann^, vhili^ the tunica inTiina 

ii btd tittle chaiiji;cd, and cW Advcntiiin ihickcncd. In the 

fondio tbc middle coil i» alicphled, and, indeed. In oktn co«i^> 

ahMmt. 




398 A MANUAL OF SURGERY 

Olinicml HiBtoi7. — The enlarged veins are seen lamifyiii^ 

the skin with a more or less tortuous and serpendne 

(Fig- Sy)j and often feel thickened. One or more veins i 

affectedf and the tortuosity may be at parts so marked as J 

stitute large clusters of dilated vessels, which look bluidi 

the attenuated skin, Occa^onally the smaller vessels are; 

implicated, ajid then great numbers of them may be involn 

The Efffrcti of this condition are very varied. The ons 

in the lower parts of the leg may be impaired, especially 

the skin. The limits feel heavy and paiof 

after standing or exercise there is usually 

cedema of the ankles. Congestion of di 

often follows, appearing as minute i 

punctx. corresponding to the papllx; 

subsequently run together ajid form bn 

patches of pigmentation. Eczema is in^ 

induced by the irritation of these, as by 

and coarse trousers or dirt, and may ttf 

in actual ulceration. Any lesion, suci 

scratch or abrasion, instead of healing 

under a scab, tends to spread and form ai 

Injury to the vein may lead to thromboi 

spontaneous cure, but coagulation son 

occurs Idiopathically in the pouches, a 

clot may subsequently shrink and form : 

fibrinous or calcareous mass, known as a 

bolith.' Gouty persons with varicose ve 

especially prone to attacks of phletntis. 

sionally the dilated pouch of a varico! 

gives way, and an alarming gush of blood i 

the same may occur from the extension of 

tion through the vein wall. The blood 

these circumstances is derived, not on! 

the lower, but also from the upper enc 

ViG. 87 Vabi]< oy much as the valves have become incom 

Internal Saphesa. a column of blood extending from th 

auricle is thus tapped near its lower er 

unless prompt precautions are taken, the patient's life i 

lost. 

The Treatmmt of varicose veins may be described as p 
and radical. 

Palliative Treatment consists in remo\ing any source oi c 
tion in the shape of tight garters, in limiting the amount 0I 
ing, and in the application of either an elastic stocking 
indiarubher bandage. The bowels should be kept well op 
the general health attended lo. Eczema may be treated 
application of soothing and drying ointments, e.g,, un^ 
benzoalis ; or if the skin is chronically infiltrated and thi 




wesUc tarry applicationSn t,g., oL Ritfici ft pul to 
k^ vaticline), or of ictubyol (:o or i^ p^r cent, in vnsclinc), 
Vtficosc til<cr& may be treated on ordinftrj' principtcs, or by 
L'lBi'i ni«lh<Kl <p^57): hui ippair U often dcUyil fill the veins 
bvcbwn dfii\X. u'llh by opcraiion. 

Mkal Trefttme&t ^on^i:it3m ibc excision of Che distended veins. 

\l Dtay aol be practicable tu teii»j\-e tlieni (^cilitcly, hwX If the 

W^ and viKWl pfotiiirbut :ire tiikm ;iway. ihc? ufli^rv tr^nd to 

ibrLD^ and disappear. There Are two duel pkinij ot tloinf; tbie : 

W Small portions ;irc removed ut ^«vr^aJ difTcrvnt »itu.ttit)n]i, 

TV ^kia i& piiM-Lcd up ijve[ [he iciu. Jiid iijcksetl by ti^m^iixiuii ; 

■i# \t%sit\ is i)«n;illy t^ared by itii* rjiraiis, but vtMny need a little 

dranbif- An atieuriftm nocdU ie pAAMd batieuth it, iind the v^ein 

aokunj^ fufficicDlly to aIIow of its bci»^ grduped by two pairs 

d ioKK^ «tnd dividcil betue^rci. Each end i» nnv frefd. and 

kmn OC1 of th« ^VDi:iid »« &r »« pnt«Ktbl«» : it ii; tlic-n ligatured 

lid rtmoveid. Probably ajr inches of vein may be taken nwAy 

ibrTorka I incii iixision. Tlie wound lssu:ured withoiil draina^jc 

taL ApmkI. (i) T-^fKe inci*inns are madp, perhapn (* wichfs at 

in length, throti^h which Inrj^er clusters of veins may be 

^tb, Tbc i%X}iind ^hnitld nnt lie ovc^r the most dilnted pnrt:^ 

(be leucl, AK thcjc the ^kiii i% vAit^i thin and uiihecLltliy, hut 

d lie curved mi n*i tf> inrhidr? :i<^ much ^niind skin m possible 

■Uit crocsinK the vouelE once or t^ice. When the mciiiion 

hu rsKfaed ihc level of the veins, it ift cas>' \o follou' thejn out 

M^ the aciHDtH. All cnlliiiniU bi^mihes* rsperially thi: dtr^p 

«ii^ muM W lectired, antl this, in tact^ con^ttlutes the Krral 

ataili^ ci tbe operation, ^-i^f., Ehat so many annstomosinR 

cbofkc^ Are oblitcratecli Mure recently a sitnpler procedure hon 

keft«il>t>aited !»> Tn^nddeobutg, \ix.. the remmiil uf it jxirtiim 

4 ibl tntema] ^phena hi|;b up. fio Jis to break the weiqht of the 

^OttwttiX column of blrx>d. In suitable case? it may \w a u^ful 

whiQBjil rtCitMjre. but the cn)4J|;c?d vein should al^o be excised. 

Ulimed Varlcoea Teins ar« nnt nnfre^vieirtly inei with, aiid 

^T rrtuli in a n^iurak cut^ of the condilion. The ^jmpioms are 

Tboic of H superficial phlebitis and the trcalinctit indicfltpd f'w 

:iu (/indi:ioD sliould be follijurd out. \u t:dse*> whcie ihere is 

luirfi parn it rtiajr hr jiunhahle to enHsw Thp thrnmlwisrd \'eS5els, 

iiJn>iD the precaution to first secure by lit^''injrc the vein nbove 

tW dot K) AA to prevent Any ri^k ol enibofie dctAcbmcnt. Such 

cvn may Iw lonvidrrAbly shuHem-*! and p^llinli^l by this means. 

llilniiiilMH> ftoit ft Enptnred Tela n^d^ prnnipE xvm\ dtnsiv«? 

hMBBil. The t>k<xliag spcit should be commanded by digital 

n^lRnioai, N.nd tbe patient laic! on the hcich with the limb 

rjbv^ted. until dttiei a jkul of ;intiseplzc drei>in(^ tiin lie applied 

te the utoundt or a hjindlrerchtpf or luindu^e fiecured frver it. 

^VWrc practicable, exciuon ot the vwn t» the Li«st pJnn to .-^dopi, 

^bove ami blow. 




joo A MANUAL OF SURGERY 



Nbvtu. 

A naevus is a vascular tumour commencing^ in the sldn a 
cutaneous tissues, and consists of a congeries of vesseh 
together by a certain amount of connective tissue. 
usually of congenital origin, or develop soon after birth. 
themselves, they may shrink and disappear, but more oftM 
tend to increase in size more or less rapidly. Two main 
are described : 

The Oapilluy Nbtiu (or mother's mark] occurs in the 
a slightly raised flattened mass, bright r«l or purple in 
according to the relative amount of arterial or venoui 
present, and with occasionally a somewhat irregular or 
appearance, in which larger vessels may be seen ramifyin^- 
merely consist of a mass of capillaries lined with 
communicating with a few arterioles and venules* and 
together by loose connective tissue. As a rule, they are quite 
not exceeding an inch or two in diameter, but sometimat 
extend widely over the face and neck, and are then very^ 
ticial in character, and somewhat dusky in colour, coostU 
the * port-wine stain.* If cut into, they bleed tolerably fredr^ 
the haemorrhage is easily stopped by pressure. 

Treatment is, as a rule, simple in the extreme. Small ^ 
ficial nxvi can be completely cured by some form of cautena 
such as the application of the electric or actual cauteryi dif 
of soda, or nitric acid ; in applying fluid caustics^ the sunovfl 
skin must be protected by a thick layer of vaseline. Id dpi 
situations electrolysis {vide infra) is the best plan to ad^ bfl 
to prevent the formation of a scar, but sometimes exdsoii 
give an equally good result. 

The CAvemoufl or Venoiu Nktiu most commonly invf^vtf I 
skin and subcutaneous tissues, but is occasionally purelfl 
cutaneous. It consists of a more or less prominent sn 
soft to the touch, and easily compressible, but refilling* 
the pressure is removed. There is no pulsation or bruit, ■» 
mass may be lobulated- If subcutaneous, the skin ovtf ■ 
somewhat bluish in colour, but the mixed forms are du^' 
Occasionally they undergo spontaneous cure from infUiDDi' 
and thrombosis, and cysis are sometimes found in the cenUt* 
nevoid mass, indicating that a partial attempt at this proctf 
occurred. Total degeneration of a nasvus results in thefoni* 
of a lobulated fibro-Iatty miiss containing cysts, somewhat si* 
ing a fatty tumour. Venous naevi consist of a coUcctii* 
vascular spaces lined with endothelium, some larger like i< 
some smaller like capillaries^ held together by fibrous til 
The arterial supply is not very great, and the arteries* 
directly into the venous spaces without the intervention of* 
laries. If left to themselves it is difficult to say what * 



\t |irafaRlil]r yxane retrcfn^RncivR chnTiscp wnttlfl orrur. In 
mctanca ukcration of tbc ftrowth hnu lot! to MTioufc 





ift by Qo mcani «ut fdmplc ju in tlie former 

'Tlie fDllowmi^ plans an- rroominendetl : 

i>r th« f^Towth should :vlwuys Ivf nitopEed wbcrc 
ible. Cases which in former linys were dealt u-ilh hyslranii^i' 
axe oow Ui^lcd l>y this iTimns^ Tlit bleeOiii^ i^ nrvri 
I, «veD If the r^vold llssue ii ^ncroncbed upon by Ihe knife, 
oaly a few v«s8els will n««d to Iw tied. CiTcuinr j^rowth^ 
Id DC rctnov^ by dliplical iiKtsion^, and a litllc ^niicrcuttin|E 
KU always eoAbtc ihc cd[^<r?f lu b<r cu^ily AppiuAiiiJulcd. 
1. l|Aii^3atloiD i^f na^\'i vtih ligivntrr*^ wa$ Inrgfiy ut«id ui the 
«ll AiTi» .uid (s r\<"n now pmcttR«<L by soracsurvjccms; but it m 
cMflbdly h«4. nnd h&s not n reflcemin^ feature. Any pa;vu^ 
friadi GUI be ciurf] by stran^xiUlit>n rjin hIso bt- excised; tht 
BnxtB ic bMh pamful ind tedious, and the i^mn^tect tlfisvie miiy 
GKOM a source oi septic inlcction. Tbc wound rcnuuninf>f nhef 
has sloi^hed anay is a Urge one. and Ic^tvo iin uirly 
dciitnx, contrast iti^ moat utit^i'mir^lily with th^ 
■car foAiowing exct«oti- T\\e only ute for ftmngiilAtion 
iKa tcmponuY oieaAire during injccHDr* 
V In caMowbeie «xci«ioi^ ia unadviialilfi and the circukticin 
'tu htr ipiripurairily <:oTji«iHed, the Injection of c:mj;:iil;t[mK and 
nva&K flukb niay be mode us*? of, Porchlondc of iton cr pure 
blM^e^ carbolic acid are employed for this purpose, ptelernbly 
iLe Uliet. To tuiitrul the Liiculatum U u nii)?>l imporUoi part of 
^ froc«#dinL'. ^inct it pr^tenls Ihe risJt ariimff from Ibe dt^liich- 
"p^ '^ rmboli Of Ihe irjt^citon of ihe coai^ukint into thi' f^eneral 
Vatwu?* mcHfiurca may have lo \x employed to 
r-Tii! ; HiMH. in Li Mjf vus of tlir tLp of llie iu>se rhe orffLUi 
ill t* ^rrn^p^^l jnM be^nu' ihe bf»n«i« by wi?ll-paddfid dressing 
'^'^n^; trt ihc for9h<«d, «c;\lp, or clif>fik. lon£ straight hare-lip 
VBodbe nuy be pai^sod under Ihf growth and the maaa atron^led 
fat the timr Iwinii; wi;li silk ; if the growth in a larg^ one, this 
MM be done in tcf^m^nts. A carefully -[{t^ualQd hyf>odermic 
>fT^e b i>ow mttniduecd into the mo^, and dropn of carbolic 
W needed at many different »pot^ 50 iu lo diffuse il llirough 
■^ yirelbng, tile tumant bccorninK firm and solid in ronsrijnrncn. 
^' irid tmmt be injecltid close under the ikin, or sloushinR may 
*t io(fuc«dH The ciKuUilion should Iw controlled for :o minutes 
dki the injection has l«eu cc^tipletcd* The inaa* nubsei)uent]y 
Udatnea swolien andhnrd, hni ^railually both 4wel1in|{ and growth 
riiniiai iog«tb«r. Any barmorrha|;« occurring- from the puuc- 
fww nuy be amvtfcd by slight pressure. 

4- In casos wb«re the circulation i^uiuiut In: coitiplclcly arrested, 
arwhrn* evHiUon ii impoatiNr-, r>r where It U importAnt to lenve 
tt<«an or only nunuio one^, ElectroLyiia may bo employed with 



30a A MANUAL OF SURGERY 

advantage- It consists in the passage of a current of high* 
motive force through the mass, producing chemical and pi 
chajiges in the contained blood. A St&hrer's battery 11 
used, or any suitable collection of cells connected in 
Both needles may be inserted into the masS| but perhif 
wiser only to use one or more needles connected with the i 
pole^ whilst the negative pole is connected with a targe ^ 
moistened and placed on some indifferent part of the bo(^ 
as the arm, back, or thigh- The needle is often with adi 
made of iron or steel, since it is usually corroded, and theci 
of iron thus formed acts beneficially in determining coap 
of the blood. The use of the negative pole is more fij 
produce scarring, since a caustic sodium compjound is : 
around it, and this may lead to sloughing of the tissue 
clot« moreover, is loose and spongy, whilst a mucb 
coagulum occurs around Ihe positive pole. If the positii 
alone is introduced, a current equal to about 200 milliampl 
measured by a galvanometer, may be passed for 10 or 15 m 
if both poles are used, a. current half this strength is sul 
.'\n anaesthetic is needed, and the immediate effect should 
make the mass feel hard and firm by the coagulation of the 
the tumour is subsequently disintegrated and absorbed. 1 
plication may require to l)e repeated several times, and the 
should l>e freely worked about through tlie mass. Not 1 
monly the child may tiecome pale and faint if the n^vus is 
head, probably as an effect of the strong current upon thee 
centres. 

A HEBTO-Ltpoioa is the name given to a somewhat rare t 
in which a fatty element is blended with mvoid tissue, 
usually of congenital origin, or, at any rate, appears early 
and is probably due to the undifferentiated formative cells 
embryo developing in a twofold direction so as to prodi 
only fatty connective tissue, but also vessels. It gives 
!L swelling, lobulated and doughy, like a fatly tumour, alth 
is usually a little denser in texture than the ordinary lipor 
may lie possilile to reduce its size by compression, but thei 
thrill or pulsiition to be detected ; a few dilated veins or cai 
are often seen on the surface. According to Erichsen, 1 
variably situated on the l:»ack, nates, or thigh ; but this sta 
can scarcely be considered accurate, as we have seen it in 
the muscles of the forearm, and also situated in the low 
The only treatment is excision of the mass. 

Venesection. 

Venesection or phleliotomy is a means of treatment wh 
greatly fallen into disuse of late years, but is still occaj 
employed with l>enefil. When a patient is becoming cy 



VEiSS 



^3 



BSptiyxift b ihrcAtentDg cither (a) aa « romilt of pulmonary 
i;n|;ui|;eiiiciil bum mtUal nii.uinpctc^[ii;y uwrni* to itic tit'tirt beini^ 
iin«N» to drive lh« blood into ihe symomir nrrulflrinn ; or [h) ni; 
» oixifioaucaoe of tiomo jicci<i«n1 iD\'olviii^ the chest wall and 
hz)f5. inr^re^ th« blood'ocratinj^ ^urfncc is so i^tmiTiUhcd that 
h f Annol dirii with the blood fMcbing it through die riglil side 
WaiT, which hence tiecoities enormously distended and 
(O eiop i" a comiitton of di^isloie ; or {£) where inH^m^ 
of ihc br^tin i» pending. <tncl the pulse is hard tind full ; 
1*1 irany inflflTiimatoTj si^ta in strong, fulI-blixHlctl indi- 
-in Any of thofic conditions vsnc^cctiom may bet usisd with 

icdian boMlic vein nl the lend of the elbow ja tlijit usually 

aaace it is fcirgpr ihar the inr^Etiun cepliiilir::. thouifti plficml 

ly over the brachial ttrt«ry, from which it is separuted 

bcipilal &L5cia- 

"Bmiritot.— A pad or anti^ieptic wool or Kmize ; a. Miip of han- 

Ll 4 Ce<-t Tor>g; a hiricei : a gramtnred Heeding howl; 




F»P 88— VttHBttciKin. 



iealiy a Mick or banditse lo bo ^ta^ped by the hiind, so as to 
coaiiacLion of ihe nruHcl^!^ thus eoiiipre^shi^; thn de«p veins 
[diilffMling ih^ «iip«riic]aJ ontt. 

-The palicEil should be Kdtcd to a ctiair ; ^Umliag 
lute ayiicopc loo lapidl^n whilst the ic^ulilIk?iiI posture 
low too grrnt an flhstrariton nf blooi'l h(*fori* N^txjre's 
(ij.t tj'ocopc) IK evident. Tha nkin of the e)how 
been p«inhepd, as aImj ihc hfigiT* <ti the surgeon And the 
the pad i» pU^ed on ihe fit^nt of the fureann, and the 
tied Annly over it, »U5 that Ihe renous drcidatioti mny be 
led wbibt the arleriat supply is unimpeded. Grasping the 
(innJ^- cauae» the \cmv to ^tnnd out. The median brv^ilic 19 
ilrodied by tbe left thumb, ^ind an olrljquf incision luiule 
lair ID tb« AI1J& of lh« limb (Fi^. IM\. Blood will flow from it 
full »ueam. aod is coUected m tne txiwh VVlitrn &uf&ci«iit 
bem vitbdntwiu the stick in Tcmov^ from the patient's hand. 



304 A MANUAL OF SURGERY 

the surgeon's thumb is placed over the bleeding spot, the band 
above is relaxed, the pad placed over the wound and firmly t 
daged in position (Fig. 89) ; the arm is kept at rest for a dayn 
Co allow the small incision to heal. Occasionally neuralgic pai 




Fig 89 —Application of Bandage after Veneskctiow. 

caused by the implication of some of the fibres of the btcfi 
cutaneo'js nerve in the cicatrix; whilst, if the lancet Is phflU 
too deeply, an aiterio- venous wound may be produced, the en 
quences of which have been detailed elsewhere (p. 338). 



CHAPTER XL 
DISEASES OF THE LTHPHATIOS. 

Ailbctloiu of Lymplifttlc VeauU. 

xnto LympbjuigitiB, or Influnmfttlon of tlie LTinpluktic TosmIa, 
-The Omim is almost invariably the absorption from an impure 
found of septic material, with or without bacteria. In either 
ue the loxines diffuse themselves along the lymphatics, and give 
iat to irritation and iaflammalion of the surrounding tissues, 
idnch may rua on to suppuration, especially if pyogenic organisms 
ttve also been taken up from the wound. The process is usually 
itmted by the nearest lymphatic glands, which Rlter off the toxic 
products, but occasionally it spreads beyond Chem, and may give 
onto general infection of the system- Dissecting or post-mortem 
wounds are not unfrequently of this nature- 

iCorlnd AjuXomj. — The walls of the lymphatics become hyper- 
■roic and inftltrated, and the tissues around are soon involved in 
fiw mischief. Suppuration may occur along the lymphatics, or 
ttthe glands above. The lymph has been stated to coagulate in 
tiie vessels, forming a pinkish clot. 

CUaieftl Sifiu. — The characteristic appearance is that of fine red 
Ed» or streaks following the course of the lymphatics, perhaps 
vp to the nearest glands ; the parts thus inflamed are tender and 
ttdematous. If the mischief is limited to the main trunks {tubular 
^piaiigUU)t these red lines remain isolated from each other ; but 
rfill the smaller lymphatic channels of a part are affected {reiiform 
fym^vngiiis), the redness merges into a generalised blush, and the 
coodttion is practically identical with cellulitis. Localized foci of 
Mippuration often foUow, the redness increasing, and the parts 
becoming dusky and brawny, until finally the centres soften and 
iucluate. These phenomena are associated with the general signs 
jf fever and malaise, the temperature lising to 102" or 103% pos- 
ibJy attended by rigors, vomiting, and diarrh<Ea. 
The DUguodi olacute lymphangitis from erysipelas turns on 
lemore localized and patchy or streaky character of the redness, 

20 



,06 



A MANUAL OF SURCSRY 




whil^ the man^ is by do mawft eo sfiurply limkod or Mud ^ 

Uiidej ^uilabli^ im^atinmit lesululion lapidly foUowvi, biK Si^ 
puraiion nuy Arise eiiht^r in ihe gUnde or tn «ofi>e looev mpsfid 
cdlular tmuo travoradO by th« lymphntic tninks, or ft« a etas 
of al>&i:es>iG» Lu tlic ccufm: of (he vessels. Occasioiuilty idc 
lyiiipliatkc vessels Iwrcoiiie peinmni^nEl) occluded, hp^ a fcin i( 
soUd or lymphnlic u^dema ro^tiltc. In a f«w ca«M the pftlvvt 
ciicA from KcrcTfl] scptjcec-mia, or from cxhAuf^lion following diffue 
suppuration, 

TrftdtpTn^nt it firm of ;ill dirnrtrd to tKr srplk wrtiind. whid 
xnu'-i In- thoroughly purilicdf »d as to cut off the lupply *f 
irnl-itm^ toxinc^ to the lymphnlica. The limb it«cL£ abo«ld k 
krpl ."^l KTht IE] fi ^liK^tly clevALed po>itio«i, and either iiri^iiloi 
With ctiUI Inlicir^!;. rir hoi hrlln^Innii'i foint^rilnlioTi?^ :Lpj>IietL Soait 
recainmtTKl paintitig tlic itifUmL^d arcsi with ^'lycefine awJ 
extract ill hclladcjtina in ctiuM piirt?», a.nJ thvn co\enn^ it »^lh 
tuUiJti'Wiijil ; Uie ftjrmer pliill^ aie pir-fti^iWt lo ihi^ suowwhai 
dirty p:oL-eedi:i^. a* tTi^y eniihlc the *ur£{i-on to inspect ibf fcnh 
iiLoria fr«c^ly, nnd thu^ utc'erl-un rurlic<r the «xist^ce oj absc«(Stfi 
wliich should \yi tpcncd os toon as po*3il>le- Any suhatqurtt 
urdt^iiKL oFtItt' [i]uhriu]*<1 de liFiilrd Iry tn^^sakjeaiul Tinn liH:i(lipQ(- 

Confetiluliotiiii twatnieni consists ir ih^ adniiriMralioci oi * 
purge. (olioAod by cjuicinc and tonics, cojt Ix-ing takco ibat 
coT^siiputioi) i*t nut thcreljy prcxlucfd> A li^tit 4ud nutritious difl 
must !)e ordered, tci^jethef with stimuUnls. hs may be reqalnd. 

Ohronic Lyiaphaiifltto either results as a ftcqocb of aa MCile 
atlcLi-U, III 13 irci \^it]i d.?> d septtfAtc condilion. It \s rwjsf, I^^ 
fjurnrly titrr m rnnnrrtinn wtib vrnereal riisesiH", th^ ilnnul Jyni' 
phntic of th(^ p»n)tii bi^m^ especially n^feeicd, 1>ocominjc onlafTO' 
Iiard, And corddikc, c^pccinlly ir cftscs qf pninitry syphilid. Thift 
i> ii5ijully ajcaiiEipunJL^d b^ a solid nilcFiiatous i:^]}t]it)f>n of EIk 
pre|nice, ;iiid swelling of the ittj^ruinal (ilcind*. titidrf »ppmprntc 
imii-syphiiitic traitmenl, thfi swelling; subsides m a i«v w-eela, 

Chrcnic lyniph.ingitis is oltcn Asioci.iled with, cr give* fi» 
111. di^tt^riHiin ^iikI flilaipitkiti nf c1i«? lymph L't^ot-K. ui Ijmphia- 
glect^ils. ivMch may be met uilb in 'A \a^iiely of loirr^. 

Cons *^mtal enlargement oi the hps(wj(rrtJ<-Vj/w, Chapter XXlLJk 
cr of the tongue {ma<ra^^iia, ibid.), depends on an overgi^wtb of 
the coiin^^riivt lissiir of tht.' pun. a?isociaitNl with chiouk dbtvn- 
sion of flip lyitiphalics. 

Ljiaplt Vftris IS occftsionally met with congcnitnlly, inx^oJ^tof 
the supiTiftci^l vessels. Any part of the Mirfacv of the body may 
1h' »nti4M(H] by rhe < ondilimi, whirh niAmfivils iiM-lf as a sprif% nf 
Email vesicles, which ptTMsl and arc unacoomtMiiicd tiy imy tn- 
tlammjLtoty lednc^s ibii^ M^tving to dislinguisA it Irom berpea. 
They contain lymph, aihL if opened, a coiisidtrable flow of lhi& 




WSBASBS OF Tire LYMPUATJCS 



w 



rM {km^k^rrktFs) tntky rts\i\U loatinic f6r some time, Tbay bAVft 

I hecmctocrved moM fie<|ocnt]y on (he inner ^dc of the thi^, and 

81 tbe prvpitcp. TicHtnicni coIlsi%t^ in hiyin^ rlirrm »|)rn, imd 

oaMuiag the bmc : if Iht^ deeper Iymph;itict ;ire niaa ufl^ltni, 

inasure nwj be employed. 

' ll ia UiU more or loa nn open que-tllon whether tlte frondition 
vbich occurs in diiMrpn. known us Oonganlt&l Hjrcronu. is ^lut? 
loik» di«Mnsioo oi lymphatic ^puc«t. vt ari^s in (he remains 
d fune vmhryonic ti9aue»* More prohiLbly iht.' former i» ihc 
conta ihoonr. Fo: u dcbcripiioii uf ihi> coailiiiyu, sw Chapter 
IXVU, 

4fiqi«E«d Fenai or LynpbftUo ObstmotlQii ^ra linhl* t^ result 

I frtmony conditions which impede the on^^ard flovr of lymph in 

|lb;ba}y. A few cHVSftrj^on rvi:oid in which iheopr-nin;g of (he 

^taadc duct ha* bi-pn nli^imrtPri nr eomprrii^pd- In 5iich ihe 

^m^. hAK usually heen a ruptiire of lli« refcpt^icuium chyli* with 

■ isF^ exudation of lymph va chylr: into the plcLind or pcrrtoneiU 

uviljQ. Turof^' tepotitfl n aw fhif posvibiy to (he l<>ilginenl 

dir4f>cerous TmlvoJuv. in which chyfout pl^nrisy :tnd uict^es 

ifodinli tmt vtiUkmiC any appiLii:nt mpturv nl iht' dficl. 

TU ooodibon knovm n^ Ohjloia H/drocde, in which therein 

a dfiisioai of mltkr fltciil (preMiinAlily thylf] iii(i> llie Itinics 

I ngwalH, tt piotKiblv ikie to some ujch obritriiclive rjtiiw- In a 

a«t ncendy seen fw u* thi: l>-mphtitK-* fjf the spermatic cord 

vnriiSAted tiy » niuLiUr Buld in a nioniliruin iii;L(]LK-r- 

ft^tan AT iitvtim t/ tSu iAomcie /tuti dnTirj; o|)*<rHiicm& on (he 

I itdl k vianiftKlod hy an oscApe uf chylous lltml, which conguUte^ 

« 3lAft4ine ; d the llo^' continues*. exhAUStir>n ciuicltly follows. 

Kent.* ttajwevcf, li^i^ ^ubtishrd cwrir!^ sliowln^ (h^t thr condtticin 

# ml nrrn^sikTily £«al, and that if (he wnnmlrd vc^^stO can I>p 

>r»td, 4b hy liffftturf^ or forcinTeisure^ rcco^^ry may ensue. In 

«di inffancci the thorAcit duct prcbnhly opcnif l>y ^verid 

«oui|i-i into the H(t>clivian vfrin. .ind only one of the liranthea 

b^i \totn injured' 

Ho(« chronie lorrnft cif lymphatic ohstrueiion iiuiy uikte from 
Cfe4qko4il of lubcrcuUr or canccrouii matcriaf in the lymphatic 
[ntuiiU, fiuru llie cooUinmiub iiiitatiun iesultin>; from & W^e ukcr 
KT n;rnqve orTrntn of the teg, rff frnm the growth wilnin ihr 
I Itmplalicv of liiHni^ or^ani^ms '-^^t the tilaria snn^uinU h^mini^ 
Tw Ukcf condili'in i» tlie cnu^e of (he diKCAse knoim fu do 
ihuliftjda ArBbnm. whiUt thr itutut-i nM> tri^i' n^e to 4 ^piiciou^ 
Jonn T>f thi'^ .iffrc'ii-^, knowri a.< Piwud-clAphaJttiuls- Three chlt-f 
y*Hmnt(iCTa maode^ themuEKv^ a** the uulcoine of ^uch ob»tra<:- 
t*tt* vu^ (#) StIiJ er iynp^iattc aJtPia. s, condition in wlikh Thf 
nbcuUDetiuH ti^^ues becuiue lunt. itifdtEaled, und Liia%v[Ly, bu( 
ifc fluid ranrtoT h? v-xprMsed from them, us in ,in i^rdin^ry 

• Tnnt fulh See , *^ UK , p i 

t PtiiUfVliihiitAeadMnyefSurgefy, April r t3«4 

30 — 3 



3o8 



A MANUAL OF SURGERY 



oedema \ {h^ kyp^rpiasia follows, affecting not only the I 
cutaneous tissues, which are markedly thickened and inoa 
in amount, but also the skin, which becomes coarse and wait 
in appearance and structure, and ts very pione to ulceiate; 
(c) lymphatic fistula are liable to developi from which a k 
amount of fluid exudes {lymphorrhira). 

The pseud -elephantiasis arising from chronic ulcers, or fi 
disease of the lymphatic glands^ can usually be dealt with bv 
pressure of an elastic t^indage ; but the limb is very hk^ 
remain permanently enlarged, and in some cases where intracb 
ulceration and lymph fistulx exist amputation is the best ti^ 
ment, \ 

Blephantlaidfl Anbum {syn. : Bath&doos Leg) requires but M 
notice here, as it is seldom seen in this country, being idmI 
limited to the tropics, especially the West Indies and Sd 
America- The legs, scrotum, and vulva are the parts most i 
quentJy altacked, but the face or breast may also be afleded. ' 





A S 

Fig. 90. — Elephant[Asis ov Fkkt. 



manifests itself as a hyperplasia of variable size of the n 
cutaneous tissues, whilst the skin becomes thickened and «■ 
like (Fig. 90, A. and B,)^ and from it a copious dischai^ 
lymph may resuh. The parts may attain enormous dimensia 
the scrotum even reaching to the ground when the patient 
sitting. The disease persists for many years, and is not as 1 fi 
fatal. 

The condition in most instances is due, as already mentian 
to the obstruction caused by the development of the Fiiari^utifft^ 
hominis in the lymphatics. These are spread (according to Hi 
son) by tlie agency of mosquitoes, in whose bodies the iiri 
mediate sta^^e is passed. The dead mosquito, with its pans 
contents, falls upon the water, and in this way the ova find 
entrance into the human stomach, where the young worm is 
free, bores through the gastric mucous membrane, and fim 
lodges usually in the peripheral lymphatics of the extremit 
Not more than two or three pairs of mature filaris are genen 



WSM^SttS OF THH Lr^PHATlCS 



F* 






^■MnM IB the sane individual. Tlie budy of the lemnle warnt 
[{■ych anain« a lentil of 3 ini:he«9j is nuinly uocnpled by Ili« 

tftprodttccJ. Sonne miioin coded up in tW Ivniplmtic M>dces. 
loJpvio rise to iht- phfrnnrnen^ of lynrpbalir otisuiiciioii, UTherft 
^hOttCk* imcc^l*d, iKX\d are then ahoitt ^*^ inch in length : rh^y find 
bar way into the blood stre.'im, u3ii£Llly aI oii^hi, ,ind cin bo 
mdOy aecn by the microscope. Mftuson claims chat the>' are 
iblam inu> thr Ifo^ly nf the mns^iuiio wtiK ihti blood which il 
gte irt*. 3iul thiu ^ frc^h K^nerition is developed. 
■^b TViAtaifiDt v^irica ^ilh the Mtimtion of the dificar^- Wbcn 
^Bkc or trunk i« involved biLt Itlttc can be done. Wbcn the 
Jncrnm ii jfT^cicrl. Ihe morbid livtue c^n br? frr-t^ly diswciptl :Lway, 
aaAciuit Utin Ikrmg iclt to co\'er in the? wound if poiiiblv : llW 
pw iDd leetca must lirst be diwicctcd out of Ihu inu^ii, und 
ifatt tbe icTOtuni U^tiy amputated, a touiniqitel Lvin^ used ii> 

fCMbt)' Kcahhcation, may be ufleful in lb« ^Tighter c:la«(4 ; but 
vkfc tbc liiDb is enormously enbiri^e^ ihc lO'C^tesI mcniLirc of 
*vcct3A fcem$ ttj ha\c folIuuT^J lij^atuit of ibc iiihui aitcry of (he 
itb, ui xs TO diminish rh^ blood wipply, and so cbrrk thr gmittb 
^ ft proc«(« of fttdir\'nttOQ. 

Affections of Lympbatle OUndB, 

into Lympluidutitu, or Infljumnatton of LympliAUo OUnda. — 
fWftpifl \-A thii zQntliiion i^ almoai .iRMy.-i tht .ib^orpd-jn of 
ic*t imtaiivc imitrmi (loi^it oi infcx;tivi;) fiiini llie [^x^riplmry. 
^iVfcm t pan b«co(ii«s intlamt^d there \% always jui irore^ised ^ow 
iktcfb the erttrent lymph channelftt owins to th- ixu JMion ; 
terotth of lbi9 il AD mcrease in »ixe of the i^'laiida to which the 
'ftc^ is c-^ifrird. whirh quickly disapfHrftfs when \\w inilHiTimalory 
pnaw is at in end. lf> however, iiritAling to^ires are produced 
■ (^ isHnmed urr», they give riee to a more prolonged and 
itriouAl^iitjit. wlietbcr accompanied or not by a siiniW condi- 
boB of \\u^ lymphaiic vp«i»1s. Whon pyogenic organisms iitc 
dw jib«orb<*d, Mippuiation almoRt invnrlablv results. In (act, the 
Ij^phaiic K^Unib muM be looked on as Ihc filters liy moonti of 
tilich Nature elimin&ien many KourccA of disciLsc. It in cunous 
iatcpriiiin penphenil infecii^^-c condiliont are nol ;at iiH liittile Ici 

Mft; formn oi cellulitis; pori^nbly the ncutcnesj oE the proccKH 
<iaKa l^mpb^lic: tht(iinl»!u^ in ihe elVtrent lnink», and thit» 
klf>6fn the :ibv)rption of X\\v noxioui* nLtleriLiln 

(>tQaJon;Lliy acu1« lympbailt?ritL& un^g wllhoiU sny ob\nou4 

klioa, Lrin^ attnbuted in such cai^es to Mitvin^ n^ from uver- 

nog ; po^ilJy !suine uimulii.cil cuUiiuuvtb It^ion \^ the cau^. 

in otber CAses it seems probable that the ^ucllin^ vi lUe 




3IO A AfANUAL OF SURGERY 



glands is reallv due to a. strain, which may have induced 
interference with the flow of lymph. It does not at 
result in suppuratioa- 

Patliologically, the condition is evidenced by hypeneniia c^ 
exudation into, the gland, which becomes redder, hrmer, 
larger than usual. Suppuration usually starts in more than 
spot. The capsule becomes involved, and ^ally yields, vl 
peri -adenitis, or inflammation of the surrounding^ tissues, is all 
associated with it, even in the early stages; the latter may 
little importance, but if the capsule gives way it may becboKi 
extensive as to constitute a diffuse suppurative celluUtis- 

Clinlcaily, the signs and symptoms of a localized inflami 
are characteristically manifested. The glands can be felt ai 
larged, tender, and rounded masses, the skin over them beiiif: 
and cedematous ; and the swelling, which is at first hard 
brawny, becomes soft and fluctuating when pus has k 
They early contract adhesions to neighbouring tissues, and 
puration may even extend widely beyond the glands, 
where there is much loose areolar tissue, as in the axilla- Fi 
malaise, and all the general phenomena associated with ail 
inflammation, are usually well marked. 

The Treatment consists, in the first place, in the removal oJ 
sources of irritation, both physical and physiolc^cal. The 
must be kept at rest and protected from injury, and the 
wound or causative lesion dealt with by such antiseptic 
as inay l>e needed to ensure its restoration to a healthy s 
quickly as possible^ Hot fomentations are applied to the 
and the patient, after the administration of a purge, may be p*] 
quinine and iron, if considered necessary. As soon as pus liil 
formed it should be evacuated by an incision, and the wnall 
dressed antiseptica^ly. Linseed-meal poultices, whilst usefnlii! 
encouraging the formation of pus, are most undesirable afttf thi 
al>scess has Ixren opened (vide Treatment of Acute Abscess, p. 4')* 



Special Forms of Acnte LrmphAdenltlfl. | 

The Axillftry Qlmadl arc usujillv afFecled as a reauU of poisooEd woon^a , 
the hnnd or lincers. alihoui-h oihtr glands exial lower down in the ■» ' 
tj^ . that miniated close lu the inierosseous membrane with the uitcrkv iolV' 
usr>euu^ arlerv, and the supra- condyloid, juat it>ove the interna] cood)^ 
Boils in (he axilla, and c^cnriaiions or septic wounds of the breast tnaytlv 
lead lu a\illary glandular abscess In thia region a suppurative peri-wedU 
is often suptraddcil, e>; lending widely under and between the pwctoral iduv^ 
reaching' even up to the clavicle t^are must be taken in opening indi M 
abscei^s to avoiti the main vessels b>' cutlinR from above downwards, i rnd^ 
between ilie anieriur and ^xr^Terior a.\ilLary folds, whilst Hilton's rarikn 
iihould be acfopled in all ca^i^s where the pua ia situated deeply. 

In the Oroiu there are three sets of glands: (j) The oblique aet, ninv^ 
paralld ir> Puupari's licameni. and l>econiin^ inflamed in affections of thi 
penis, scrotum, perineum, anus, buttock, and lower part oi the abdomtn; 



DtSBASSS OP WE LYVPITATrCS 311 

MiVptdkn} TfTtin) vrr. runninc wjlh ihr lcri|£ tnphrdon^ wtn. mil mcivlng 
fSfifc facn bO tbr lupaflcLaJ poiti of tbe hnili. cAtc|.)t pcrh^pi ibukc ftom 
4iilt ibe blood ^« rttufnod b\ the exlcdul uijlicjiuuk vclij. iIlc pui^lilc*! 
fitdt fvcetvlQi: the Irtoph from UtU r»iDn ; uid | ij Ibv iloop ixrtlul tct. 
1^ ai0|i tyniB^aCio c4 th* limb, part cF which, li-<\vnt ilciun hxv* 
In thi* jmCHinr tibial gi^nii. ^idiniwl cJwply on tHr iniTf^wKiiii 
. d< iMo tbe pQoUiuJ KTcmp ;\tf9cesii la ibc si^iln Li opened by 4 
llndriod, was ioaJIoa tli? wounil it> (»pc when ihc joijcnt »ju. uid 
pocbettitH of nult«r it iJtCTtaio}. 
tion in ihs i-bLiid« of ihi* H*^ in «HOMiJinitly enmmrtn , iriiimfj mtHV 
AlfKironB nl ih* vciJv f«cmaa tt p«l!CiiliHi<] . #i( fnir^irhou or 
, Itucai. sw \ijK Into [Q« eurt dinnViiiion ol ihr ]yrnnri;i[lc« wr 
9icr bcrr, bgi m\t^t trfti biud«nt4 10 AiiAlumicii] iriLtmuU When 
acBvicA! aIalmv.u^iv muu bvuJ&cii (uatujiI intt^JLAuE kUuLluia. 
the csttcroAl joiEaUr Tvin. uid vo tnk* induoM atcrou Iho Gbm of 
in oHfT i'> Moia vpocs far cfici«nt drolno^o 

Chnnio LrnkphAdoniUt- — Throe vanclicd of chronic intianunu- 
ikv «i IjriaptuUic gliUMU arc ntct with* vi^^., (he Simiiltr, SypliiHtk. 
ttd Tubercular. 

fliiiipio LyntpludonitiJt it n condition rvaulting fron 
penphiCriU uni^tian. whi^h us innifticiciil to cqum; A& acvitc 
flBCk- [t alao txcii-'«Ui:)^U rcT^iilU ficm blows and Miaiiis* as 11 
Mf-vrnHdAg. hdng in 4uf:'h cuw pCKuibly dui< to obsirtLrtinn ici 
'>te Ijnipbiitic How. ourinf to compression or rupluro of the 
Arcflt vcMcla. Tbc f'LinSA become rml^vgctt, tender, and paiu 
M.Uc 1^ <i Idle ihey do not l>cutii:ip ^clhavnt lu unc aiiothci. or 
^k^uxai siruciures. And tJiow but \\ix\v t^nd«ncy to suppumle. 
nk condition oK^n prcc«<lcS| and. indood, may be IooIuhI on as 
tKodbposini^c&UMoLlubcicuki lympheL<lcuiti&, ThcTitatmont 
CttwEt in knf{>ui^' tli^ |iiirt dl rent, TriiKnin^ if po^>iMr ;ill 
loffccs oi local trTLtatit^, combme<d pt-rhiipft with ih^^ IocpI 
^K^Dilttn ol >odiAc pAJnt. 01 inction vhitti loditlc of potn^iutn 
« iodtdc of o)Cii:uij uiiamc^iil. Tlic ^ciitrrdJ health should abo 
>( itlrtidrt I In, pspKiAlLy in rhilfIrT prfdi^^pntrd iti thr dpX'clop* 

J- dfook SfpUliUc LyinphAdo&itla. — The lympluaic glands 

ut mvrtlvt^l in w^frral uay^ iri iltr course of ^yplli)itic tli^ro^c : 

tiilV primAfy lc«ion ia asscriaJcil wilh the dcVT^opnieni of an 

«1ito« bubo in tbo ncnro^t lymph.itit: ^'lattds. which becomr 

brj Old aliolty, »onKwhAt Uk<: baiittn und^r tbc skin. But htttc 

Jtt t» aoCicrcil Lit;k?A Htippund icin is ukin^ i^Ut*.'; iliis is ncvtr 

te to thif ^yphltitk vifUfi ;ilonc« bul 10 tht? ^ilwoiTpiinn nf vimc 

i^ BULller from the primaiy Ivtnon. I'her* ik usually mnch 

Mk la^tx&tion and cnl^rifemcnt d ^linndt* in extra iccniul 

diUKiA lluii in ihii%r ocLurtinj; aliuiil the Kratital orgnnit^ 

llf^ii Ite Mcood «l*g«. when gvner^ mfection h;ift occuTT«^d, 

ikt^KMls &fl over the body are aSec<«d in the %Ame indolent 

UkOD. {{) In ihe teftuixy perkxl the lymphatic i-lande iiuiy 

undcrsoA true |£ominalon^<.hnnge,(rr livcomccnlaryod aiid tender 

OMiqg lo the aworpcion of &«{>tic n^Aicn^il fiom n 1uulu-n-4lfl<ATi 



3W 



A HAVUAU OF SOMCBBf 



(uppumtinff f^xiniina. For fnrtber pArtlculais tnd TtrMtDuL ^iil 
Cluptcr XXXMIl, ■ 

3. CQixDnic TubercoUr LjniphAdeiiitiB is au aflcclion xTty occi-^ 
muni)' rif-1 wilb, cti^ cLiture of wliith is rtuw mucli inorc lulif 
uadiri'^totxl llian formerly, ;vrd in ihv tfeutn)^ni of whicb pm 
iiupicvenionu have boon made in recetil yeuts. 

OauMa.— 11 occurs moal conmiooly in children or yotm^ aiIliji^ 
v^pcrcJAlly in eliofi« who havs received an Inheiiird pTMli«pcrnuw 
to tiie dev«lopmGt>i of tjbf>rai]ar dUesu*. Although it ouy am 
in all cUs^cd of the ccnm^unttyi I1 ia; (spcciaUy prone to cctM 
Anion^>it liic childitu of iht- pyoi, uhc^v stiiioundin^ are ii>- 
hp^lthy, ard who^ goneTnl contliiion i^ df^toHoritirti hy inisifllvdcaE 
or had food and wnnt ol fre&li nir. Not uncomnLooly tome local 
fccuit of iiTitAlior ia prc5crtt in the forrn of pediculosis captlii, 
i:hrtjnic otorTlki^i?a, or ci.zcma of the fucc. Am a tgmiIi of thb. 
nt;i([hbouring glwnds Ijecomp chmnkallj' inflam«1, and, ai Pro' 
Cesaor Bunion Sundcrson sEiyt, ' the i^oil is thereby prepared br 
the »ed/ Thr haoilU arc convc)'cd to the gland by tbe blood er 
lympb, i-iiinin^ ^cccati IhtiniKh i^ume breach of MiiEocr, or petlmie 
through u lirtdthy mucouft membrane. Any lyinpboid tksutf m 
the body may become the iiciit of tubercular dism^e: but th* 
gifuidfl of the uecl<. j^apeciiilly ibe^ ^obuiaxdtary and the coocate- 
natevare ruich mor>f commonly invoU^ed Ibaii any otbeffa. Tba 
axillary and inf^inal glands ar« also not unfrvquently afl«ctf4 
whilst luburculur diTwusc of thoee in the cn«»cntcry fiivvs rise to 
tbe jLfr«~Fiun knuwn a& ^ LlIhts nicfitnt erica/ 

The rourw of the ca***- in^-^y Iw nriiAcially dMcribed under eIm 
lollowir>g h^diiics nlthoiigli 1I inust be remembered ihat therde 
not □co.-zrisanly follow one another in exact scqucaee; (i.) The 
earliest iiidmle^t:ittoiJ8 of ihc disease consist in RjUtfy fainrgrtWl 
of the glfrnd^H ^^'hich r^nnnr ^[ first be distin^Uhed from a 
»iraplecbrooic hyperplfuia, either clinicnDy or pAtholo0caUy. The 
Iflnnd niay be enlarged to mnny times its ne^luml jnEc, and oa 
»cc1ion Iqc^Ls {pinkish in <:olntiT. nnd is of firm n>nM94encc. 
MicroscopiciLlly, all that ie noticed 1* a STmit mcreaw tr the 
lymphoid corpUEclcs lopjcther with tome overgrowth and thicken 
ing of the tibrous capsule and trabrcuJx. OccAsionally a ievf 
niuHi undented cd1& may \v ^*^xk and ar<mnd lbe»e the uuial 
a^gregnTion of epithelioid ct^lls may 1w clustered, but the typicaJ 
gray i^ranulation h not urdiiiarily pre^nt- |ii') CtutsHm of Itn 
tubirrcular tissue follows sooner 01 later, anv pari erf the gUnd 
heme alTerted. This change, as etpl.'uneil elsewhere, 16 iliu 
partly tn the rompression of the arteries by (he cell pioliferalion^ 
partly lo iheii lumon bcm^ oblitcmted by a tubercular endartetitiSt 
and pitrtly to the dJii^cL inilucocc of the bacilli and IbcJr toaincs- 
(jii,l C-akificati(i» nf Ihr riisroii* tielriluii may orrnr in iho«if rasst 
which are lending to rtcoxi^ry. Snch is noc:o«ipaDked viith a 
Abroid thickening ol the ^londr resulting from oi-ergrowlh of thi 






«ad tubfciiLir cotincctive ris9u«. Thi» chftnipo U most 

jucnily obfc; 1^ In ttit ^LuiiIh wiihiii tlL« tLuiUA uiid abdorocn. 

r.) More commonlv ti^fti$f^iM «Ti&i>e8, itom^times from a Kimplt 
tfn t p Acatioc d llw casSBtin^ matvfUi), tomtHm^ from a 
wciodjuip' infociion wilh p]r^^i<^ organwiis rcAchntg ihn gl^tnd 
bxD withoui. Poinl^olpus &how ihemsclvcs ^i v<uliiu> >j>oi*t 
b the ^andaLu parcnch^-mn, vid when unce Tormf^cl, tht^t^^ leml 
1banlRunAteaDdcau!u:thcdc;itnictionof th<:rc&i of thc^l^uiclul:ir 
lUMtt tbc fibrous tmbccu]^ rcniupinif Jon^i^t unaffected, ^o iha.X 
teUy the ghmd U repmrntcrd hy a dnglc ;i]>M:ev^ cavity ^ui- 
aauoM by a pycigcaic mcmtir^mc of the onliiiaTy tubercular tyi>e, 
Bitedk tiaces of the ctpsutc con he ohnrvcd. Several ol the&e 
tbccttes may tnci^c bit^ one otiothcf.uml tliun akttE« multilocu- 
Ind cax'iiy. (xniainin^ \ms irixwl wiih t^urdy dfiuiK. v/\\\ lie 
ismfd. (v,} A tercatn aTnouct of ftn-mftrntu \i ^Imott alwayfi 
WX ♦Jtlj, ihotii^h not io liny great extent in lh« cailv stages; 
^Ko, iHim^^ci, suppuiJitiun hti^ ixicairnd, ut i/ ilie i^IhiicIs arc 
ofttBd In |ir»S8Ui« or friciion, they ti^omo adherent nnl only to 
Ughbouring ctands, but ^lu) to sut rounding eiruclure^. In the 
iMredironic torms the filiro-cicAtricial tissue \}\\\h fornicd inny be 
Mei3aisi>c Ah lo reudci ih;: ma^b L[iLitc iiiuiicjvL'iitile un tlie deeper 
puiii, mch a^ th^ n^flin \e*ii*ls and nprv*^ of Ih*^ tnmic, mnderin^ 
imovi] bv cDuclcAiion nimost Lniprncli<:nbte- JmpcTtanI veaiHJU 
uy occaAioo>a]ly be eroded by ah exlcnaiun of the suppurative 
pocrak and ibis may lead <o f>ilakl ha^iiiotfba^j.v (vi,) StHmet 
cv blcT ibe abiC*»fi, if kfl to \l^\U bursts either at ont- or 
trvvnl £f>ol^ IcAvin^ utccratcd opcringfr, through which m^y IfV 
■<vc ^tmatou-^ srAnalalion tlMue ntiKcd uilb cn^-ating maternal. 
The edges are undennined. Ibin, and purplUh. Thr ^r^nubitUmTi 
tfB KmeCiinei very picfmnernt, and mxy protrude through tb« 
Dpiaiiig) as fungnlinf; nia:ue:s, A \tihable nmouot of pus e^captjH 
fnsn these, aod tbia ctHidilioo may pet^Ut fcjr many yeai% \l ladLUil 
(t«NUnent i*t not utiiWtaken. (viL) Under Huiliible IiK::d und <:oii> 
iAMkooal mva^ures tlic^^ ftore* m^y. and uHUfdly do, h^od afl^r a 
lisci ffi^^^ ^^^ '^ '^ P^py ^P^^gy ckatrtM, which it olte^ tKApod 
■P4im1 puckered, Uid wIulIi uiay ictdJu il^ v^i^uuldiiLy fur a itiuch 
kofivr porind ihan voiild a br^ilihy vrar, 

Tht usual eompUcatlOAB mri with in ih«ccim«cf all tuhercubr 
teft*c^ nijiy nine ninnife^i thcmulvcJ jp, 13^). 

The TnvtnMlit nf i^l>i;rcLilaT inlands w palbalive or mdical. 

IkJttftttw TnAtintat<:fln«ivi« mainly in improWri; Thf? ^m^ral 
b«Mi by mesuuL of «uital)de diet and tonicc, such xs cod liver od 
tad synip of the iodklc oE iron, lo>fclher with residence in » 
bcaltby, bmcinf; situatian. cApccuillv at the M^iside, a?i. Tor 
iinUnce, at Mafgaie. All ftOt]ii:ts oi IocaI irnlitlion sfii'^iild hr 
rcnored so sa to exclude th« ^idvent of pyu^tiivic or^Aiu^m^, and 
OQuatCT-irritAnls, such a» iodirtt: pjLint, arc beat avoidod. RrU of 
lb BSec^led pait should be ciiLrt;ed tu* much Ai puttiihW: m 



3U ^ MANUAL OF SURGERY 



some cases the application of splints to restrict movemci 
advisable* 

E&dioftI Treatment.— Wherever practicable, glands eridl 

tubercular should be completely removed by dissecticHi, addt 
amongst the wealthy too much time should not be wadb 
palliative measures, inasmuch as the longer they are left, 
nrmer will be the adhesions which they are likely to contract^ 
surrounding tissues. In the later stages, so far may thispn 
have gone that removal by dissection is hopteless. In suchc 
a free opening is made down to the diseased tissues, and as i 
removed as possible, whilst the remaining deeper parts are sen 
with a Volkmai^n's spoon. In the neck very exten^vc opexri 
are nowadays undertaken for the removal of tubercular gta 
The incision necessarily varies with the situation of the ii 
but where feasible it should be kept well behind the stv 
mastoid. Where, however, enlarged glands exist both m ft 
behind, and lieneath the muscle, it is well to make the IDQ 
parallel to the course of the external jugular vein, enii 
dividing the stemo- mastoid, which may subsequently tKstib 
together. Special care must be taken of the chief vesseb 
nerves, and the situation of the spinal accessory nerve i 
crosses the posterior triangle must not be forgotten. Natu 
adherent glands may be dealt with very much more freely ii 
posterior than in the anterior portion of the neck. 

Tomours of LnnphmOc GUnds. 

Several conditions are met with in which lymphatic g1 
Itecome chronically enlarged without any signs of inAamm 
liein^ probent. and such are generally considered to presen 
c ha riict eristics of tumours. 

The Primary New OrowtliB occurring in lymphatic gland 
lymphadenoma and lympho-sarcoma, A few instances of i 
ently primary epithelioma have been recorded. Amongst ol 
Sir James Pa^'tl mentions some cases of epithelioma of the ing 
glantls, following ec^tma of the scrotum, caused by 5001,1 
paraffin, in which, on the most careful examination, no pri 
scrotal growth was discovered; possibly it had disappeared. 

LymphadenoDia is the term given to a new growth occi 
in lymphatic glands, corresponding in structure with ti\ 
lymphoid tissue — th-U ii* to say, it consists of a stroma, more< 
delicate according; to the consistency of the mass, in the tii 
of which are packed a great number of small round cells resen 
leucocytes. 

There has l^een much discussion as to the nature of this gr 
and also as to the relation it bears to Hodgkin^s diseasi 
leuka.^mia. Nothing Rnal has as yet been made out, but 
seems every prol>ability in favour of the view that it is 



[iipiiHi-iT^iioicia^ yfii Eiic (Hiit^i iiiuiu, ii I'l strirLt^-cunc^ 
1 widely throuj::;hoiit the system, cilficr nfTtctini^ ni:iinly 
I lymphoid (issues, and then const it uJ in;; H'uli^kiirs 

else attacking chiefly the ^^pleen iind other internal 
. lymphatic nature, such as the bone -mar row. and 
ien with blood changes of a leukemic nature, giving 
lisease termed 'leucocythsemia.' Although we must 

there are difficulties in explaining all cases by the 
thesis, yet it will serve as a useful working theory, 
X look to further investigations for more light on the 

fmpllftdoiioiiui is usually met with in young adults, 
iher one gland or a large number. It is most often 
neck, and though the patient may be slightly anaemic, 
esents any blood changes of the leukfemic type. 
■ingU giand is affected it becomes slowly enlarged, and 
ndency to caseate or suppurate ; it remains free from 
J adjacent structures, and is hence moveable and pain- 
quite possible that many glands thought to be of this 
in reality tubercular, in the early stages of fleshy 
t. The Tmhtment of such is by removal. 
my glamds are affected, the disease may be limited to 
; the neck is a favourite situation, both sides being 
/ed, and the disease may here be so extensive as to 
vearing of collars impossible. The special character- 
is condition are: that many glands are enlarged, that 
o tendency to suppurate, caseate, or ulcerate, and that 
t little peri -adenitis ; hence they are freely moveable 
her and on surrounding tissues, and are neither painful 

val, the glands vary somewhat in consistency, being 



ji6 A MANUAL OF SURGERY 



This affection is sometimes markedly amenable to 
especially to the administration of arsenic. Small doses dL I 
arsenicahs combined with iron are at fust given, but thefl 
gradually increased, and as the patient comes under the ioil 
of the drug, retrogression of the glands may be observed. 
however, they persist in spite of medicinal treatment, tba 
moval should not be delayed. Where many glands are lA 
this may involve extensive and repeated operations. 

Hall^umt LymphadenonUL [syn. : Hodgkiii'fl Diuaae or Ql 
LTmphadenosiB) is a condition usually met with in adults, ■ 
chiiraclerized by an overgrowth of all, or nearly all, the lyiw 
tissue in the body, including glands, the spleen, the n 
or agmJnated follicles of the intestine, etc. Where the ^ 
IS primarily and mainly enlarged, the disease is often tl 
* splenic leucocythaemJa,* owing to the fact that in it 1 
changes of a leukaemic type are present — that is to say, tbs 
marked increase in the number of leucocytes, whilst the red 
puscles are deficient both in number and in the amoo 
hxmc^lobin contained in them. When, howeveri the tt 
lymphatics are mainly affected and the spleen not spedaUr 
is termed ^ Hodgkin's disease.' In it the patient is profo 
anaemic, but is not necessarily leukemic, although the 
change is sometimes met with. 

The tumours thus produced grow slowly, are painless 
when groups of glands are affected, adhere together, fo 
lobulated masses, but with no tendency to caseate or supp 
The skin becomes involved in the tumour later on, and sup( 
ulceration may follow, but there is no subsequent fungat 
the growlh- 

The prognosis is exceedingly grave, the disease usuall; 
gressinR in spite of all treatment to a fatal issue, which is < 
exhaustion. Where leukaemia is present, hemorrhages in 
tissues, or from the ttiucous or cutaneous surfaces, arc 
noticed. 

Treatment. — Arsenic combined with iron may be admini 
and» latterly, injection of an emulsion of bone-marrow ha: 
s1roni:^]y recommended, but the results gained hitherto ha 
t>een al all satisfactory. It is useless attempting to remo 
external jjrowth;^, since they are only an evidence of a 
seated general affection. 

Lymplw-Baicoma^ — Lymphatic glands sometimes becor 
seat of a primary sarcomatous growth, the microscopic cha 
of which have t^en detailed elsewhere (p. 139). The 
occurs in adults, and is met with not uncommonly in the 
sometimes in the glands at the root of the neck, and ma; 
sionally occur in the mediastinum or in the testis. Whei 
mencing in a region where its development can be followt 
seen to form a rapidly growing tumour, which is at first firm. 



s involved in the K^o^^lh. and uktrates, an occurrence 
■wed by the sproiitin;^ up of a i)!!.-^^!!!^ ftiii^'atin^ Tnass, 
haracter lo that formed hv any oihcr rapidly j;rijwin^i 
uinour. Dissemination of the growth ihroughuut the 
y also be met with, death quickly resulting from 
and cachexia. 

itmont consists in the removal of the mass, where 
, without delay. If, however^ extensive adhesions 
>ecoines absolutely impossible. 

f Growthi in Lrmplutlc GUnds are a special feature of 
us tumours. In Che sarcomata they are less common, 
ays present in the case of melanotic sarcoma, lympho- 
nd usually sarcoma of the testis, tonsil and thyroid. 
, characteristics of these are noted elsewhere. 



CHAPTER Xll. 



AFrECTIONS OF NEBVE8, 




In^ailea of NerYM. 

'I'liu «impLe«l And rnu^t coniiDon form of injui^ to wliidi A DtfM 
is liablt? 13 Ji ContTisioii, causing a scn^tion of tmxluiicoc pinilBl 
ncHlcs, iA!iif.!i usually wears off m Iht muise of jn few buiirv U 
wver« CAse& vannble d«^««s of loo of power luid st'matwn nu 
(TDfiue.un<l in hy^uricuJ ^vomen more or Jtfsftfieurul^'id. JnpatxM 
Truffcrirt; froiTi i^out, syphilis, or rlK^umntism. A chrunK ^xripbtfii 
UL'urilis n icadlly iLidu^t'iJH ufleii of ^ auiJJE^wlirit iiiUatEaNcr i}ft. 
nn<lthi«<ivon occurs in h^jlthv iritiividiiaU. As a nilv, »ll1hp cri^- 
mc-nl noctlcd consi^lfi m gcrntV friction with stimulaling luiinieiiU. 

A uoive nirty aljio bf Str&Uied lt> any suttdcti, uriex|3ccud cr 
exee^itioual mnvoirKriil. ]iii>dui.rTL^ cETtcLs i<lm(itiJ t«ilh ikoE 
Arising from contiisioris. 

BuplUT^ of ncTvc?^ s\'ithoLjt on external wound only ocean is 
couLicx^tioii with &cvcrc^ [hjuml-^, «ucTi ;i« tli^JooitioLi** or fractOTk 
and vvpr\ ihr-n loTnl cKvision tvvpry rari*, th^ !>h«2ih r«i&ina^it» 
mto^nty^ ahhou^h Thci :txis cvlindort may hav« mvma w%y^ t^ 
mediate pnrftlysiR and los3 Ot 5Wn!witi[>n uMial)}' fdJon* am flA)> 
be pcrmaiicitl. iilliiotigl) not uiifcrftLLi-iitly ri-[>atr ocritr^ ifticf i 
time, owin^ to the Tihe;itli rpmaming ininct. The tionH i\viyi 
cxittinft Oft tr> the condilion of the ^iCBlfa reguJottc the treiiinrjTt 
which must bo followed, via:., one of cxpectsncy. Frictioo af"J 
elpttritily ih'julil )>piip|d]eil la the p;trts,nitd only when these bfirt 
fuited should opecatitrii lie undertaken. Secondary nerre wnn* 
under the^' circ:iirii<^t^UK'c'^ ia do! a %-«ry euccettsEul proceecfing- 

€ompr«uien uf n nerve ia usually due to the grawlh of lumoucft 
oi ;iiii'iirisnis oi tu somt* di>i]i];vcmeiit uf Ixjne^, a^ in fnu:tiuW 
dislucanoui ; or, again, the n«n« may b« inclu<1ed in the oJhtt 
formed in the repair oi a fracture, the 8ytnpCona» not spMtiuiC 
till four or ^\\ weeks .tftcr the injury i os it uiay he met with iathf 
form of trLitih pais), ur as ji R'Siilt of <phDt ^lessuie, l>i vhlien iEk 
ojiltrnMl pop]Lte;il nerve lk cQmpr«&«o(i agniniiC lh« nadc of tti« 
libulft. Tho-^e nerves also which traverse bony canaU m tbs 
skull are liable to prcj^urc a& a result of chrunic osleatJA mad con- 




jspecinlly in neurotic women. Ocrasionally a cbninio forni 
iu:? i^ starit'(l> which travels up the limh* ami may cau'^ 
ufferin;" or impaimicnl of fiinctian. 

I DiTiston Of a Nerve. — Nerves are not uncommoiTly cut 
:tely across in open wounds, and it is most important that 
ultmg phenomena should be fully understood and accurately 
I. 

Imnadllftte Effects are : (a) Total paralysis of the muscles 
id by the uerve ; (b) complete anesthesia of the parts 
mI by it, which* however, is not necessarily permanent* since 
OD may be apparently conveyed by anastomosing trunks, 
Lzstfaetic area passing through gradual stages of partial 
on before recovery ts complete- (c) Vasomotor paralysis is 
roduced, resulting in the limb becoming hypertemic and 
r for a few days^ and then subsequently colder and in- 
mlly supplied with blood, (rf) The excito- secretory nerves 
-aJyzed so that glands may lose their functions for a. time. 

SflConduT Effects vary with the character of the nerve 
1, and are much more complicated than the former. We 
liscuss them under five headings ; 
bUKfW in the KvreB ik9maelYM.^Locally, the two ends 

very slightly, perhaps not more than the twelfth of an 
iid the space thus formed fills with blood, which is quickly 
ed, and replaced by a cellulo- plastic effusion of the usual 

Immediate union has been supposed to occur in cases 
total restoration of function has rapidly followed complete 
n ; but, as a rule, a mass of fibro- cicatricial tissue is formed, 

which may be found spaces filled with fine nervous 
: coiled up in loops and arising from overgrowth of the 
flinders from the upper end. After an amputation, most of 



390 A MANUAL OF SURGERY 



itself m the medullary substance, which undergoes a 
segmentation, becoming broken up into irregular m 
myeliue, and disappears entirely in about a month. Tbe 
cylinders also degenerate and disappear at a somewhat lata 
and finally only the sheath of Schwann and the peiioeunl 
nective tissue remain. The nuclei of the sheath prolifierato 
form a fibro- cellular mass, which represents the nerves^ and 
long lost atl power of conducting nervous or electric stimuE 

Pn>3r»i«a/(yf degeneration of the medullary sheath occurs, 
to that which is seen in the distal portion, but only extending 
as the next node of Ranvier. It is of but little significance, 
axis cylinders grow downwards, as already mentioned. 

2. Changes in the Hnscles. — Complete paralysis of 
necessarily occurs when a motor nerve has t>een divided, ind 
muscles involved slowly atrophy, and show signs of degi 
changes. The atrophy is not noticed at first, and is ncd so 
as that arising from infantile palsy, since it is dmply dm 
separation from the trophic centres, and nol to their 
As a result of the paralysis and atrophy, various 
deformity may ensue, owing to a disturbance of the eqmli 
normally obtained between opposing groups of muscles. 
ekctrical changes, too, are exceedingly important. At fina 
may be a slight increase of excitability both of the muscles 
lower end of the nerve to faradic and galvanic currents, bat 
is not constantly present. The faradic current rapidly loM 
power over the affected muscles, and its effects lotally 
in two or three weeks, whilst the galvanic excitabih^ 
for weeks or months, and even then only slowly dimini^iek 
that a condition follows in which the galvanic current 
a much greater contraction than the faradic (i.^., ' the r^ctiot 
degeneration '). As long as this phenomenon remains, tbefei 
hope that restoration of the continuity of the nerve may befoUoi 
by restoration of function ; but when the muscles react neitbff 
galvanic nor to faradic stimuh, the case may be looked uptvi 
beyond repair. 

3. Various modifications of Samation, both special, ^entf 
and muscular, may \\t met with, in the shape of neuralgia, h 
testhesia, anaesthesia, etc. 

4. The blood supply to a paralyzed part is always 
although congestion may result in the lower extremities, owing 
the w<:ak circulation ; consequently the lemp>erature falls, aoil 
vitality of the part is decreased. This, associated with thek* 
trophic influence of the nerve centres, results in certain coimSI» 
which may lie of considerable importance. Thus the sldn in^ 
become thin, atrophic, bluish-red, and shiny {* glossy sldo' ■ 
Weir-Mitchell), or it may l>e rough and covered with scales, ' 
even cedemalous. Chilblains are readily produced, and uW** 
posure to cold or heat may result in vesication or even slougfai'V' 



jiFFECTtO:^S OF SERVES 



9« 




k 



Wonids beal tadly, and ulccrAlion from sTight irnt&jits Is very 
^ktly tu ijccut, ^^p., romral ulr/riaTitm aflrr Hividrnt of The fiflh 
nefX^, aiKl pejiomiing ulcen; of ihc fool, Tlis cat;kneou« ap- 
pcMllcco Are al!H> mvolvcd, the hciirA falling oljI, ihe nails w- 
ini; rougl^ liriUlcp mud «caiy. And the seb^ccoti^ atiiI $iwciil 
giifltb nlht-r Ui«rharging un Aburdanl softretion, or rffmamlrtg 
lAldi«:«fy funciioai««»- Atrophyoi the smaller lioiie^ mriy follow, 
;iaJ a&kyloai9 of the terminal joiut:* of the lingers or ioc». 1& a 
duli llw dt-h'dupiTiQiit t)f tilt? (util lit always itiurc ar Ikk^ 
npurra. 

j- FiittUy, in a f«U' cut«6 chimk^eTi fiu\'e developed ui the cciitral 
wnwis sysiem uhich arc of cAlmnc intcrc&l. Tliuii. in the caj-ly 
iU^ rrflcx ^pasiHS ijt p.jrAlysis aft sunit'tim^s Eiitl wilh a* 
i;^^' phcnoiTicnfi ; uhiUt in r^^e^ wht^r^t ch«i trrilxEJOD of A 
Imy U prc&enc in fiddition to ihc division cf the nervo 
Mrt Mdiokis fiympiom^ jiia>' rc^uli. ThEi8i in a ^iMfr wotiJid of 
ihe incilun nrrv^, ;i hr^liliy niAn triT^tirtl »i hr^^piinl dflrvflontd & 
i^pkaJ epikptic lit u-hcuc^xr the neuntlgic bullvjus end waa 
iHctwd The bulb wnA excised, arid the nerve cleanly suivircd, 
Ut. vtihoui cflccl. the epilepsy 'ind pain t^tiil rcTiiitinnig, The 
nokm iiFiie wasdiviiled in ihi? uppf^t ^irni, ;indu poninn excL*ied, 
Ui: ou benelit y^-st^ derivvd from iL £''m:dly, the patient pfis^ed 
bi»acooditionol cbronic dementia, and died, no uimi^us nervous 
loon beiniE found at\ iKiM'muUcin examination. 
llgiUilBHuu a( a divided nerw cnniiit netesuLnly ensue If 
of function is obtoinedn Nothinc cettoin i% known 
to tbe cuict nature ol thiji chon^ in tne fovr invtances of 
.udiolc auion wbidi liavf? Ireeii iKtrurOed; bitl lE appear;* to 
occurr«<d in cui-ei wh«re a Uee cotUierul com muni caiicn 
b«we«n itt divided end und utiitf OMves* In d«lay«d 
, t^pcciaUv nhcn a fibro-ciciiUicia! bulb has formed, and 
lower end hns ;iirophied, il \\ proliahlc ihm afttfT opem- 
ihf tilft cylinders from ih© upper «*gm©m grow down^ 
t into llic iowcr end, and oithor sot up new action in thu 
h of Schwann, whereby n«w OMts cylinders arc formctJ 
donti, ot thry mrtHy cximd ^ilon^ ihc dc^cnerjlrd nr-tvp 
to tbe pfifipht^r^'i uAm^ it an a »;afrolding to dirctl ihcrir 
proKTc^. A mcktullnTy liheath is subficquently formed, 
tbe procean takes some months to reach completioQ. Clinic 
yfly. ihe etirlieit evidence ijf renptiefiiiimj is n slight return of 
■dtttttion, which may be at tirtC ubnonnal. »nd ooly sJowly 
klcORicA of a normal t^pc. Motion i^ f^cnerotly much later in its 
iDloiatioii tlboj] Mrnuiiou, and trnxy never be eutirciy recovoced. 

The TFMinwnt uf n dividt^d nt-rve will dc^pend t^iilirtfly upon it« 
■Ktnd function. If smatl and of slight nnportoncv. no «ptfciftl 
Umtveiii » colled for; but in &ay dT tlie mair nerv&» of the 
?iLrrTnrties it la tteosI eueulUI lu tl*^A\ With tlicm Al uncc hy 
snouij nerVft ittturt- In faci^ The s^nie rule ohiains nowadays 

21 



3U A MANUAL OF SURGERY 



for a divided nerve as for a wounded artery, \tz., to cut doum 
expose both ends, suturing them neatly together. This isl 
accomplished hy using a domestic sewing needle without cd 
edges, or a fine Hagedom's needle, and the finest chnKmd 
catgut ; one or more stitches should pass through the nerve, 
the rest merely through the sheath. Absolute asepsis is I 
essentia] in order to gain satisfactory results. 

If the wound has been inflicted months before, and a bulb 
formed, SecoDd&ry Nerve Sutnre must be employed. The d 
is first exposed hy a free incision through the cicatrix, the 
ends identified and isolated, and the fibrous tissue of the 
removed to a sufficient extent to expose healthy ner\"e fib 
in the section; the divided ends are then brought together 
as little tension as possible. To supply the inteiral nece^s 
resulting from removal of the bulb» traction upon each end oj 
ner\'e should he employed to stretch it, and the limb subseqiu 
put up in such a position as to relax the parts, e.g^, the 
flexed to a right angle, or the elbow bent. In one cas 
removed an inch or two of the humerus to allow the divided 
of the musculo- spiral nerve to be approximated. In ord 
diminish the drag on the fine end-to-end sutures, a tension i 
should lie passed through the substance of the ner\'e, abc 
to A an inch from the di^'ided ends. 

Ser\e grafting, in order to bridge over a defect, has not 
the present been found of much practical value, although ; 
cases of success are reported. A ner\'e more or less simil 
size to that to be operated on is removed from an animi 
previuusly killed, and carefully stitched in position.. Proba 
merely acts as a carrier to the nerve fibrilla from the upper 
and possibly the same result would be obtained by passing s* 
fine strands of catgut from one end to the other. 

During the time that the paralysis continues the limb 
must be well massaged, the fingers or toes worked daily lo 
them from getting stiff, and the muscles treated with electric 
prevent them from degenerating too rapidly. Perhaps the 
means of accomplishing this is to use the electric bath 
electrode being placed in a basin of warm saline solutioc 
other held in the patient's hand or against some part of the 
and the affected limb then dipped in the water tiJl it becon 
a bright red colour. 

In many cases where the original wound has been compli 
with spreading septic inflammation the impaired molnlity 
much due to the inflammatory adhesions of joints and tendo 
to paralysis, and this must always be taken into considerati 
giving an opinion on a case, or in suggesting treatment. 



APfECTtoas OF NCJrrcs 



SM 



Inflara auction of ffemfl. 
VMtittt ti nol ft vtffy cof]tmr>:i coodilion- It is uBually 

'w&n Kiih ATptic wcnindii- The nerve mav »ionicliTu**s l>e ftlt 
UtitnraMcn And trndtr, whilfil ao^crv pain oia neiu.it^r lyp« U 
itoi cotnpkaned of by the pnciont. Od microscopic cxuiiinfttion 
ie ofidmiy sttCtts of Ini^niTir-naiion &ic well markcdp Uiough 





n& f I — Ck>oxic Si-nirtis hHiAviM^ ]»gcirtii:«v m tilk AunrruT fir Cam - 
QCmr TiHiLt, AHD iii£ NeiiV£ Fzuh):>i \it SttiioH Al-tkickli Amu 
CoHTRnSAAO (A). A» JU^O aS AftTEJll WlT» Thi^m-heo SVall* {^}. 

(Per* am) 

Bainlf «vkknt in the ^heaih. The Troatmaiit consi^s of reu to 
(W limb, lOKCChfir with leeching qi dry cupping over (he cour^ 
^ [he ocne, comhincij with hnt Mladonns tojitciiUlbtis, itod ami- 
able |cneeal Iherapetitic mc:isufes. 

Cuoak ttwjiHt, or Perinctiritis, is much more common than 
eU fooRcr. U U c\idcpced pitiholopically by an incrctisc of all 
tkt onnoctivc tLsMtc uf ;i nerve, Utih uctiunU il nad Ixrl^wn ihe 



3S4 A MAlfUAL OF SURGERY 

fasciculii with compression of the vessels and nerve fibres { 
91}- It may result from injury, such as sprains, strains 
pressure, especially when the patient is suffering fr<Kn 
rheumatism, or gout. It is very common in the fifth 
and in branches of the brachial plexus ^ aitd is met wiA 
a peripheral neuritis in various toxic conditions, e^.y aJ 
diabetes, malaria, etc- The Symptonu vary a good deal 
the nerve affected. Occasionally it can be felt to be tbi' 
and tender on pressure, whilst more or less severe □ 
is also noticed, accompanied perhaps with some loss of 
in the muscles supplied by it. In a few cases this pareas 
be associated with spasmodic contraction of the parts, 
of a tonic type, as in some cases of talipes; but such 
as facial tic, or scrivener*s palsy, where the contracliois 
clonic, are more frequently due to central changes. T 
lesions may also be induced, such as perforating iticer, or 
losis of the terminal joints of fingers or toes. 

The Tro&tmeut in the early stages consists in the administn- 
tion of ant i 'diathetic remedies, and, indeed, iodide of potassiifll 
with or without mercury, is generally applicable. Locally, 
longed rest is needed with counter-irritation in the fonn 
blisters, and later on massage with suitable liniments, 
there is any paresis the muscles must be stimulated daily bytlM 
faradic current. Excessive pain is combated by administtfB| 
hypodermically morphia or atropine. Failing these, other m 
should lie adopted, such as acupuncture, in which needles IB 
passed into the substance of the nerve, and allowed to remain fc» 
a few moments; lliis probably acts by relieving the tenaOT vA 
inflammatory exudation within the sheath. Various operalfit 
measures dealt with under neuralgia may be called for in stvtn 
and protriicted cases. 

For Tumours of nerves, see p. 149. 

Nenrolgia- 

Neuralgra is a condilion which either the physician or iht 
surgeon may l>e cailfd upyn to treat ; it is exc^dingly conimoa, 
and may be one of ihe most terrible afllictions to which the 
human frame is subject. It is characterized by a paroxysmal « 
inlermiiteni piiin of a darrin^^ or slabbing character, which fcJlon 
the course of some p;irlicular nerve or nerves, especially ^ 
trigeminal. The attack commences suddenly, and the ptfi 
steadily increases, until it reaches a climax, and then gradually^ 
suddenly subsides. Thes<^ paroxysms may last minutes or hourti 
and may recur at varyint; intervals, either a few in a day, or iMfl 
in an hour; they maybe induced by natural conditions, or phyw 
phenomena, such as sudden noises, a draught of air, etc. SloW' 
over, pressure over the affected trunks may originate, relieve, Ci 




JFFECTIOSS OF H£StyES m 



I* wbUX the «kiii afBeded by them in often b' 
^aad ercD bypervmic iind ardcEDAtous (the ^'ai> 
Utvtmx of Valleii)- 0cc4»ioim]l) ^dj^cenl musdcimdy beLuiilc 
ipiflnodicA])^ Ritd s)^Tipaih«ilcally contracf^ during the ^Ttnck, 
mst MCtetAvo ti«cTetion, such a& from t^ii^ lachrymAl or swc&t 
lUnds, t* aJ»o induced. Herpes n sumctiEiKra met with In the 
ttcanf dJ«lnbutJon of ihe afftK.ned iicivi.' (f^'., shingles in connec- 
ttcnwifh intrTf^iiial reurnTgU), Th« fifth crarii;il nrnc U mcst 
pMM to this Atfcctiorii but timiJ&r monifoMaiions niiiy occur m 
lof purely fcn^ofy or inJxcd nerve, ^uch as ihc inEcrcoMals or 
<aIfC At ia com^drv tmdii^i, i,ti<^h a^i ihr- hreu^t or cr&iJSi <ir the 

Tie OuMi of n^rftle:!^ nrc very diverse, ncd the sutf^oti 
aftn hu to look far aM'\ in ofdrr 10 find ihcnu Thus, o^pft- 
h f w iy C3I1M3 may lip mfniinnrd ihn hvstcrif:;il lemppramcui, 
tivm, suid deprcttiiig drcumstAnott of nil kindt, «4peci^y 
oorsil mxiety and worry. The Sir/^ catucK inay be toxic, 
i-tt floaUna, lead, or tiicrcuty ; icHck, ^.g,, cvarian diaeatCt 
^amk. nc: cenirat, fruni diHCJiM* cii ihr spinjil cord or brain; 
ttdoL from pT<«mre on the roots of the nerves a^ Ihey emerge 
hx the bptnol caaaJ or cninium : or penph«raJ, ovtitijc; to IcAon* 
ej tk nan^tiuiiLs tiiJti[;eiJ tilher Uy imunm, iufldni ruction, or 
wwitmirthv 

Tnuatnt consists primarily in attention to the ^'«iMmJ health, 

~ 'ftafijocal application of counter- in itnnts And scdntivc^. Iron 
SHADic may lie given to atijeiikic fxitivni^; ^fiii-^pj^MToilict. 
Ml V t^lerianaie of zirK, to hyster)^! women; quininp or 
■fioic for mal&riu ; nlnUl st^i-bithmi; oir change oi uxr is often 
^TrbUe, lodiife of potd:»Aiiim zind incicury Jirc beneficial in all 
itaa dnf- Xn i^yphills- Whfre the pain k rtrpwivr, morphiit. 
KW in lar^ft do^, m.iy l» called tor. Empirical remedies, such 
ti utLpynnc, phcrtacetin, and crol on -chloral hydrntc ^ill also 
WKtimcs do good- 

Whm, however, modirinAl a^mtit fail, «itrgicn] measures aie 
odkaied in order toaJlay the pnticnt'it f«Liflcrinj^. The foUov^n^ 
*nlhe more u«ua1 mcthrxlR aiicptcd : 

1, In poittty Saniory Nsrvoa. siu II a« the trigcnunnl. simple 
dmiion or uMfotAiuv h;u aHcn hem reiatt&.l to, buT ihe rmlef 
pia«(J tf od a mo«t temporary nctturc, since sensory nerves rcfldily 
MiScafter ilivi^ioc. and sen^ntion i.i rnpidly restored even when 
ttMk is SfKomplete, |irTjbwbly ]*y tr^iMniwioii lluouL'h anasto- 
Qodtig tiranches : hence the openition ha* fallen intji discredit. 
Atmch more attti&isctory procccdjn^ is wurfft^imy ox the removal 
^a portion of the nerve-Uunk, no tlut unluii of the divided ends 
*dlbeleis likely lo occur, Mimychf thif^tases, however, are due 
tooninl dia«a5«, and it is an interesting riiieRmn how ttic Trouble 
'»be bsnefited t^ such proceedinc^. Probably th<^ cxplaniiion of 
tfasivlief ^oe<l is tliat the centre is put Into a condition of r^t 




330 A MANUAL- OF SURGERY 



by the exclusion of afferent stimuli. Acting on this theprj, 
surgeons nowadays endeavour to remove as large a portion of 
affected nerve as possible^ and Thiersch has suggested a plu 
nerve-extractioH in which he lays the trunk bare at a suitable 
and then, grasping it with forceps, proceeds to forcibly extnd 
by torsion, tearing it from its central attachments^ and 
it from the peripheral. The details of the various metl 
employed on separate nerves are given below. 

Finally^ if all such measures have failed, the roots d 
nerves may be divided either within the skull or in the spinal' 

2. In a Uixed N^we, conveying motor as v^-ell as 
stimuli, mrve-itretching has to be mainly relied upon. The 
is laid bare, and traction exercised, both centrally and 
ally, by means of a blunt hook if the nerve is small, or 
finger placed under it if targe. The clinical effect is to 
the conductivity of the nerve for a lime, either compleCetr 

fiartially ; but since it is not divided, repair and restoratkn 
unction follow. The elasticity and extensibility of the 
are considerable, and the pressure needed to cause their ni| 
has been accurately estimated. It varies much in different 
viduals, and allowance must be made for this in all oi 
Thus, the sciatic nerve will stand about as much traction as 
ordinary man can apply with his finger and thumb; it shooU 
used steadily and continuously, not in a series of jerks. TU 
effect of stretching is to free the nerve from external iiifli»] 
matory adhesions, and to alter the relations between the sbciA 
and its contents. Thus, the perineurium, instead of consisticf 
of wavy fibrillic, has the fibres straightened out, thereby co* 
pressing them, obliterating the lymphatic spaces between tfci 
fibres, and possibly rupturmg the ner\'i nervorum. The Dent 
becomes hypera^mic, and the medullary sheath of the tubules ni^ 
be irregularly broken up- The gray matter of the cord majM 
possibly be influenced, becoming hyper^emic if but slight tractii* 
is used, or showing hemorrhages and exudation when mwi 
force is employed ; but this has of course only been observed ii 
animals \ it is doubtful whether sufficient force could be exerdscd 
to produce such effects in man. 

Affections of Special NerrftS. 

The Oranial Nerves. —The Olfftctoir Nerve may be involved « 
fractures extending across the cribriform plate of the elhmcttd, * 
in severe cases of contusion of the anterior lobes of the brain widi* 
out fracture. Loss of smell (anosmia) may be induced thereby- 

The Optic Narre is sometimes ruptured in fractures (^ the bl> 
of the skull involving the optic foramen, and sudden irretnediabli 
blindness results ; or it may be compressed b^ hfemorrbage « 
Indammatory exudation, either within or, outside of its sheatl> 



AFFECTIOSS OF KERVES 



W 



I 



» 



PPtetDaqn or \ctat complr^c loss of vision pfcccdcd by optic 
ttttm (iV,, 'mAHmrnjtiton iif 1h^' Tnitiiof.'ut^r lermiiialiuu cif the 
mvt, or papilhliiti: but if ihe ha-morrhage is not tery t^ver*, 
IkaaUyopia (or loss of vision) mny l»c in itieiisure Tt*cover*d 
Iran. OrUta] cellulitis nnt unfiefnicJitly causes pressure on ihc 
^Hie^eiilin as a ipsult cjf iht* rit(]rii?ili.ileinll;LitiTTia(ioTi or frntu the 
cubv^»«iii dcatticul contrattioa. bvphilitic dJ*F;ise t>i rhe sheath 
«ihf fomution ol » ^uimnu m ttn nr;iKH1x:<urhooil» ur inira-orlxtnl 
ucjfisrns or tuiiiotu^. uuy lik-wix: iutlutf aiuUyiJtjiA Uoni prcs- 
wifr ,^T tIji- !(^JT^k. 

The Thlrt N«m iHwr^r mu/j) bcring entirely motor, paralytic 
mfionu Arc tho^ to be chiefly lo^ej for. Iht^y mny arise? 
niaMHnni/cAU6L-s. biK^li asbvphiliui: ft di^i^vuctAlivc changes in 
fii flanf of ihr third venfricip; or from f^ifhrral lesions such as 
imridtj^, turno^ir«> tr^^uiri;^, otc^, either in Ihe orbit, sphenoidal 
uvire. ot bfix of ihc brain. 

The Srittptoilis of complrtu parftlysie arc as follows : ia) PxtXoH, 
<f itroofun^ of the upper cyrlid, from loss of power in The levator 
pdpdv^ «upciiori£; (&) external ttmbismus, or ^'.luint, from 
ptnlyvfi of the inner, tipper, or lower recti, the eye licinj^ aJ»o 
^Ktnl ti litiip rlownw3T*U from paralysis nf ihc itifcrioj ubhuue ; 
if) mydriujfi, Of clilatalioti of thy pupil, fiom pai*y of the fris; 
(/llow of ^tccomnioJation. from the cihary muscle being para* 
V*^l*»d('^ some slight protrusion of IheeyctwUl (exophthalmos), 
mriDf: [0 nwnit vi iu imi!(d» tieiri^ f1:r<:d(] an^I rrTa?<ocL In con- 
teqwic*, howe^'eT. of the cloi* proximity of this n'?r\c to the 
wlh, Wth, and sixth in the wnlls of thf? cavtmous ainus and 
^Ittnoickl fissure, symptoun. itfcfpibie to these trunk* rirc often 
laMciAfed u-ith ihe above, as also vcacus coiiffesthm nf the eye 
4Dd whil from pressure on the J^inus- Sl^ould ihs e)'eha]] be 
IfitoUy sniDobilifeci from paialysia of all its muscks without venous 
coQfcsiiun. tilt i;uiuhliiitL is kiifnvn as cphEhalmople^J*^ rxterna. 
icdif Alu'4y4<lue to central cli^ira^ affj-cdnj; the floor nf the thirri 
tdthclc, An&tni; from scloro^i^ due la syphibg or tabes- 

Tbc TrMtOMAt in tnosl utses coa^I&ts m the administration uf 
moQirr and iodide ol poias!4itim. 

Pualyvit of 1h« F^UtUi tT^rrt (Pathetic), which ^upphes the 
obhquc mufick. rvault* in defdclivo movement of the eye- 
dobriu^fd^ anil uuCwarUs. 

Thn FlfUk or TrtgamliiJiI Herr^ ie ncra^onatly torn or Ucemied 
■ hetd mjiifi««, giving rise toanaoBlhet.xn,with perhaps nl^eraiion 
of tie comca ; but such casts arc enccedingly tare. M iich more 
cannon i;^ the di%tM^ known as trigeminal tnurai^id or tic 
dmlourmtK, which U met with mcKi umully in woin*», thoagh 
»3t unlnquenlty in men. ll i^ to be clearly dislint^uished from 
lU lifDplcr form,% of ncural^iia dtic to some local irritation or 
pAci^ weakness liy ihc paiiAj^mii! ch^acter arid violcTicc 
ilW pun; hence the term 'epileptiform tic" has been applied 





328 A MANUAL OF SURGERY 

to it, and not inaptly represents the terrible nature d 
affection. As a rule, it commences in the infra-orbital or " 
dental branches, radiating thence to alt the other divisions al 
nerve- The paroxysms are not very frequent at first, but 
rapidly increase both in number and severity, until at last 
patient becomes utterly prostrate, and ma^ be so depressed aa 
contemplate or even attempt suicide. The condition often 
pends a good deal on the general health, and intermix 
of varying length occur. The attacks are accompanied 
twitchmg of the muscles of the face, and even of the neck; 
by unilateral sweating and hyperemia of the head, and 
development of such marked * points douloureux,' that posal 
the patients cannot brush their hair or wash their face on 
affected side, which becomes dirty and often shiny from It< 
changes or as the result of friction. Lachrymation is a ma 
feature during the attacks, and there may be a considerable ii 
crease in the salivary secretion, as also in that of nasal mucus- 

As to Ihe CftiiM of lie douloureux, but little can be said for cenaio, Altl»a| 
many contributing conditions have been described, which may t» clasiii 
under the following headings; {a) Central causes, such as changes of asdenoi 
lype in the deep centres of the fifth nerve, or in the Gasscrian gangboa 
{h) radiial. or those due to ccmpression or disease of the roots of the " 
reaching from the ganglion to the cranial foramina; (j*) rraniai con 
such as diminution in the size of the foramina of exit of the nerves" 
vary immensely in different skuIK being generally smaller in vpomen; 
may be encroached upon by callus, inAammatory su-elhngs. or tumoai 
(rf) pci'phtml causes, tg.. dental caries, najrowing of the walls of tlie Ix^ 
canals, etc , [t] tuxfc agents, e ^ , malaria, which especially tends to Aflect iM 
aupra-orbUal nerve, constituting the so-Called 'brow ag:ue ' : and (/) fi^ 
phenomena, t.e., ovarian disease, errors of refraction, etc 

In ihe Trntiattnt of tic douloureuK, innumerable remedies have beeo o^ 
uith a varying amount of success or failure, t g , f^uinine. where there is I 
malarial history , iodides and mercury for syphilis; iron and arsenic to 
aniemic patients: and, failing these, crolon -chloral, paraldehyde, etc ^ 
sources of refles irritation should be removed or treaiedi such as carious t*rtk 
errors of refraction, intranasal trouble, ovaritis, etc. If the pain penA 
0[wratiT« ll«BBure* will, sooner or later, be called for Neurotomv and iw* 
stretching may give temporary relief, but most surgeons have been led hj 
experience to the conclusion that the greatest measure of succera Wto* 
neurectomv. and that the larger the portion excised, and the nearer that port» 
is to the central organs, the belter the results attained. Hence mucn idM 
extensive operations are now undertaken than formerly, e^"en exlettding (n 4i 
Gasserian ganglion itself 

We must now de'icril>e the different operaliona applicable to the t^ 
branches of the nerve,' premising that all purely subcutaneous oraBbmuc* 
methods are to bo condemned for their inaccuracy and inefficiency, as *l>Dtf 
account of the bleeding which is likely to result from ihe clo«dy contip* 
bloodvessels. 

The Sufiia -at brf,ii jVfnf does not very commonly call for diviMon or eitm 
lion, since neuralgia of this trunk is olten due to malana, and ii certaitily oB 
amenable to therapeutic measures than other forms. The pain usually im* 

• Owing to necessary limitations of space we must refer readers for ftfflh 
details to Rose on ' Trigeminal Neuralgia " (Bailliere, Tindall and Coi. iSgt). 



AFFECTfOHS OP NERVES 329 

nt the fame time each dav. and m&y be treated by giving a pill containing feiri 
ijpli, 1 graia. quIniK disulpb., 2 grains, and morpmns hyarochlor.. ^ ^nun, 
or hours before the attack is expecled, and repearing it everv hour till six 
Oil in all have been taken At the same time attention must ttc directed to 
DT kfCaJ cauK of irritation. Should Ibis fail 10 give relief, neurectomy should 
coDdenakeQ. The nerve emerges from the orbit through the supra-orbital 
lOlch, l>ing at the junction of the inner and middle thirds of the upper margin, 
lod ii readily reached by an incision following the course of the eyebrow. 



fK lii^a. Incision for division of supra-orbital nerx'e , b. line indicating 
pifliiion of supra-irochlear neoe, pas^ng from angle of mouth through 
■be inner canthus^ the short cross-line at its upper end is the incision 
Tiqiiired to expo^ it; f, petition of infra-Ofbital nerve and incision: 
d. Camochan's incision for neurectomy of the second division. 

i^TJi^h uhich the orbicularis can be divided aJong the line of its fibres 
'fi( tfi. jj ^ ihe ncr\'e is then easily exposed and dealt with By inciting the 
ocricBtcum and depre^ing i(, together with ihe orbital fat, by means of a 
i^Iola, The ner\'e can be followed back for some distance, and a considerable 
■UTioii removed 

The Sbfjd-innhlfar Servt has been stretched (Mmeuhat empirically, it is 
TK) for sundry- obscure neuralgic affections of the eyeball, ana occasionally 
ilk consideratle success U emerges from the orbit along a line drawn from 
eadgle of the mouth through the inner canthus jFig 9a, ft). An incision is 
ide at right angles to this course just beltjw the eyebrow, and the nerve^ 
lich is found in several filamentSn stretched or divided- 



330 A MANUAL OF SURGERY 

The Infra-orhital Nrn't emerges from the forajnen of the same nunc tf 
aboui \ inch below the lower margin of the orhii, and al the jimcticm 
middle and nuier thirds. It may be reached by a horiEontiil « 
incision placed over this site (Fig- g2. c) : bm snrgeom are ncrv 
unanimous in ihe opinion thai such an operation is unhkety to give DOn 
temporary relief, and hence utiliie one of the three following 
reaching Iki root of Ihr itcond diviston • 

[a) The orbital operation, rerommended by Lajigenbeck. W. 
Horsley, consists in tracing the nerve along the Hoor of the orHt. 
incision along its lower margin, and in breaking ap the roof of the 
which il lies Care must be taken to strip up the periostenm in iu 
50 as not ID open inio the orbital fai. and to ficcure the infra-orbital 
as far back as possible We cannot recommend ihii method, since it doM 
deal with Meckel's ganglion, or the posterior dental branches, 
as the antrum is in most cases encroached upon- the wound 'n LiaUi 
become septic. Hnr^lev recommends that if this cavity is by chanct 
it should be immediately filled with po^'dered boric acid 

{b) The antral method, devised by Carnochan of New York, and 
by Chavasse of Birmingham, lays bare the anterior wall of the antrum 
a Y-shaped incision^ the junction of the limbs being over (he irin 
foramen (Fig. gz. d). and the three flaps thus majked out. including thf 
osteum. are raised from the bones. The antral cavity is now opened 
j-inch trephine, and the posterior wall divided by a ^inch trephine. » u 
expose the lowest part of the spheno- maxillary fossa, in which M 
ganj^lion is situated. The infTa.-orbita] canal is now traced back lo ibr 
spui by chiselling through the upper wall of the aiitrum, and thus the o* 
can be isolated, and its point of exit from the foramen rotundum tnadedi 
It ia divided bv scissor^ as near lo the skull as possible. Free hzinorrtV 
always results from this operation, but can be conlroUed by pre^ure wiih »■ 
hoi sponges The results are fairly satisfactory', although a disfiguring »v 
the face remains \ the space in which the surgeon haa to work is vtry limBi 
and the opening of the antrum probably involves sepsis. - I 

[^} The ploycoid method, or, as il is called, the Braun-Lossen opera[ii»-J 
without doubt' the best for dealing with the root -of the second division T|j 
incision which we alwavs employ commences at the external angular pn» 
of the frontal bone, follows the upper border of the zygoma, and cun'Eido* 
wards in from of ihe ear to reach the angle of the lower jaw (Fig. So, F) Tm 
flap thus marked out. consisting only of'akin and subcutaneous i«- i* *J 
sected forwards, temporarily fixed by a suture lo the nose, and protected ™ 
gauze. The zygoma is exposed by a horizontal incision through ibe ' 
osteum, which is cleared from the boneby a suitable raspatory, and drilkd 
and back so as to carry silver wires in the subsequent suturing up (Fi« 
il is then liawn through and turned down together with the masseter 
moulh is -»li|^htly opened with a gag. and the temporal tendon p"l'*'J^ 
backwards from the front of the temporal fossa by retrafitorSn or if "TJ^fl 
is partially divided, exposing thereby the pterygo-majiilLary Assure, ml* 
interna] maxillary arter> entering, and the vein leaving it. These air 
by ligaiures, and divideil The root of the second division of the fiftb 
can then be hooked up on an aneurism needle as it emerges from the 
rotundum, and about h inch of it removed. This step i» tacilitated bye 
away a bony prominence which rises from the base of the great ^"^i 
sphenoid, on the posterior aspect of the junction of the two lim fa j 
piery go- maxillary fissure My also dividing the nerve as it emerge fro* 
mfra-orhital foramen through an incision in the face, the whole tnuii* 
free, and can be removed by traction, all the dental branches being tnn" 
The displaced structures are then put back in position, the zygoma ii i 
with silver wire, and the incision in the skin closed. The results g*J"*°. 
this method {a modification of the original operation) have been v«J ^^ 
factory, scarcely any scar persistini^. 



AFFECTIONS OF NERVES 



3Jt 



' drvjsum of the IrigeniiDa! nerve has many branchea, but ths lineal 
■ dental are those mainly affected with neuiaJgia sufficiently severe 

□pcraiive mterference. They have been divided separately in the 
portians of their course, but with little success, and. a^ a ru]e» it is 

with them at the same time close to the fonLmen ovale 
hi/ Ntrpt can he divided from uithin the mouth by a simple incision 
? bone, as it crosses the junction of the upper and midd'e thirds qf 
□ from the crown of the last lower mo!ar tooth to the angle of the 

may be sought for more carefully after division of the mucous 

Such methods, however, lack precision, and are nor only use1e3»» 

»us. owinR to [he necessary occurrence of sepsis. 

lor Dental Nervt bas been approached in three ways ; (j) From the 

jidin^ to the old plaUr The mt^coua membrane is mcised vertically 




ftiOHk AND Lower Jaw in situ to show Position of Saw-cots 

HILL-KOLES IH THE BrAUN-LOSSEH OFERATIOSh ANU THAT FOR 
I^L- OP TH£ GaSSERIAN GanGLION. 



to the canal, which can be easily felt, and then, after defining 
liiie of Spii. which ruards it. the nerve trunk is isolated and as 
away u possible; \b) by trephining the inferior maitilla, and 
alf its thickness, so as to eiipose the nerve in its canal, making the 
iciaioa aJong the lower border of the bone ; and (d by making an 
ow the angle of the jaw, and working up behind the bone to the 
the dentat canal, and there dividing the nerve (Lucbe-Sonnenburg 

(kt third divUufU of tht ftfik nerve at tkt foramen ovale is best accom- 
[be following manner: A flap of skin and subcutaneou$ tissue is 
nnrds ^m the parotid region, extending from the zygoma above 
1e of the jaw below (Fig. So. ¥). exposing thus the parotid gland 
oda puotldis and the mafiseier muscle, covered by fascia. If the 
kepi mictly to the subcutaneous tissues, the facial nerve is in 



33* A MANUAL OF SUXiGBEY 



no way endangered The masseter is then divided tniuvei^f 
bdow the socia paroEidi^. and the venicaJ ramus of the inferior """H* 
of muscle ajid periosteum to a sufficient exietit to aJlow the * 
V-inch trephine just below the a^mo^d notch» the remaining 
b«ng subsequently removed by cutting pliers \ enough bone \i left in 
behind to preserve the continuity of the jaw with the articulftTtnd 
proces&es. The Abi-es of (he external pteryfjoid muscle can now be v 
mg the upper part of the wound horizontally, and over it the intenut 
artery sometimes courses, giving rise to considerable hzmorrhtge if 
wounded. The lingual and dental nerves arc usually found close (0 
emerging from cinder the outer pten'^id muscle, and lying between the! 
plerygdd and the bone. They should be divided below aa br down as] 
whibt by drawing the exiemal pterygoid outwards with retractors, the 
ovale can be seen, if electric illumination is employed, and the nem 
divided at the point of exit. The wound usually heals well, and lonv 
little scar, although some impairment in the mobility of the jaw ony I 
parley from the cicatH ration following disturbance of the muscles udlr 
but maintv from paralytic atrophy of the muscles supplied by the divided 

In cases where such measures have been adopted and have foiled, v 
the pain is referred to the whole ner^'e. rtntoivi of thr Gaarrian gft^'^ 
been successfullv attempted The operations are so elaborate and 
that we can only give a hare outline of them here. 

Rosf's operation approaches the ganglion through the pterygoid regim. 
the 3rd division as its ^uide. An incision (Fie. So, F) similar to thtf 
exposing the foramen oxate is made through the skin, and the flap thai 
out is drawn forwards and stitched out of the way. The lygoma it 
(Fig. 93). and turned down Together with the maaaeter ; the coronoid 
is then divided or removed, and together with the temporal musclB 
upwards: the intemat ma\illar)' artery is. if possible, secured, ■nd 
sphenoidal attachment ol the external pten'goid scraped away so as toi 
the exposure of the foramen ovale, which lies just in front of the b4K 
pterygoid processes A j-inch trephine is now applied immediatdy 
the foramen ovale, and the bone around the opening thus made ii 
removed by forcep;^ or chisel $0 as to ^ive more space The trunk of the 
division is traced upwards, the sheath of the ganglion opei^ed. the 
division cm through hv means of a sharp cutting-hook, and the ganglioi 
away piecemeal, or. at anv rate, broken up There is likely to be * gocd 
of bleeding, especially in [he earlier stages of this operation. chieflydM 
from veins : it can. however, be usually restrained bv packing the wooaJ 
a few monientfi wuh sp<mt"es wrung out of very hot Motion. Eflicieaf 
Lllurninafion is .ibsoluielv essential, since the wound is a very deep one. 

The liartky-Kriiusi opoitdcn was devised independently by the two mi^ 
whose names are associa.led uilh it. An IJ-shaped flap is marked oat ml 
temporal region, the ba'^e siiu:iied just above the rygoma Through thvl 
subjacent bone isdividetl bv chisel or electric saw. and the whole flapcf 
muscle, and bone is turned down rjt blot, exposing the dura mater, 
^ntly stripp?d up from the middle fossa of the skull as far as the c»' 
sinus. Profuse ha'morrhage is likely to be caused by this proceeding. dtfi4 
mainly from the middle meningeal trunk or its branches, and must be ^ 
trolled partly by pressure, or possibly by plugging the foramen spinosua^ 

Eurifietl sponge' The second and third divisions of the nerves are readily m 
cneath the periosteum, and are traced back to the ganglion as it Ikioib 
apex of the petrous bone A speciiil cavity in the dura mater (or ctf* 
Meckelii). in which the Cntnglion lies, has to be opened, whilst the 6mitin* 
courses along the walls uf the cavernous sinus, to which it is matt iuditfri 
adherent. Electric illumination is necessary in order to effect the removal 
these structures, bui ap|>arent]v the whole ganglion, together with itsbrudi 
has been extirpated in this way 
As to ultimate results, it is even now a little difficult to speak antbdil 



1 Nerve may be lorn or oanipressed. cither in it^ iiilra- 
rse in llic uiilcr wall of iht (-;l\ crnous siiiEis^ or as il 
jgh the sphenoiJnl hssure^ or in tlio (irl)i[, iis a result 
ing wounds or blows. Us paralysis causes internal 

HiUi, or FAdal Nerve may be paralyzed from a great 
causes, which may be described under the following 

-tranuU Usiotts. — If simply cortical, as from pressure, 
e, degeneration, etc., only a limited portion of the 
leof the £ace is usually involved, li sub-cortical, or in the 
ata, or corpus striatum, as from haemorrhage, or soften- 
Qg either from carotid thromlKisis or embolus, it appears 
>5ite side, together with hemiplegia, and only the lower 
face is palsied, the associated movements of the eyelids 
If the lesion is situated in the fnms, the facial centres 
plicated, and then facial paralysis, with rapid atrophy 
:Jes, ensues on the same side as the lesion, together with 
er of the opposite arm and leg (crossed paralysis). If 
;he nerve between the centres and the internal auditory 
iovolved, the whole of the same side of the face is 
accompanied, as a rule, by deafness. 
ial LeiioKs. — There are two not uncommon causes 
ider this heading, viz., (i.) fracture of the base of the 
Iving the petrous portion of the temporal t)one, the 
■upervening either immediately after the injury from 
a rare phenomenon, or some weeks later from implica- 
s callus, the usual cause; (ii.) as a complication of 
due to sclerosis of the temporal bone, which leads to 
■n or inHammatioD of the nerve in the aqueductus 

»_ L^.L i.1.^ c__ ^ -L_ I :_ ^^ .l_4._ ^_ *i>^ 



IH 



A MAlfUAL OP SL'BGEitY 



of the face IS ^mmoSile artd express I or less, nit the natunl Udi 
anc) wrinkles Iwin^ ln:tt i )he py»^ canniil ir rnmiil^^r]}' rioted. Md 
on ailpmpting to da so ihc eyeball is usiuUy «cca to roll wpwdt 
and outwards; ulccrationl^uid i^vun pcdoration.of itbcconic«TE^ 
result ftmi) this exposure. Ftuni tlic dioopinx iuid rvlajutirn oE 
tlie luwei eyeli<l, the nppositifjii of the punctum Iftchryttult V 
tbe coiijuactiv^L is impvift^ct. and thu* learu escape ovier tlwfu* 
(epiphora), « condiiior determined also by the Jon of tbe suditi- 
likc ;i.ctiu]i uf clic lachrymdj ^c, owIq^ la tbe atsux-^ed panl^ 
of the TMifto nruli and ten<ior lair^i. On aiietnptinf? to moie ihe 
face, aa in laughing or showJrg Che teeth, it ia diAvi-Q o%Yr to (be 
opposite eidC' The lips eannot bo closed firmly, and heoce wbist- 
hlig AJid sucb-lik^ actions are p^^-venl(^d- M[>rei>ver, food cdDttXk 
between the cheeks and tbe tet^ch, owin^ to pjtralyais dt iIm hid- 
HAtrtr, and the pnCient after n mcftT ha« to cloftf out the dfibri» «Jft 
a spoon or bis fingers. 

Thr- Trefttment of facial p^vtAlyvic nncrs^rily Hf>pi*nds upon iti 
cftu^f. tn Che TTUjorify of ca^cs medical treatmeni (ted 
the adminUl Tuition of porcblaride of mercury and iodide 
pota-*ishim| will »al^ce, together with Tna5s;tec and t 
in oiUcr^, stngical nicnsnics with a view to rcmov*? iinme o 
cau^ of pressure will l>e necessary- 
Facial Tie (or histrionic ^vpasm) consi^? of c. clonic cont 
cif the bitidl mLLsclea, dvie cither tu sume leson of fhe centn 
the pon?:, or tci some irntalion of ihe ner\« tntnk. Thfl 
cauTU;u ffrtsit discomfort to the patient, rind may mvoU-e the 
aide of the fiicc. or merely one part of it, such as the orU 
oculi. Trea-tment tuiifiists in strettfiin^. or even in w-vem caao 
division uf iht.' fiidal ntrvr^ tint i« mo4l tjnMitiifaciory, 

OpDT&tiet). The nerv« ig expo^d in the upper part of tbe 
laJiEicdiaLL^ly below the car, \i% poiutioa being indioitod )rf 
horizontal line drAwn fioin the mlddfe of Ihp anterior border 
the mastoid process, and usually corresponding with th« 
whefc the mosioid meets the lobule of the oar. The in 
extends from a point jusi behind the cxceraa] meatus aJoOf 
anterior border of the *;ieTTio-mflMoid muKcIc trt ihe leviJ rf 
fingle of the jaw. The parotid gland is separftted from 
muficle, artd both arc well retracted, cxpoaiit^ by thi» nuaof tb# 
posterior ]x^^y erf the di^a^tric- The ficUl neTve \i foond tbo^ 
this, rnnnins slightly downu-arrU and forwardi; from ihc c«DtT«of 
the maiitoid procc««' The ^rcat aujicuJar nerve U partly dJtiiled 
in the fupcTnd&l inci^on, and the posterior aurictwu vemls niff 
tcc^uiir? a ligature. The in tettial jugular vein ia clooe to thepOfctfrior 
in;ucin of * nd. 'Hie operation is by no mean^ ra$v sn i 

■i«cJe, The/jf^f of theop«ration cf ^r; 
temporarily paralyze it, but the \iLj„:. 
no nutans encouraifln^, only oats tase out cl . - ^ 




to Vie compressea tne paiieni surrereii ironi [imiciiiiy in 
i<^ and speaking-, to^icihor wiih persistent nlcLratitm of 
le ; death resulled from fn-dcji];! of the iiloltis, 
re injury to the Pneumogastric Nerre is, ns .i rnk, rapiilly 

symptoms of palpitation, voimting, and a sense of sulTo- 
llowing head injuries, may indicate that son:ie less serious 
IS occurred. It is also exposed to injury in operations 
\e neck, ^.g., ligature of the carotid, or removal of 
IT glands. Irritation causes vomiting, and inhibition of 
t's action ; one-sided division sometimes does compara- 
tle harm, but if both nerves are divided, death results 
yngeal paratysis, or from complications, such as o°dema 
^stion of the lungs. When the vagus is injured in the 
jt of the neck or compressed by an aneurism, or if the 
: laryngeal nerve is divided or compressed, hoarseness or 
ihonia is produced* from paralysis either of all the muscles 
ide of the larynx, or in slighter cases only of the abductor 
ytenoideus posticus). 
^nal Aceawory Narre may be irritated, either at its exit 

skull by a fracture running through the jugular foramen, 
I peripheral course by innamed lymphatic glands, etc. 
pasm of the stemo-mastoid and trapezius is usually due 
J changes, and it is for this form of spasmodic torticollis 

that strrtcking or division of the spinal accessory nerve is 
d. The nerve runs downwards and backwards at right 
> the centre of a line passing from the angle of the jaw to 
: of the mastoid process. It is sought for as it enters 
QO-mastoidl at a point about 2 inches below that spot, 
he deep aide of the muscle. An incision is made along 
rior bcnrder of the stemo-mastoid, reaching from the ear 
ofBu of the hyoid bone- The fascia is divided, and the 
drawn backwards to expose the posterior belly of the 
T from under the lower border of which the nerve emerges. 



3j6 J MANUAL OF SURCERlt 



Th9 Spiiuil Nerr«>. 




Tkt ii«erv«» constituting tlic Cerricttl n«zu iuc cHpo«d to 
Injury eillier fnon) blows, tJisIotALinns uf t!ir i^crvicai ^picc, pen^ 
irsiling woLini^fi, or diirin^ operaiinns- A> ;i rulr, nn vtfj moh 
rt-sults follo^v^ e^cepI in the cAse of the Phreoic N«tT«, lJi^-wcb d 
wViicli may cftiisc iiistanl death by paralysis ol the diapZin^ 
although v^'hel1 liul one ntrrvi? is ilividr^J (he p;tii<^iit nay Mitivrb 
IiritAiioTi of the nerve gixe^ mc to i^pAtntodic cougb or mccovgb. 

Ihc Brachu>l PJexus may lie injured from exactly siimior oMt^ 
pAfAlysis, or ^pnam of the muscled of the arm, nn^n^ ina 
division or irriution c)f the moloi tiunks, whil-< hyprrj^bcBtf 
i>i Rn:K'sthcsia m-ty follow from damage to tiM khufv ifutfe 
Thus a blaw on ihc lack of tbc tvxk opposite tbe 6ftb or lia^ 
vctlcbitc caused paialysm of tlir >erratu» iiia|;nus and f homlM^ 
(u'ingeJ ^capuliO; au old uiin^uced unilatnal rli&locatHm of i< 
5«v«Dih ccrN'ical v<ertebra pioduced intense neuralgia akHU ibi 
couT^ of the ulnar nerve, and many similar in^aiKcd BiiipiE b* 
mciEiiLjiui^d. Lc^^a nevciir lujuut-s !tu;.h ii>i slralu^ aud cuocowit 
(reijin-'ntly y^ve ns* in rlirr>nir neuritis of a somcwhai fte\«f^ljpt 

1 ht ^Mtm«at must be depondenl in l^rgG measuit on t^ 
catuc. if Mucb c^iii l)c a^ccrtoiiicd > otherwise tl is mcrd^ srir^ 
toiiiatic, iniMudin^ ibt; atliiimstrftiion of iodide of potassioic » 
the local application of ttlifteni or olh«t counter- itritaor^ In 
OiseB whc-rc; ihtiri-' i^ scvuri' aud EiitiaclflbJo neuralgia, not nfcncd 
to aiiy discoverable tcsloji, oi where clonic spasm of tbe novfclt* 
of the Arm and i^hoiiMm' arc fn^t with, iirtUhiwg af ihd ^rmJiw 
flfX'ii niiiy in" calltrd for. 

OperatiOQH— The palJent lies on the biictf, with ibc bead ilin:<Md 
lu the oppuhitc side. Ami tlje ann \\«l] drawn down ; «t cut^ion >^ 
inserted under the shoulder to tlendy ti. An indRion h itiuW 
aliove the centre of Che clavicle, 3 or 4 inches in IcHKlh, paratli^ 
to the anterior border of ihc iraj>cxiu»- The platysmi oMdeep 
foj^ia are divided* supeificial vein^ dealt with a« need \<c, uul th^ 
deep cellular tissue opened up by rctractina the margin* uf lb< 
wound. The posioricr belly ol the omo tsyoid is Iha* e^pc***** 
and the po&tenor border of the M:aicnus onticun defined, Tb« 
cards of the plexus will Iw fiaind r-metgiTiK iHrlwcirfi ihc bit*' 
mu^de and the medius ; tliey are carefully iM>Ure<d by divisiivi *>i 
Lhv sticatb covering; them, and pulJud upon by the Imi^er or M^ 
aLicutiam needle pati^d under ibem, Spcckl care muM be lake^ 
at the lowest cord of the plexus, wliit:l] pa?iS(*.% M^ind the tut»' 
claviaii anvty. The n«fves s^hould be stretched tx>tbceolnp«ull7 
and cuninhj^aUy. Exctllrnc icsullA have followed thboperabo^ 
dl though ill a few LAiiew iht' iie^va^iy LiLatiitaiiou wliicb toUovt^ 
led 10 a ri»riirfi»Tirc iif th*» ^iyniproms, 

Tho Ctrciuaflax Harva \& Liable to injury from its exposed po0>' 
Ion, wjiLdiiLK louiid Ehe outer »de ol the neck of the hujncn>* 



AFFECTIONS OF KERVES 



337 



It a finger's breadth above the centre of the deltoid. Blows 
D the shoulder may in this way cause paralysis; it may be 
f or compressed m fractures of the surgical neck of the 
sems, or in dislocation of the shoulder, or it may become 
■Mcted in the callus arising from the former injury. Paralysis 
ihtt deltoid and teres minor follows, evidenced by inability to 
m the arm from the side, whilst the wasting of the former 
ttcle causes undue prominence of the acromion. There may 
bcniporary anaesthesia over the posterior fold of the axilla, but 
» does not last long- No operative treatment has been adopted, 
imogb we see no reason why it should not be attempted in suit< 
t^cases- 

rbe Hnacnlo-Spinl Nerve is not unfrequenCly damaged in 
Stares and dislocations of the upper extremity of the humerus, 
'- » especialiy exposed to injury in the musculo- spiral groove, 
Ore it lies close to the bone. It is implicated with or without 
«r nerves in crutch palsy (p. 373), or by lying in bed with the 
j) Dodar the body. 




ft. ^^. — Wrist-drop from Paralyst^ of the MubCULo-StiRAL Nbhve. 

(TlLLMANNS.) 



rhe Symptoms arising from its total division are as follows : 
IL Anxsthesia over the &ont 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, extending to the 
base of the last phalanx (radial nerve» Fig. 95 B). 
B. Paralysis of the following groups of muscles : 

(i.) Of the extensor of the forearm (triceps) ; hence the 

forearm is flexed, 
(ii.) Of the long and short supinators; hence the hand is 
pronated, the only supinator remaining being the biceps, 
(iii.) Of the radial and ulnar extensors of the wrist ; hence 
wrist-drop (Fig. 94), a condition also present in certain 
lesions of toxic or central origin, e.g^, lead palsy, and 
progressive muscular atrophy. 

22 



338 -* MANUAL OF SURGERY 

(iv<) Of the extensors of the fingers and thumb, which di 
haDg litnp and motionless, or may be bent up leiCi| 
palm irom the unopposed action of the flexor mj 
If, however, the wrist and proximaJ phakngtt 
supported ajid extended, the terminal phalan^ 
be straightened by the action of the inteiosn 
lumbricaJes. 
TrMtmont consists in massage and electricity applied to 
muscleSf or in some cases an operation is necessary- The n 
best exposed as it emerges from the musculo- spiral groove 
outside of the arm. The incision is made obliquely ako^ 
outer border of the biceps muscle, * its centre correspGodiiif 
point midway between the insertion of the deltoid and the aU 
condyle' (Treves). The anterior border of the supinator la 
is defined and drawn outwards, and the nerve with the ten 
tion of the superior profunda aitery found between it au)d 
brachialis anticus. From this point the nerve may be traced 
wards, if necessary, by dividing the triceps. Where this has! 
preceded by considerable loss of substance of the nerve, so ' 
the ends cannot be approximated, an inch or two may be eic 
from the shaft of the humerus with advantage, the bone b 
subsequently wired, and the nerve sutured. We have perfcr 
this operation with a successful result. To expose the upper 
of the nerve as it enters the groove, the arm is placed over 
body, and the lower border of the deltoid defined. An obi 
incision is made a iinger^s breadth behind this, and the interset 
between the long and outer heads of the triceps found. By a 
ing up this space the finger can be passed down to the bone, an 
nerve, together with the superior profunda artery, readily exp< 
Where the nerve is impacted in the callus arising fro 
fracture of the middle of the shaft of the humerus, it is ofteo 
to expose it by a median incision down the back of the 
splitting the triceps. 

The Median Nenre may be damaged in fractures and disloca 
of the humerus, but is most frequently injured just abovi 
wrist by glass wounds, due either to bursting of bottles, et' 
to thrusting the hand and arm through a window. Pat 
necessarily results in these cases with the following sympton 
If divided just abovf^ the wrist: 

A. Anaesthesia over the palmar aspect of the radial ^de G 

hand, over the front of the thumb, index, middle 
half the ring fingers, and over the dorsum o 
terminal phalanges of the same (Fig. 93, A, B), 

B. (i,) Paralysis of the outer group of the short muscles < 

thumb {i-e--. abductor, opponens, and outer half t 
flexor brevis pollicis)» so that the movement of 'q 
tion* is impaired, the thumb remaining extendi 
the side of the fingers (Duchenne's * ^M-hj 



AFFECTIONS OF NERVES 



3M 



This is always associated with marked wasting of the 

thenar eminence. 
i.) Paralysis of the outer two lumbrical muscles, causing 

loss of power of flexion at the metacarpo-phalange^ 

joints of the index and middle Angers. 
great impiairment of mobility in the hand and Angers so 
icen in these cases depends not so much on paralysis of 
?s as on the fact that in the majority of cases the synovial 
s of the wrist are also laid open by the wound, and involved 
tic inflammation, which leads to the formation of diffuse 
ons. Hence the pro^osis is often unsatisfactory, even 
the nerve has t>een skilfully treated by a secondary opera- 
c nerve suture. 

wided at the bend of the elbow or in the arm, to the above- 
)ed symptoms are added : 
[i.) X^oss of pronation from paralysis of the two pronator 

muscles, 
i,) Paralysis of the flexor carpi radialis, causing defective 

wrist flexion on the radial side, and impaired radial 

abduction - 





J. — DisTftisuTiON OF Sensorv Nehves of Hand from Frost and 
Back. (Telluanns) 

mi. Median oerve : h, ulnar ; m, radial. 



i,) 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- 
exten^on of the wrist. 

r.) Paralysis of the palmahs longus. 

olhws.— When the nerve has been divided, primary or 

ajy nerve suture should always be undertaken. In the 

22—2 



340 



A MANUAL OF SURGERY 



latter case incisions are made through the old scars, whkl 
be removed with advantage, the ends of the nerve clearly di 
and the bulb removed. Suture is often very difBcult from ll 
material^ and to assist in the apposition of the segments thv 
is flexed to a right angle^ and also the elbow, and maintvi 
that position by a poroplastic or plaster of Pans splint. 

In order to stretch the ner^'e, as in some cases of neura)| 

may be exposed in the arm by aa incision similar to thai for 

ture of the brachial artery, or at Che wrist by an incision j^ 

the ulnar side of the Rexor carpi radialis tendon, betweoi 

structure and the patmaris longus or flexor sublimis tendott 

The Ulii*t Nerre is exposed to injury at the wrist, as alsoi 

hollow between the olecranon and the inner condyle of the bun 

and paralysis may be caused by wounds, fractures, blows,! 

cation in callus, etc. The symptoms are very characteristic- 

// divided at the dbow : 

A- Anaesthesia of the ulnar side of the front of the wiid 

palm (palmar cutaneous branch), over the backo 

hand, and of the httle and hall the ring fingera, 

and front (Fig. 95, A, B). 
B. (i.) Paralysis of the flexor carpi 

ulnaris, causing weakness 

in flexion and in ulnar 

adduction of the wrist, 
(it.) Paralysis of the inner haif 

of the flexor profundus, 

with weakened hand -grasp, 

especially in the ring and 

htile fingers, 
(iii.) Paralysis of the two inner 

lumbricales and of all the 

inlerossei ; hence, loss of 

adduction and abduction 

of the fingers, with flexion 

of the two last phalanges in 

each finger and hyper-ex- 
tension at the metacarpo- 
phalangeal joint (main- 

en-grifjc or claw - hand, 

Fig. <)6}. The interosseous 

spaces also become very 

evident from atrophy of 

these muscles, 
(iv.) Paralysis of I he short muscles 

of the little finger, of Ihe 

inner group of short thumb muscles (adductor p 

and inner half of flexor brevis), and of the pal 

brevis. 




Fjg, 96. — Claw-hasd i 
en-Gri^fk) from I 
Paralysis. (Aftea 1 
Brahwell.) 



AFFECTIONS OF NERVES 341 



divided Just ab&vt the tirrisl, the ana-sthesia only involves the 
aar aspect and back of the terminal phalanges, whilst the 
dysis merely aRects the short muscles of the hand- Additional 
urment of movement may, however, arise from septic inflam- 
ioQ of the long tendons and their sheaths- 

■nhimiil — If divided, the nerve must be dealt with {according 
be rules already given) at the Injured spot. 
'o expose the nerve for the purpose of stretching for neuralgia, 
, the following methods may be adopted: {a) In the upper 
I an incision is made similar to that for tying the brachial 
ay, but half an inch behind it. (£} At the elbow, cut down just 
ind the iDtemal condyle, and find the nerve behind the internal 
V'lnusciilar septum with the inferior profunda artery, (c) Just 
ve the ^vrist it lies to the radial side of the flexor carpi ulnaris 
»een the tendon and the ulnar vessels; the skin and deep 
3a alone need division. 

rllfiri or neuralgia of the great sciatic nerve, is a most 
iful affection, and often exceedingly intractable. It may arise 
n a great variety of Oaotts : (a) Inflammation of the neuri- 
ma (acute or chronic), the result of cold, trauma, gout, rheu- 
ism, syphilis, and many toxic agents ; {b) pressure upon the 
a-peJ\-ic portion of the nerve, as by aneurisms, tumours, or 
standing dislocations of the head of the femur on the dorsum 

(f) similar pressure upon the nerve in the pelvis, or as it 
fges through the sacro-sciatic notch, as from sarcoma or 
onua of the pelvic bones, rectal or uterine cancer, a pregnant 
us, or uterine fibroids ; (i) pressure upon the nerve-roots in 
spinal canal, as from caries or sarcoma ; (e) chronic diseases 
le spinal cord, such as tabes. 

lie aynptonu are very evident, the pain shooting down the 
t of the thigh and often referred to the loes. It is of a 
ucysmal nature, and may be brought on by pressure over 
Dst any part of the nerve or by movements of the thigh, and 
zc the patient's gait is stiff^ and shambling. Tenderness in 
line of the nerve may be felt when the cause is a peripheral 
ntis, and the trunk may sometimes be detected on palpation 
. thickened cord. The limb is usually kept slightly flexed, but 
plete flexion of the thigh on the pelvis is an .impossibility ; 

if, when the patient Is standing against a wall, the limb can 
wnt to a right angle with the knee extended, it is certain that 
tica is not present. 

he Trcateunt necessarily varies with the cause. If due to 
ritis or perineuritiSt general anti'Syphilitic or ant i- rheumatic 
edies may be adopted, and blisters or sedative remedies in the 
e acute cases applied to the back of the thigh. Hypodermic 
:lions of morphia and atropine may also be useful ; but if ail 
usual anti-neuralgic remedies have been exhausted without 
:fit, stretching of the nerve may be employed. 



343 A MANUAL OP SURGERY 

Stretching of the sciatk nerve ma.y be needed for : (i.) neui^ 
an intractable type ; (li-) paralysis of spasm of muscles a| 
by itt owing to adhesions contracted between it and suirotf 
l^irts, the result of injury, cellulitis, or perineunCis; (I 
paralysis or spasm due to some forms of tabes. The ucni 
also need to be exposed in order to suture it after it btf; 
divided- Nerve- stretching may be accomplished without 4 
lion by flexing the thigh upon the abdomen and then exU 
the knee ; in cases of sciatica an anaesthetic will be reqint 
this, and it may be attempted before undertakiiig & 
measures- The nerve is best exposed for stretching at the 
where it emerges from under cover of the gluteus maximn, 
way between the tuber ischii and the great trocbaotcr. 
patient lies in the prone position with the limb slightly fl 
and a 4 or 5 inch Incision is made vertically downwards fra 
fold of the nates in the middle line of the thigh. The 
border of the gluteus maximus is first exposed, and its 
seen running downwards and outwards. The hamstring is 
emerging from under it are drawn inwards, and the ncn-eis 
ensheathed in loose connective tissue ; it is stretched, by a 
hooked under it, both peripherally and proximally. 

The Anterior Cniral ITatto may be paralyzed as a re 
trauma or pressure, and may t>e the seat of neuralgia or : 
Its division causes paralysis of the quadriceps extensor, pec 
and sartorius^ and the most marked effect will be sec 
flexion of the knee-joint from the unopposed action of thi 
strings ; anesthesia extends over the front of the thigh ani 
the inner side of the leg and foot as far as the ball of thi 
toe- The nerve may be exposed on the outer side of the f 
vessels, just l>elow Poupart's ligament, by a vertical i 
half an inch outside the hne of the artery. 

The External Popliteal Nerve may be divided during tet 
of the biceps tendon, to which it lies immediately inter 
compressed, as il winds round the neck of the fibula, by str 
bandages, or the pressure of splints ; or it may be injured 
tures of the neck of the fibula- Total diNision causes ana 
over the dorsum of the foot, together with paralysis of thee 
and peroneal groups of muscles ; and from the contractior 
unbalanced opposing- groups, the paralytic form of talipes 
varus (p. 629) results. The nerve may be exposed by 
an incision i^ inches long to the inner side of the biceps 
terminating at the neck of the fibula. The knee is then 
and the nerve is readily found embedded in the loose 
tissue of the popliteal space. 

The Intera&l Popliteal N^rre is much less exposed tc 
owing to its more sheltered position. Division results in ana 
of the back of the calf and sole of the foot, and in paralysi 
calf muscles, flexors of the foot and toes, and of the short 



I; thus, paralysis of the extensors of the foot and paralytic 
equinus result from division of the anterior tibial ; and 
ns of the short and long flexors of the foot and of the inter- 
vith resulting talipes calcaneo -valgus, foUow lesions of the 
lor tibial' The nerves may be exposed in the same way 
accouipanying arteries (p. 288). 

Brnv^Uiotic N^rre Tnuk in the neck is occasionally com- 
d by aneurisms or tumours. If merely irritated, dilatation 
pu^ on the same side and unilateral sweating of the head 
Lce are produced ; but, if divided, the pupil is contracted 
mbalanced action of the third nerve. 



■^araniift ^SD BUlU 









Z^ISrL.I IT TZiS £*^:^ 






jl3giiiyl31£K ^E "I'i'^if 'i."'; 



_-7 _: ::.:: ■i;-;^s rrfdisposttl* 

,-':^ n-:i::i :r r^-rii :-rr:oris. Ill 
" TM, :r:cn.:** ::L':t:^h the op* 

' ' r. :.^ zt ir^v i: r^: is sndii 

x-rir-:, i^i^z!: -.Ti ports wta 

■ifiL: :::.i^^TC. LHiringsooi 
:t* -'X:i- v;^^ 2iLiir.. Ebllotvcdtq 
■-' zy 7'--:? ij^i^ent is pcpJ 
:'.^ z.i^i :-t iifpLiced tenda 
r i'^:^:cTr-il rcsition. and lln 
; :: — :■ - i:. Thus the loo 
:f-i ^J:r: :'zi; bicipiial groovi 



AFFECrtONS OF JfCSCtES TEKDOHS. AND DUttS^ 34S 



xtnaax tendons; about ihc wrist or anl<le, especially that of the 
pKneus Icn^s, m^y similarly suffcu as iUso ihc smalJ muscles 
dihr tudc. If i(?ft ;ilone, rh« patia settle down mcir«r or 1c*» 
CDniorlaUy, but vomc peimanent ne^kness may persist ; whilst 
nauiencc is very likely to cn&uc, especially it movcircnt is per- 
Billed bdore the ocvrly'forTiied connections have had lime to 
ojEuEdale- 

Tnttunt consists in fully relaxing ihe niu^les. and rtpl^cin^ 
Ac Ecndon. if poA^ttu, by nianipLiEaticnH The piixXs aru then 
teuDolntified AtuI well tmpported. tis by a. plH:ster cif PurU ^pltnt or 
uniipiac. and tliK should be mainlnincd for six or eight weeks. 
Ifibf di^Acenteat recurev oa is coTnrioiily the ca^e wh^^re such 
insmnoK ha3 not boon itJoptcd, it is sornoiifncs adv-ianble to 
ox doftiit expose ihe tcTidtJiit aiid fititch It l^ack into positiuii. 
tm^ farljr pw^ve mm^prnflni to prevetit ihe fonniition of trouhle- 
icneftdhMions. Thi« i« cal!«d for motit friyquoiitly iti the caBC of 
tepcroncus longus tendon^ wtiiclj aiips forvraid fiuui il» gioovc 
)cm ihe external ni»]lcoliis^ The e\Eeriul uunutar li^amtiil Is 
tetrf ruptured, and ih** oprration called for consists either in 
mnnc the divided srKmcntjL, or in more aggravAtcd cascs it 
M be ficccanry 10 turn up a flap of periostcuLii from the 
BuUbs and Ivy stiltrhing its apex co rhe outer sirle of the os 
dkk 4*cure thf ti^ndon in place. 

llptQJO of Mtuclea DUid TondouB is by no means an uncommon 
tciikui, rcAuliiiiK irtJiu ;iiiv exceiaivt violence of a sudden aud 
nupMlal naujrr. Mo^l frefjupnlty the tendon gives way at its 
ttion With the mutcdaf twlly; less nftcn the Iwlly itself yields, 
*Ust occasickimlly the tendon may snAp, cr the point of bone Co 
'iich it n attacheil may lis tmn off. 

fi|&A — The patient at the [nomeiil of the accident experiences 
<iUrp jvnJ ievere pain, au it he had Iwen struck with a whip; he 
^J wAo feel or be^r a snap- Lo» oJ function follows, together 
•tb 4 Cdljun armmtil of swcllbg aud liruiT.inKf ^hich i-t more 
ftdm kf the muscuhtr fibres have been loin across than if the 
lEMan ha8 alon« bu«n huxnuod. On attempting to contract the 
*fccicid aau^clc, the l^lly ibes up si^ a imh, lomided. »cmi- 
icctiatbie lumouf. dmwn towards (he uninjured aituchTiieEit, if 
^ tiniott between thu tendon and belly ha* L'iven way ; whilst if 
ibiksioQ has been through the n^u^ular substance, the divided 
Wicsof the belK become tjmilariy pro^uiuenU mid a dialiuct ^ap 
ttM^iK raui hr fell lipTwepTi ihr^m. 

Rep^r is. e<tahh«hed in the \ii^uid way Already doscribod (p. loi}, 
^acellulO'pl;i5tic ntfuiion is tirsC poured oui| takinij; Che p£ftcc 
« ihe ItkhxI-cJot which \>. ab^oihod ~ thiii lircomcii vascuhLrizc<l 
oiOpumUlion tiwtue, end finally cicairici;il tissac i* developed- 
^wc a muKuJar belly is involved, n lonj^ and weak bond of 
*4ao ji likdy to form, if the cnd^ have been mxich Ncpariitcd : but 
*Wa they are clcHndy ^ipptMed, the cicatrix nuiy be a sluKt oew. 



J46 



A MANUAL OF SURGERY 



braki 



and then tends sooner or later to be replaced by true m 
tissue^ When a tendon has been divided or torn, the 
medium is at first attached to the sheath, and if this 
persists, it may lead to much pain and weakness. It 
exceedingly interesting fact to note how rapidly this 
attains a considerable degree of strength ; a rabbit's 
ten days after division requires a weight of 56 lb. to 
(Paget). 

Treatment.— It is essential to relax the parts fully so as to 
vent separation of the divided ends, and to maintain them in 
position for a lengthened period, «.|^., four or six weeks. 
stiffness resulting may be combated by passive movements 
mass^e, whilst, if need be» adhesions nu; 
broken down under an anesthetic. T 
accidentally divided in open wounds 
be sutured together by catgut, spcciaJ 
septic precautions being adopted to 
spreading suppuration along the 
sheaths. Where there has been actoal 
of substance in a tendon, it is possible 
remedy the defect by grafting a poitiai 
tendon from another patient, or from 
animal, between the two ends ; or, 
one end may be split longitudinally ut 
a way as to leave it attached peripherally, 
that the &ee end [a) can be turned don 
and united to the other segment (Fig- 97^ 
When muscular bellies have been dividedi» 
is not difficult to secure them, if the fitW 
ha\e l>een severed longitudinally or obliqud][! 
but when the section is transverse, there a 
a great tendency for the stitches to cutooL 
In such a case it is advisable to encircle wilfc 
a ligature a bundle of muscular fibres » 
either side of the incision, and then tiede 
two threads toffeCher. This may be done A 
several spots in the cross -sect Son, and tba 
muscular ends can thus be safely approximated. 

The long tendon of the hkeps is not unfrequently torn frcwn t» 
muscular l'}elly» ^vhich, on attempting to bend the arm, is dra*> , 
down towards the elbow* constituting a soft tumour, somcirW 
resembling a lipoma. No special treatment is needed beyflrf 
keeping the forearm fltxed for a time. If the iendo Atkwk^ 
rupturtd* union tnay be attained by keeping the knee bent tfw 
the heel raised, as by securing a strap to the back of a siiW* 
below, and to a do^-collar passed round the knee above. PossW 
a better result would follow an antiseptic incision and siitoi*' 
Similarly, if the ligameninm paidia gi\'es way, suture throujcb ■* 



sM 



Fig. 97— Methoo ok 
Unctinc Tendon 

AFTER LOSlv OF 

TiSaUE BV TlTHSISG 

Down a Portion 

OF IT AS A FlAV 



jt^JBCrtoss OF uvscLES. rtsooss. -f.vj> bvhsx ^7 



Qpto wound is more salis^xctorv than mere elevation of the leg 
ttdrcii: bul ro^ucb open metntxls must Im ;u1np|t-El imlrvK thp 
oigMD K i^uite i!orfi{l'^r in hi« ability fo m:jimaia ^ibiioluic 
tsipas. Tbe ihk^ hrad <*f IJn t^nstr^cntfitttts is ^nnictimcix inrn in 
KRDcbesoiT slips, a; at lawn tL'ittiis; and it is pos^iMc lh*it Ihc 
ft^Mkm iTiiiy br Miniljily H^lTrLtr^d. Thir aJiiticftrt hn^it txv.iy \u* 
iKMalcd in violeiil jittenipt^ to maini^in a mxl on hi>r^i-tKi<:k. and 
Mtfilutett ODc form of fidere' fiprain: it is treated by re»t »nd 
Uk )pp1ic«tion of a firm sptcn bandnge. 

DiaeQ^ea of Uuselet, 

Uuunatioa of Muscles iMyoHitis) niay ariw from a wintity of 
cniaaiUiicitss but llie ^liii'f re^uita art' alike. :\hati-vcr ihc Lau».', 
Til. 1 iTiOTP or l-?s». painfil infiliraiion of tlie muffle, with in- 
o«K<] di&comfoTt oTt attumptinj^ movemi^nl. The pan foeU 
hud and rigid, and may \ft tcndt^i to lite touch. If »uppu- 
nlJaof»5ue-s iho ordirtary signs £>f an alwcesH *iulisur]iJirnTlj make 
Ittfltefvefi P^idimt, A certain amotint of ronin^lilff (i»:^io t« 
Ihotby dc^rL>yc(i, and the dcntriciAl chixngcs induced will 
pCBVrUy lead to ckfnimitv. 

Tutatttn. — (r) ftlmpte Tratunatk Uyoaicia resiihsFrom coDtti^-ior 
«■ iKcration of Ihc hbTes, and h merely a pbsiic inflammation, 
filli or WLlhout harnorrhage, running on to rcsohiLon^ with 
prtlopt a little filinjid ihickcmng uf ihc puii. It is liciblc: in M>nie 
OSttto become chronic, and mny Irad lo cnr sKleralile chanj^e^ in 
ftt dnictttrc of tho muscle \M. fibrom), whereby ii becomes 
teteDed and replaced by hbrou^ tissue. The indni'ation of the 
miD-nuudnii) tnijitcle mti with in childrp-Ti is prubably fif llii* 
tTPt. In Ktill other cafes oasificalion of a limittd portion of the 
flMCle or tendon way occur from I out^ -continued and fTtqucntly- 
tipntcd imtAtion ; thus, in rirlei^ the upper portion of the 
^u(t^( iFiiJr3ii4 may in thit& vtiy Iwcomrt Ivsny, constilnting 
tiWu^rjllwI * ridtr*' bone/ 

1- Ehgnmatic MtojiiUb usually result^i from cxp(»ure to cold, 
f^ vij Qcck £<wi3 ^Lttiu%' in a drauj^ht. It is of a, ploivtic 
tfjc, and may produre wine Milrstfjuenf iniliinilitri. It ts 
■TBTfd by hoi fomentation t&. jinU ordinary saline aj^tl rheumatic 
■mdics, whilst Uter on ttdion with sttmnliiliug embrocations ia 

y Anit« Suppurative Myosltia U th* eflen of infertion with 
Hnfenic orgnnisms^, either t'rotu without, as after operation 
**u«&. punctures, j^fuH'Shot iujurics, gangrene, etc, the pU-<^ in 
.aa^n sp'eading widely np nnd do^vo ihr riuscukr pUnea; 
withm rhr body, as in pyaemia, or by extcnvion fTOrn 
bbouhn^ fiuppumtivo foci, auch as from sub - periosteal 
it niAy aI*o arise after a contusion or sprivin It*,- auto iii- 
Grrjit drairiHal deformiiy mny rrsiilt in such Kmaebt 







TT '-r^ "*j^ X :r 1 loci) 
-T--. T^ir 3*tr::J^s '±e UN 



H-i^Lia. 



-^ o^tirc. n t^'iz. out 



-=^ Z. XSS^A ^' 



::=rr i r :r:^x =o=cisJ t 






^l^ftKL^Bi ^' SSlCdtt K ^vivnS' 






Ji-n^ &Jtjrf *iau 5: 






-: r t-_* - .linevsr the 



AFFECTIONS OF MUSCLES. TENDONS, AND BURSM 349 

limb for a few days, and apply hot fomentations. As soon 
the more acute symptoms have disappeared, friction, with 
lulating embrocations, and pressure are employed to assist the 
option of the fluid ; whilst active and passive movements are 
ouraged to prevent the formation of adhesions. 
I, Acuta SupFOtfttlTe Teno-Brnovitlfl may result from a punc- 
ed and septic wound of the synovial sheath, or the inflammation 
J spread to it from neighbouring tissues. The thecal variety 
whitlow (p, 190) is an example of this affection. Suppuration 
tj extend both up and down the sheath, and gives rise to both 
al and constitutional symptoms. Unless promptly treated by 
iy incision and evacuation of the pus, the tendons will very 
sbably slough, or may contract extensive adhesions to neigh- 
uring parts ; in either case considerable impairment of function 
lows- It is also possible for suppuration to extend to neigh' 
oring articulations, leading to their disorganization ; thus, the 
ist-jotnt may be involved in suppuration of the extensor tendon 
Ealhs. 

3. Glmi&ic Simpld Tmo-BTnoritlB is a common affection, and is 
Macterized by a passive effusion of glairy synovia, somewhat 
ambling the white of egg, into the tendon sheath. It may be 
nited in extent, constituting one of the varieties of ganglion, or 
Bnse. An elastic finctnating swelling forms in the course of a 
ndon, usually associated with crepitus. There is no pain or 
ndemess, but the affected part feels weak. Treatment con- 
its in counter -irritation and pressure, as by Scott's dressing; 
iling this, the part may be freely incised, the synovia removed, 
id, if need be, the cavity washed out. In the more localized 
rms it may suffice to puncture the cyst-like swelling and squeeze 
It the contents, pressure being subsequently applied. Of course, 
le most rigid asepsis is an essential in such treatment. 

4. CRmmie TaWcnlar T«u<hSynoTitifl is of two distinct types, 
n one a puJpy degeneration of the synovial membrane occurs, 
iculai to that met with in tubercular arthritis (p. 569). The 
heath is lined by cedematous granulation tissue of some ihick- 
Kss containing tubercular foci, giving rise Co an elastic pulpy 
welling along the course of a tendon, which increases slowly in 
aze, andisbut slightly painful or tender. Chronic suppuration 
svery likely to result, and subjacent bones and joints are liable 
^ be involved. Troatment consists in immobilizing the part, 
pressure, and improvement of the general health. If a cure is 
Dot quickly established, a free inci^on should be made and the 
iseased tissue removed. 

The other form of tubercular disease consists in a passive 
Effiwaon into the synovial space, the lining membrane of which 
^^comes thickened by the deposit thereon of fibrinous material. 
At the same time there is usually a large development of the 
wxalled 'melon-seed bodies,' which are in reality laminated 



iy> 



d MANUAL OF SORGESY 



aWtfa»o of fibrin, perhaps containinjOf tracw of tubtrculai ^^^^I^H 
sytC^ms- When numerous they give n»c to a curious ud chm^H 
trrisllc fi)fm of crepitus. THaI ttiry ai^ of 4 tuhcvcultf utai^^ 
can he demonstrated by inocalAiinn pxperimcntK; lh« cpo«<r 
bncilli couUmed iherem Jire not, however, in a ytay active tfitt^ 
TieiktiQeiit coTi^ist^ in Inyin^ the pan open ana rcmoi'ffift dk 
effusird filiriii ami mi^luii'Sccd Ixxlic^, together with ba mtdi d 
the thickened mcimbranc ;is possible. 

A Ganglion i» the krm given to \ localised c)rit-like nwline 
fonnitiK in iiimiiccliun wiili tendon %beatbx It ia moat cunnuunlr 
met \s\i\\ :ti the VAck of the wnst. uri^iog (rom the lesdorKd 
the thumb or mdox-hnyi-r, but it sometimes occurs on the frc"! 
i>r die wiiat ot ill ihc foot. Jt vario ia idxe coD^dembtjiio' 
coniitiiK :i clff^ir tran^pareni ydaitiiou^or toltoi(l:il Huh^cnflct- A 
roundc^d (irm «bstic swelling is produced. somewhAC movKibkat 
jirulc^. and nL^itlici painful nor lender nt hist, &llliouj^h some poinlul 
wr?HkiiF» uf the part may be t^u^rvd h> Ji luLit^scs ta &izc- A^ 
TO it4 i^fi^''4. majiy opinions bnve been expres^rt. but prohaibl; 1^ 
Duy be dur to one of sevGT;^] uttises: thus, tt msy rv^ult fno ' 
chronic LicMiZcd lenO'Synovilis, or ti liornial prolmaion ol tW 
ftyni>vi;i1 mrmlirunc thiojgh an opening in ihi? Icndoa iJtfattl]' 
Ottn-rii wrm lo nriftin^ite in a colloidal degenrration of the tfll* 
lininj;? tho Rynoviai" space ; whilst certninly Eomo few AhM in ctt ' 
(wciioii H'icli ^ubJAceitt articulations, in the same wsy as a BilRf*^ 

Treatment. — When sma.1], a ganglion miy often be ruptumi \ff 
manipulalion iind pressure with the thumbs, of by it forcible bloo^ 
Willi fi book, rirm compression by strApping ovxr it a coui or 
imall portion of wocmI t?ntl£jsril in lint has iier.n rprummrndcd, bufl 
18 of little v;ilue- A rapid cuie 1$ iisu;illy ubEi:imcd b>' ^u aseptic 
puTicture of the cavity, and the subscqiieni appUcjiiioct of nnn 
preuure- In swne cu?ic?t it may he ^idvUat^le to lay the poit freely 
optn^ and ri?movp the (y\t wall ; tf such tr^ilmfmt it pM^omied 
atcptically no harm will rcfiult^ but, if a«put is admitted, most 
9cnou3 consequence?) may unaue. even Icadirig to diaorgaiutAtiofi 

of U lie];,^tibiiti[iiik^ jojiLl. 

A Coiii[H>and Palmi.r Oangllon consi^Ts In a tuberoilar afbctto 
ol th« common synoml mem bran* uarrounding tb# Beicor 
tendoni of ihc wnst, the cavity be>n£ distended with ftynovia. 
usoHlIy ciJOlHiiiiiifc; many mrrlon'SiTd liodic*. Jt fonns a Urge 
(welling cxti^ndin^ ahove and billow thi? wri«t, f^ortitaiion b^rtng 
rcttdily trfinsinitled from one part to the other beneath ihc annular 
t; it alfto extends Amonf^t the mLL^clc.% of the ihciuir ctni' 
ng the lendun of ilie ftrxor longiiK ptJhdv In ihc tnnt- 
iciiion «l^uld he made both above and below the annular 
ibe cavity b4^m^ ivcll washed oul, aiKl all metonsced 
debris removed with a abaip f 




iFFECTIONS OF MUSCLES, TENDONS, AND BUHSM 351 



;e-tube is subsequently inserted. In a few severe cases 
be necessary to divide the annular ligament in order to 
tly deal with the trouble. 

Tenotomy. 

tenotoTny is meant the division of a tendon through an 
r subcutaneous wound with the object either of remedying 
deformity, such as talipes or torticollis, or of assisting the 
n to reduce some displacement, as in the setting of a 
e ; thus, the tendo Achillis may require division in fractures 
lower leg in order to overcome the muscular contraction. 
re are two chief methods by which division of tendons is 
plished, viz., the subcutaneous and the open. The gab- 
<nu method is made use of where there are no important 
ires in the neighbourhood liable to injury. The object is not 
lude the air, the admission of which, it is well known, does 
m to an aseptic wound, but simply to divide a non-vascular 
u-e through a small puncture, which is healed in a few days, 
tated in certain accredited text-books that antiseptic pre- 
as are unnecessary in such a proceeding ; we desire here 
emphatically to maintain that the strictest attention to 
^ is desirable, since the character of the wound, viz., a 
ire, and the entire absence of drainage, are most favourable 
development of septic organisms, if entrance is once given 
m. Moreover, the synovial tendon sheath is often, though 
gnedly, wounded, and any septic inflammation would 
f spread along this structure, and give rise to the most 
s consequences. The operation, as usually performed, con- 
n inserting a sharp-pointed tenotome through the skin down 
tendon. This is then withdrawn, and a blunt knife passed 
the wound thus made, either superficial to or beneath the 
1. The cutting edge is turned towards it, and the tendon 
d by a sawing movement, whilst the structure is put on the 
h t^ an asdstant. Various opinions are entertained as to 
jer it is better to pass the knife above or below the tendon ; 
■vantages of the former method are that there is no likelihood 
king an unduly large wound in the skin, and that there is less 
f dividing the lax subjacent structures if the knife is turned 
ds them. On the other hand, if the knife is at once passed 
' the tendon, and any such subjacent structures are by 
ke included, their division is a matter of certainty. On the 
:, then, if a subcutaneous operation is considered ad^'isab]e, 
>reters to cut towards the dangerous area rather than away 
it, £d those cases, however, in which there is any risk of 
ng important structures, such as the external popliteal nerve 
lotomy of the biceps cruris, it is wiser to adopt the opfln 
)d. In this an incision about i inch in length is made over 
ense tendon, which can thereby be exposed, lifted on an 



35> 



A MANUAL OF SURGERY 



aneurism needle, and severed without danger. There n 
b^moirhage worth mentioning, and the wound is closed wA 
point or two of suture. As to after-lreatmettt, all that is 
is to place a pad of antiseptic gauze over the punctiu^Tud 
secure it by collodion. The practice of surgeons at present 
a good deal with that which was formerly adopted in the 
tion of the deformity. Formerly the pan was put up with 
deformity still persisting in an adjustable apparatus, by meuBl 
which it was gradually brought into the desired position. Nl 
it is a common practice to at once remedy the malposition by 
mobilizing the part in plaster of Paris. Equally good resuUsi 
thereby attained in a shorter space of time, and without anj 
for expensive or complicated apparatus. The fears 
entertained about the immediate separation of the di^'ided endifl^ 
the tendon have been shown to be groundless. 

As to the method of repaiit as soon as a tendon is divided, 
ends retract to a greater or less degree, leaving an interval, 
is at first filled with blood clot. This is transformed, 
to the method described elsewhere, firstly into vascular 
tion tissue, and finally into a fibrous cicatrix. The tendon 
becomes actually lengthened- This new tissue is at first adht 
to the sheath, but later on may regain free mobility within it. 

Tenotomy of the Tcndo Achiliis. — The foot is placed on its 
side, and the tendon relaxed by pointing the toes downi 
The tenotome is introduced about i inch above its insertion at 
inner margin of the tendon, either superficial to or beneath it,, 
it is readily divided when the fool is extended. If the 
cuts towards the skin, he must be careful not to diWde the 
few fibres loo rapidly, otherwise a considerable external w 
may be inflicted by the suddenly liberated knife. 

The Tibialis Anficui is usually divided about i inch above 
insertion, as it crosses the scaphoid bone. There is here 
synovial sheath, and the arteria dorsalis pedis is separated 
it by the tendon of the extensor proprius hallucis. It is 
relaxed so as to allow of the introduction from the outer side' 
the sharp tenotome beneath it ; this is then replaced by a 
pointed instrument, and the section is readily accomplished «l 
the foot is acain m:ide tense and abducted. 

The Tibialis Posticiis is usually divided together with the 
longus digitorum just above the base of the inner malleolus, ati 
spot about a finger's breadth from the tip of that process in 
infant, and about i^ inches from it in an adult, A small tul 
can usually l^ felt at this spot, and the section must l>e madeji 
above it. The kiiift is inserted vertically between the tibia 
the tendon, and is kept as near the bone as possible. If corred^ 
placed, it remains fixed without the support of the hand, bda| 
grasped l>etween the tendon and the bone. The blunt tenotoow 
is then introduced, and the edge, being turned towards th 



4PP£CTtOffS OF ItVSCLSS. TEHDONS. JKD SVttSM ^ 



I. the* Uti^T fiimciuffi i« d3v-i^cc1 when the fooE k vjriended* 

tti posterior ulji;ii vcsscU m.iy he w&undcd if the tcrtdc^ns &rc 
ioa niddeiily levcrcH. btil even ^liould ihls occur^ a link- uell- 
.A<ljui<eJ pc«!:3Mirc will uiffii^ Ta prevent nny Krnnii!( r--in vqiirr^cp a. 

The P/ntKfi lemlom arc divided ju£i nbovfi the b:4(c of the ijutcr 
nuUccJiM. At a spot where the ^iyoo^-inl shcatti m. iisuntly .^bf^ent 
The lenotome ik inacrted cIom: lo llie fihub, Itelwecn the tenilotiK 
«nd the Ivme. 

Tl« &*r//» Cnrm tendon i« b«ai divided b>- an op«n op^dtion, 
<ic iccouat oj \hf clofM." propinqtiit/ oi the external poplitwJ 
MTic. vhkh bii?t Iwen divrili.-d uictc ihiin mice, wlii^n live \ah- 
mtowou^ (^)erat>on ha^ been adopted, An Incision is rnnri* in 
thrilirKlion of th« 1«<ndoii just iLi>uv« it« inst-rtion hlo the libuk-L. 
Ii ATcadily lifted ujXiT^ An anc\]ri»in riccclk' JLnd dividid : rriuKulAr 
nhmirillj piulubU l<i' f^miid (u t-'xleud quJti.' clu^e tu its lu%%<:t rnd, 

TW 5rf«K-ammbnwiui ,ind the- -S^iHiiriiiiWjiu tr<ndont arc dt^A]! 
wiftyut »bov« tbc Imo of tlio kncc-jomi, and th* aidicuUn<yitifi 
ofNntioa may be conveniently adopted where they arc proinincrt 

Fsr dvviMan of the Sttmo-mattoid^ Aec p, 6o3. 



Bai&ff cxi»l HA iiLpriiial sliutlujea in iiuirry pdit^ of the l)od> 

^^foml Eo pfVss:.ire, iheir obj«ci bemg to dimmish friction and 

r*«il of A ^lidiD^ movement. ^miliLr ca\iticdi, known as 

01 AdTMkUUovB Bums* are developed tit (cK>on>Mbcrc 

lal presMtrc i-> bruii^hE in bear on some pToiiiijierl part 

body: th*y con*isi of ^ fibroii* wall ltr»*d by nt^rnii* 

ibniKt cofilain acritm, aird nrc formed eiih<:r hy Jilat^ition 

l>mplMtk bpucti^. C'l as a result of a locali/cd ctfiition into the 

«upt RxampVsiof thiiflrp m^T with in mm fi^lIowinK ]uttitul;ir 

"[■upaiic^s; i^., Covent G^rdorj porters from cvrvinif b:v»ket» 

tbcir bcad^ a pfid or snckinj^ rcnchtri; down i j thmr []uci(^ 

ilxentsiinR, dc^'cK'jp a biirKa LAcr the \t:[tebE;i pEuminetis. 

a«a'hummy ' ; BillmK*K^teftthcani«H(H'r:iMt>ria]ly ha^w 

'■<rttaadcrthecc«tfeof ihctcilp; atKldcaJrunntifiofttn present 

*>«■ on the upper part of the shoulder. Thcv <-ecur over Iho 

VsaXprnfiiincitceN arbjnj^ fmm m«lfuiii]atLoti or diitpiui^ciiiciil. t^., 

'o tiKpe« cqviino-v;uu«, over the cuboid ; in hi^d cs<^\ of gprmi 

y^lfpn, <^^'er the internal coii<lyl^ of the f#mur ; whiUt the falc© 

)0«9sp9eiMUnlLroii» which occurs iD iUKcduced di^ocaliona or 

^UQiCfJ fiiiduies is :ilwj uf this natiiiP. 

TWIoUowin£ are the morbid conditions whieh nrite in .nd- 

*<BthiDus u well ah nt^niul burstc : 

t tetaSfiBplaBmniUft.whicb mdy result from ARonpcnetratirt; 

f^wj. i:>r from piol"nj;'-J irritAtion, espcdnlly in t;ouiy or rhcu' 

^1*: iedi vidua Is. Thepirt becomijusrwolletr, painful, and lender. 



3H ^ MANUAL OF SURGERY 

and if superficial the skin aver it may be hyperxmic. Eft 
into the cavity quickly occurs, the fluid being spontaxM 
coagulable in the early stages^ and if resulting &om traumi 
mixed with blcx>d. Lymph is deposited on the serous saA 
and in many cases results in the formation of adhesum,- 
possibly obliteration of the cavity, TiefttaBflnt consists in hi| 
the part at rest^ and applying hot fomentations, whilst soil 
constitutional remedies are also administered. If the cA 
tends to persist, aspiration, or removal with trocar and cai 
under strict asepsis, may be employed, or even the whole a 
excised. 

s. Acnta BnppnratiTe finrsittB arises from infection occm 
either from without or within. In this condition all the d 
mena, local and constitutional, usually associated with then 
tion of a superficial or deep abscess are present- The pus, fa 
at first within the bursa» tends after a time to come dired 
the surface, or bursting through the capsule to be diffused tbn 
the tissues. Where this occurs, the characteristic features 
gesting a bursal origin of the abscess may be masked- 1 
in suppuration of the bursa patella, the pus may tindits« 
the lateral aspects of the limb, allowing the patella to be 
tincily felt through the skin ; the case is then very apt I 
mistaken for suppuration of the knee-joint, from which, 
ever» it is easily recognised by the absence of the more 
arthritic symptoms. Extension to subjacent bones and ^ 
may. however, occur ; thus, the patella or olecranon may be 
carious, or necrose. The Tnfttment of suppurative bi 
resolves itself into an early free incision, and drainage, 

3. Ohronic Bursitis with ZffuBion is, perhaps, the mosi cor 
patholo^'ical condition met with in connection with burs^ 
cavity becomes distended with a serous effusion of va 
amount, giving rise to a Ructuating tumour. The walls dil 
thickness according to circumstances ; if the condition is c 
long standing, or if frequent recurrences have been presen 
bursal wall is usually reticulated and dense, and adbesionsOTfi 
cords are often produced. Subacute exacerbations are frcqi 
grafted on the more chronic variety. The TrMtmwLt consi 
rest and counter-irritation, as by blistering or iodine painty 
this fails, nmoval of the fluid and pressure. If the coo 
recurs, the bursa should be dissected out. Special care will 
to he taken in deahng thus with bursa; communicating with j 
such as that under the semi-membranosus tendon ; the 1 
of the tumour should not, if possible, be opened, but its 
must be isolated, and its communication with the joint sb 
by applying a catgul or silk ligature, 

4. CliroDic Fibroid BarBitis- — In this form the walls < 
bursa become chronically thickened, as a result of the prol 
irritation, and also possibly from the effect of syphilis. 



I jFrSCTiOSS OF UUSCms, TESVOSS. ANt* Dl/RS^ 3SJ 

I iibut Jittl# j0f1bcu»]; ^AAft^xic-ntly a hard fibroid tuinoitr is met 
I dilb io the rc^on of lliv bur<^, and in tli« centre of lhi$ j& a 
wall ra\Ity. Thr .»nK Treatment is i ijifi|ilcle i«mi>\ML 

S^ Obronk Tab«rcuUr Bnnim nay ocair tiiher in !h« form of 

L iftUuMUS dcpoAil oj-i lh« inner i^all, Eo^^crlher with GfTusion and 

I iU prcKflCc of mc]i>n'j<c4 bodies, or tlic liiiini,' riniibrLinc nmy 

I mdeien A chanKt-rtn.iWoiis willi Umi il^.^ritwdii^niilpy ilcj^tnera- 

I iDfi of a )[:iitnc. leading io the formation of a chronic r^bacefi^, 

I lilhw condiCicD mny tic «condnry to n tubcrctilnr archntis, or 

I aA]r £ivc riw; lo il. vvticn Ihc hor^A cnmmtjnic^tcH with A joinli 

I IT total removiiJ i^ iniptaciicnblr, ilir Trtm^tmctit cohmkIs in laying 

I 6itju% freely open, scr-iptnfi au';iy ail titlJcrcular tisfiut?, And 

I ibAB£ the c-avity mtli gzivizc imprcffnntcd with iodoiorm, 

> ^ SndlilitEc CQuncM uuy ^Inj occur in burns.-, in the sti^pc 
dbn of A Hyinijwit'itiii} luir^iti^ in ihr^t^Arly stnf;;rs, or Ui^r on a^ n 

I tuuEiMoiic per>-$ynovul developni«nt ; Ilitiy reqiuTB no special 

I OccaMiaU^ Ooutj DepOKiU are obseivcn! in the walls <jf bursa.-, 

I WHinuing tnphi, thf trtlimifm of \^Ju^h may predkpo^e to 

I thcoc Cornution. put mixed witfi ur^te of «oda crystals being 

I 4idttT)fcd. Tbc bursi over ilic olccrancu is ^'id to be inoal 

I lv|asnily afiE«cl«i in tnU wny. . 

I Special BnrvK. 

1\k hvr^jt ttttfUit^ u'hii \\ Wx [ni»T the lortti marjGiin of the bone 

JSdiui ov«r kt« centre, [« rxc««di(]gty liable to injury and infl^m^ 

nMKn from ils <xp3sr.-J sttuationi and especially tn those who 

tfecalifij upoi) \o l^iicrl much, tivm^ nw to the condition knoun 

u 'ba>«rmnid'«ikTirp/ Anyof ih^nbiive varieti*^ of bursitis may 

U met Mith, and chcit aignfi arc so evident that it H unnecessary 

I touaiD mention ihcm in dcldil. Tbc rciation oF the biir:^ to the 

F pftlnti expUin't ibc ttit Ehat suppiEiatioo sometimes give» rise to 

I Cir^ ar lupcrlinal nrcrnvit; al ihil lv>De. whilst the cbr^inic nnd 

ttit!ttcuii« iufUrnrnxEicns nuiy lead to thickening of the bone from 

oMoo-pl^Mk prrio9tili». 

71« /^fjfl Un^ath the li^imrntHia paUUif, between it and ilie head 
of ih* Ttl*iA, whrn <l]«eTiJefl with fUiid gives rise to n flnrTiiflting 
Kir*llioL' t«tl on eithvr sidv of th« tendon, more especiAlly ivhen 
tfcc 1im1> h extended: vslien the lev; is flexed the swelling di^ 
ipfSTAis. Chroiiic enl^trijemi'nt *if this bursa nmy tJiuse Ihe 
l^metiu aUriA to iv pa^h^ii barlcwardti Into the jVmi «o th;vt 
tbcy arc nipnrd between the bonrs whenever the patient attempts 
lo Ktand with the Icji extended ; the pftin thereby induced i^ &omc- 
wmilar tn ih^t raiiwvl by .1 di^phmi v-mihinar ciiniliije, oi 
A looH fortiflO Iwxiy in the pint. The inabilily to sinnrj with 
;htlcf?, andthc presence olthccnIarK'td hvirua, are Bul^icient, 
T, to ifuidc the surgeon to ,1 correct diai^nosi^H 




J56 



A MAUUAI. OF SURGERY 



The bursa tn the popliteal space are often enlarged, especially 
beneath the inner head of the gastrocnemius* leading to a ro 
fluctuating swelling, sharply limited on its outer aspect, aod 
Rxed and less defined towards the inner side. The 
imparted to the fingers varies according to the position of 
limb» the swelling being Unse in exietision and flaccid in jUjom 
occurs in most of these peri-art icutar burste. Owing to 
proT^imity of the popliteal vessels, pulsation is occa ~ 
detected ; but it is only heaving, not expansile in character, 
fact that the bursa usually communicates with the joint n 
tates considerable care in its treatment. Aseptic tapping* fi 
by pressure, may sufRce ; but if this fails, (he cavity ^ould 
entirely removed by a careful dissection, the commun 
with the joint being closed by ligature or suture. 

The bursa btiuafh the insertion of the semi-tcndinosns and gneSk 
sometimes inflamed, and is very liable to lead to osteo- 
fieriostitis of the subjacent inner surface of the tibia. 

The ktrsa boieaih iJu tendo AchUlis^ if enlarged, prcseni* 
fluctuating swelling on either side of that structure* 
simulating disease of the ankle -join t* but necessarily limited to 
posterior aspect of the joint. 

Distension of the bursa bettfath tht psoas itndon gives riw to 
fluid swelling which usually projects anteriorly, presenting on 
inner side of Scarpa's triangle. If painful, it necessitates 
of the thigh, and thus leads to symptoms resembling in 
those of hip-joint disease. It must not be forgotten that this 
often communicates with the joint. 

The bursa ovtr the titbcr ischii^ if inflamed, gives rise to the 
tion known as * weavers" bottom ' ; it causes great discomfnt 
sitting, and is often soiid and symmetrical. If troubtesome, 
should be removed. 

Enlargement of the bursa over the olecranon constitutes the ccMfr] 
tion known as * miners' or students' elbow * ; suppuration witta] 
it is not uncommon, leading to necrosis of the underlying \XM\\ 
the elbow-joint is but rarely affected. It is sometimes laid 
as a result of a fall on the flexed elbow, the overlying 
splitting : such must be treated by enlarging the opening, it 
be, and stuffing the cavity. 

The large muUilocular subdeltoid bursa is occasionally enUrgrfj 
it leads to prominence of the deltoid, and expansion of 
shoulder. (For diagnosis from effusion into the shoulder-jO*] 
see p. 557.] Where treatment by counter-irritation and rest tA 
the cavity should be incised and drained. 



CHAPTKR X)V. 
INJURIES OF BONES. 

tettuonof n Bon« >nd of lt% undertylng p^rio^eiim i«, ns a tuI«, 

■ Oltloof angr«-;tr moment, although the part bccoai«-« pnmfuK 
«i)IUn, uid hntiivil. OcciL^ionftlly h sul>aciLt« pcriosLlliA raiy be 
OUBidt r^ipecUlly rn p?<n[]I(' lUbTtf- lo rTieLimmi&m or gmil, or in 
tK 4abject« ol %yphil]t; whiUt in pcopli? who iro thoroughly 
c« of hoftKb. and with low f^rniicidni power, acute mfccCivc 
ICfHOtkis or Oi^Ico myelitic rc.*«uliirL>;f In nccrtjsls, may be lifhiei) 
*9 The Treatment <*f «ii vir>rnmpli rated case consists rnrrdv 

■ iW Appikution of A band;i|fe an^ oooHng totion. whiUt if 
|Ki«UAi thickciurii; riemlCp iodide of polfis&ium may be needed, 

BipUd^ of Bone m;iy or mtiy nnt ho nssoriatef! with fnirturc, 
liakJjiu- without fracture occurs nuitily in chiklrcn, ;ind in ^idulti; 
vtolf the result al»omc local disca^. More commonly apartinl 
Hdin^iapre^v^iit- t«oMiti.itm^ the rotidititin known iis ^recn-^uck 
■*rmr*(f>. j^^i. Thr J^formity tan geoenilly tie ri-t:iedif*d by 
^if^t^tion ci a Jililv force. 

FrKct^rea. 

A^ture may be defined ns ;i sudden solution of contlituily ia 
[■t^M, rr^uItinL; iiuuoJly from e>tCn^AJ violuncu. 

hidi«Qdac Omom «r Fnwiun. — H^ baa a coaanderable influ- 
inih^drterminaiionof frflctMrc^, and for tworeaHMii*: firsily, 
the strength and tilasticity of bones v^ry eonKidcrftbty at 
r-^<^l periods of hie', .'lad. secondly, hccaxisc the linbility to 
Mvjisltkcwifc \uriable. Vtotti iwo to foiir, fractures nfc not 
ftoaauDOQ, oiling to the unsteady gait and freqnent hills to 
*ftidi tittle children are evposed; from four to six they are lefts 
^iaect« the boocK oflcr bending so U to cnuse ]j:reen-3lick frac- 
^■ci, nrliilM mj;iries near joints iniluce M:p;iiiition of epiphyiie^ : 
■Qb *kt yenri: nnu'^rdti fririure^ me <rmnnon emm^h, snd 
'*riiiML slieadily intb the age. old people hsin^ peculiarly liable 
I^Uiftibcin of accident, owing lo the bntllcnussof Chdr bones. 

Sti.— jV» miKht be eipcvlcd, frafiuircs ;ue moic cumitiou in the 
tt*fc vt during Ixiyhxxl and adult life : but up to thr age of 



2i9 A MASVAL OP SURGERY 

four or five Ihey are equally frequent in the two sexes, 
after forty-five they are more common in women, owing to I 
great lialiility to intracapsular fracture of the cen-ix feraoris 
to CoUes's fracture. 

Morbid Conditions of the Borus, moreover, predispose to iatt 
ID a marked manner, very slight force occasionally sufGdflf 
bring it about* Under this heading may be included: (i) AtTi3| 
of bone, from whatever cause it arises. Thus, it may be d 
senile type, as manifested especially in the cervix femoris 
lower jaw ; or it may be caused by want of use, as it 
paralyzed limb or from an ankylosed joint. Certain 
affections, such as geiieral paralysis and other forms of hxsua 
and even tabes dorsalis, are often associated with atrophic 
tions of the bones, which lead to fracture without any a^noB 
cause. (2) Inherited osteo-psathyrosis is a term coined by GcfQ 
pathologists to indicate an inherited tendency to spontana 
fracture. It manifests itself in a mukiplicity of fractures, 
ring even in children ; thus, a girl, aged twelve and a half ji 
had suffered from forty-one fractures since the second year d 
No explanation is given of this state, but the lesions seem 
unite perfectly. (3) General bone diseases, such as rickets 
osteo-maUcia, also predispjose to fracture; in those due to 
latter affection there is usually no attempt at repair, (4) 
bone disease may also constitute an important predisposing 
by so weakeninj:; the bone as to lead to its fracture from a 
slight injury. Thus, cancer and sarcoma of bone are often 
recognised by causing an apparently spontaneous fracture, 
manipulation of a limb which is the seat of caries or necrosis 
lead to a similar result. 

The Exciting Oausea of Fracture are threefold: {i)Z)iV«(twM 
the fracture occurring at the spot struck. The direction of sad 
lesions is often trans\erse, and they are not unfrequently «• 
minuted, or complicated with injuries to the adjacent soft parti 

(2) Wlien due to indirect violence^ the bone gives way at a distwoi 
from the point to which the force is applied. The accident is usu»0j 

! produced by the compression or bending of the bone with soa 
orce as to exceed the limit;; of its natural elasticity, and it ojam 
?[Uently yields at the weakest spot. Thus, when a person iutnpi 
rom a height, the le)^ bones are compressed l>etween the weipi 
of the body and the resistance of the ground, and, if the violcW 
is excessive, a fracture occurs at some point of mechanical di» 
vantage ; if a person jumps from a carriage or train in moiicB 
the same conditions obtain. Fractures produced in this way« 
often oblique or spiral in direction, and as the displacement mv 
be considerable, there is great risk of them l^ecomine compoupi 

(3) Miisculiiy action is most commonly the cause of fracture ( 
small l>ones. or of osseous prominences into which powerfc 
muscles are inserted- The patella and olecranon are not unfn 



ly if ihe liquor amnii is ilefeciive in [iiiidimiT; wlun 
■;, ihey are usually dut- to f<i'iai syphl]j^, '\']h-\ iii.iv 
any v;iriely of deformity at I'irth, and may hf patlidlly or 
:ely uniied. They must Ue clearly di'-lin;^'uii-lioil from 
nations resulting from imperfect development. 
mitai Fractures are produced during birth by violence used 
accoucheur, or from excessive uterine contractions. They 
ft common in the thighs if due to traction, or in the skull 
o the pressure of forceps. 

itiM ctf Fnctnre. — Many terms are used to describe the 
icity of conditions which may be met with in connection 
broken bone- The following are the more important : A 
Fract ur e is one in which the skin is unbroken, or, at any 
lere the external air has no admission to the site of injury. 
Hmnd Fracture is present when the skin or mucous mem- 
iver the injured spot is lacerated, so that there is direct 
□ication between the fracture and the external air. In the 
the skull, however, a fracture may open up one of the 
ur-sinuses, and thus cause it to become compound without 
rarent external lesion. 

ures are complete or incomplete, according to whether or 
continuity of the bone is entirely severed. Various forms 
Bq»lete Frmc t Tirea are described. Thus, the green-slick frac- 
ne which only occurs in young children, and most often in 
hat arc rickety; curved bones, such as the clavicle, are 
affected, and the fracture merely involves the convexity 
urve, whilst the concave half is bent, just as when a green 
or twig is partiaJly broken. Dtpressiom of the sktdl may 
larly incomplete when the outer table is driven in without 
i and the inner table alone splintered. Fhsured fyiutures 
•- often only partiaL 

lete Fiscturei may be transverse^ though this is not very 
Q ; ohiiqiUf arising usually from indirect violence ; spiral. 



. . r 



jfio A MANUAL OF SURGERY 



fragment is driven into the other ; tutslHplt, when more 
one fracture exists; contpiicated^ when other important str 
nre damits^*! ^^ ''^'^'^ ^s the bone. 

The BepAT&tioQ of &n Bpiphysifl is not an uncommon oc 
in young people under twenty-two years of age. It results 
injury or \iolence directed to the ends of the bones, but 
ally is more or less spontaneous or predisposed to by diseiK 
the epiphysis or of the end of the diaphysis (f.g.* from Id 
syphilis, or acute infective or tubercular epiphysitis). The 
of the femur, humerus, or radius are those most often a 
The line of cleavage usually runs through the soft spor^ 
on the diaphy^ai side of the cartilage, so that there is 
with spicules of bone on one side, and spongy bone on the 
The direction taken is in the main transverse, but most cpi 
are more or less conca\'e or cup-shaped^ the ends of the di 
i'teinf; convex. The displacement is lateral, and resembles 
of a dislocation. Union usually occurs readily by mcansof 
but arrest of the longitudinal growth is likely to follow. THk 
a matter of special importance where one of the two bones of 
lower leg or forearm is affected, since deforn^ities of the band 
foot ofieTi result froEH the continued growth of the uoi 
bone. Suppuration sometimes occurs as a sequela in u 
children, or when the accident is due to preceding disease 
the epiphysis, and may result in an acute arthritis, 
neces^iitatini:; amputation of the limb. 

Signs of Fractm-e. — The history usually given by the patioU 
that, as the result of some accident, he fell, or perhaps 
somc-thjn^' ;;i\t way with a, snap and experienced sharp 
which hecniit much intensified on attempting to move the 
On eNan;ining the injured part and contrasting ii nith 
oppoHk' side, fho fcjllo\\-ing points are usually noticed : 

1. The ii);ii^ of a h^al irauTftCy viz., pain, brui^ng, and swelfi* 
as a result of the effusion of blood from the torn and lacetawi 
structures. The amount of this may he so great as to oblittrti 
all the ordin.'trv btinv prominences and landmarks. Bleb* ifli 
bulla- sometimes form in the course of a day or two on thi 
surfjicc i>f the sUin o\er a fracture, and these should be carefaUT 
protected from injury. The bruising continues for some time.iiJ 
m^vy spread tu p;irts far removed from the original mischief. » 
is \crv unusual for suppuration to occur after a simple fraciun 
Vul i( the paiiem is very debilitated, and his germicidal po»*» 
dimimshed. ;uitii- inflection and abscess may resull. j 

2. PytUnuituial mvhility ;w the continuity of th€ hom may li 1 
demonstr.ited by manipulation, but never unnecessarily. 1* ' 
paction of the ii.ipuems will prevent its occurrence. 

3. Partial t'\ complete loss of function also follows. 

4. Cnpitns \<- obtained by movinj;; the limb and rubbing tta 
rough ends a;;.')inst one .another. It can only be felt uhtn ll* 



ly JURIES OF BO^ES 



361 



re moveable and can be brought into contact, but 

here is wide separation or impaction. When an 

s been detached, it is softer in character and more 

nous type. 

■ in shape of the limb or defottHtty from displacement is 

t'S present. There are three chief factors at work in 

:formtty, viz., the direction of the violence, the weight 

, and the contraction of 

1st injudicious movement 

ndling may aggravate it. 

for obvious reasons, more 

Dtique than in transverse 

d hence is usually greater 

le to indirect violence. 

■es of displacement are 

z. : Angular, usually due 

^sed curvature of the 

he unantagonized action 

muscles; it is especially 

)tain when the line of 

situated not far from 
L bone, as in fracture of 
lird of the (high; laierai, 
displacement Is merely 
be other side, and most 
transverse fractures ; 
when one fragment o ver- 
ier or is forcibly driven 
isin^ shortening of the 
y also occur in the form 

iration of the fragments, as from contraction of the 
n fracture of the patella ; rotatory^ when one fragment 
n the other, as in fractures of the femur, where the 
he limb causes eversion of the lower end. In flat 

the skull— deformity may exist in the shape of 
dtvation. 

the typical signs of a fracture, but it goes without 
all of ihem are not present in every case, and that it 
ys easy to ascertain the existence or not of such Ji 
nparison with the opposite limb, and gentle manipula- 
instrate abnormal mobility or crepitus, must be under- 
tie this point, but no undue violence should be used, 
/a have recently proved of the greatest advantage in 
and where there is any doubt as to the existence or 
ture, the limb should be at onoe skiagraphed. Fi^, c^H 
ation of the value of this proceeding; the case hiid 
sed by the practitioner as a simple sprain of the wrist, 
gram at once confirmed what had been suspected by 




Fio, qH- — Skiagram ow 
CoLLEs's Fracture. 



36a 



A MANUAL OF SURGERY 



the sur[,'eon, viz., the existence of an impacted Colless 
It is also possible by this means to determine whether ai 
fracture has been rightly treated, and for this purpose k is 
unnecessary to remove plaster of Paris or splints, provided 
are not metallic. Fig- gg shows a forearm which had ' 
operated on for an ununited fracture of lioth Ixines- Tbc 
overlapped considerably, and portions were removed so i 
brin^ the fresh surfaces into apposition, and the fraginenis 
then wired. The skiagram was taken some days sul 




Fill f)(> SHiA<;>i.\M ft I'm'mtei) Fracti-re of R^nivs aki> Vl^\ iFin 

Ol'ERATIOS. 

The Ihiuus ore sLtn in lit iti ^jtpctsitioriH and the silver wiren are clearl v ei"»i<Bl 
This sVjiiTTi'ii-ni ''^"■i* taken ihrou^h riresainKS. Kiml.iacs, anj ^litit fcint 
(bys aflcr ^iivratiun. Thi: lacks in ihtf wixxltn spljnl comr out ^litt 
(lisitiKih- 



thmuLih (Iri'ssiiii-s mid splint ; the linntd lacks in thu latter arc 
("liMfly >vv\\. as alsii ilk' l^n'ps of wire and the cuds of ihe Iwues 
in npiH'^^ition. 

Oeneral or Oonstitutional Eeaulta. These may be di^iJoil into 
tui) ^mu^is : 

I. Immediata Effects, cini'iisunjr of shock and hamorrhii^^e- 
Sh'ik is i^TciU'i bH less aivi)rding to tin' ;uuouni of violencf 
:ind tho sr.il Iff jiijuiv. Il \Hirits from :i iiiitc passin;j faimiw*^ 
In I ho si*\ I'lvs: |inKti;Uiini, If iht' lionus of tin* head or spine ai* 
injtirnl, sprrinl sMoplnuis Jiic Uj concussiim of the bnnn a 
injury I'l ihr -*|uii-d iou\ niav also he produced, lliimortkatf 



INJURIES OF BONES jij. 



V>ay5 occurs either in simple or compound fractures, and it may 
lOfre&s lo a considerable degree from laceration of important 
flVBcIs or even of the main artery of a limb. 

3- flMonduT ox Bemoto Effects. — Fracture f/ver is met with in 
btt majority of all cases of fracture, commencinj^ twenty-four 
Omtn after the accident and lasting two or three days. As a rule, 
- ii Dot at all severe, the temperature rarely rising alxjve loo' I'". 
■ QDCompbcated cases, and the general signs of malaise, etc., are 
Iftgjit. It is a form of aseptic traumatic fever» prohalily due lo 
kftC absorption of fibrin ferment. In compound fractures wliere 
iMCxsis is not attained, any form of wound infection may result, 
mae\'en genera.] septicaemia or pyemia. 

Ddirwm tremuns is a not uncommon complication in fractures 
)f the l^ in debiJitated individuals or habitual drinkers, such 
\» brewers' draymen. The general characters and treatment 
itf the diseswe are dealt with elsewhere (p. 20S). As regards 
kical treatment, the limb must be fixed by splints or son^e 
ttnnioveable aOTiaratus, and suspended in a Salter's sling so 
U to prevent tne patient from moving the upper fragment inde- 
pendentlf of the lower. 

T'jkffvnw in fractures shows changes of which but little notice 
hu becD taken, {a) Urobilin is present in excess owing to the 
AuinteqirRtion %A the extravasated blood and the absorption of its 
dert\'ativc9- On the addition of chloride of zinc siilution and 
•nmicnia, a fluorescent yellow-green colour results, {b) Fat is 
■omerines eliminated by the kidneys for a period which extends 
nDm the third to the twenty-tirst day. It is absorbed into the 
uood-stream from the breaking up of the medulla, and is excreted 
in the form of an emulsion, tne molecules st>mclimes, however, 
ninning together into larger drops. The amount varies greatly in 
difiertnl cases, (r) Albumin is occasionally present for a few 
*iay5> as also casts containing brown, nucieiir-itKjking bodies, which 
are 5upp.»sed lo l>e the remains of re<l blood cells, absorbetl from 
it* local trauma and eliminated. Similar casts have l>een met 
■*ith experimentally after injection of blood into Ihe periloneal 
Q\ity and after experimental fractures. 

fat itntfotism is a condirion resulting from the alfiiorption uf 
broktrnMip fat globules after any injury which results in the t<m- 
tusion or laceration of fatty tissue. If at the same time there 
TS( as in fractures, much haemorrhage and local tension, this 
process is more likely to occur. As a general rule, no harm 
results, since the great mass of the fat is filtered <ifl' by the- 
luEg^ or eliminated by the kidneys (as can be deuifjnslratc.l 
after death by staining with osmic acidj. The pulmonary 
obsiTuciion may, however, i>ecome so grtiit as lo Ifad lo a fatal 
^Ssue from dyspncta; whilst if the cerebral vl-sslIs are alsi> 
Wockeil. syncopt, or even coma, may l>e induced. The sympiojiis, 
which are ii;radual in their onset, usvially connnence about the third 
"iav, but may not be evident for a week or more. 




364 A MANUAL OF SURGERY 



Oompllcited Fnctnrei. 

1. Oonunimitlon of one or both fragments is an 
to excessive \'ioleace, or perhaps to exceptional 
of the bones. As long as the wound remains sim] 
surgeon need not be in any way disturbed by its 
as sound union is usually obtained, though with an 
amount of callus; necrosis is practically unknown. Ida 
pound fracture things assume a very difTerent appearaocd 
serious mischief may result from the super\'ention oi l^j 
No special treatment is called for in simple cases. 

2- Fractnie impllGatiiig a Joint- — In healthy iadi^idinli 
untoward result is met with ; the joint is for the time being 1 
with blood, which, however, is soon absorbed, and the fissd 
the cartilage closed by plastic lymph. Adhesions are, boM 
very liable to form, and the subsequent mobility of the I 
may be thereby impaired. Early passi\'e movement oA 
breaking down of adhesions under chloroform may intt 
matters. If, how^ever, the patient has a tubercular tenoi 
arthritis will possibly be lighted up. Osteo-arthritis in»j 
be induced by an accident of this nature. 

3. The same \'iolence that causes the fracture may at the s 
time produce a DMocatlon in a neighbouring joint. Treati 
should be undertaken immediately; the limb is fiimly ' 
in splints commanding both fragments^ and reduction atteo 
under chloroform. Failing this, consolidation must be iB 
to proceed, and then the case dealt with as one oS old-stK 
dislocation (p. ^Z5)- ^U however, the fracture involves, 
close to, the articular end of the bone, as is not unfreque 
the eihow and shoulder, it may be advisable to operate at 
opening the joint, reducing the dislocation, and wiring the 
ments; or possibly it might be better to remove the 
detached articular portion. No absolute rules can be 
down to meet such cases, except the all-important one 
such treatment is quite unjustifiable unless strict zscpi 
maintained. 

4. The Main Artery of a limb may be compressed, coni 
punctured, or ruptured. The local results of this accident n 
arterial thi-oinhosis, with or without such an extravasati 
blood as niiiy imptde the venous return. If the peripheral v 
are healthy, no permanent harm need result from this occui 
unless the vein is also implicated, and then moist gangr 
likely to supervene: an aneurism may, however, de\'elop : 
cjuently. If the terminal vessels are calcareous and rig 
that there has l>een a precediuR^ condition of chronic an 
dry gangrene will probably follow. For further detaiS 
Chapters I\'. and \'III. The Treatment to l>e adopted 
necessarilv varv in different cases. The correct rule to 



INJURIES OF BONES 365 

»e to cut down in every case where the artery is 
d or ruptured, remove clots, and tie alxi\'e and below 
")' m the vessel ; but, owing to the extensive laceration 
lacemeut of the paits^ it is not always advisable to follow 
ctice, and, indeedf it should never be undertaken without 
c rigid asepsis. If it is considered unwise to lay the parts 
le maiu artery may be compressed or tied above Che 
, but only where the distal circulation has been re- 
hed : in the absence of this condition, gangrene would 
jn to ensue^ If neither of the above-mentioned expedients 
adopted, an expectant plan of treatment must be folio wed- 
nb 15 thoroughly puriRed, wrapped In aseptic wool, placed 
ropriate splints, and slightly elevated. Should gangrene 
!ne, amputation is the only resort : it need not be under- 
for a few days if the limb is aseptic, so as to allow a 
■ line of separation to form ; but if septic, early removaJ 
h or above the line of fracture is essential. 
aceration of the Telns of a limb results in extravasation of 
which is not so extensive as when an artery is wounded, 
ie fact that thrombosis is more easily determined owing to 
ser blood -pressure, but the congestion and cedema of the 
^art of the limb which follow constitute serious additional 
ts predisposing to gangrene. Simple compression of the 
produces cedema, which, even in favourable cases, may 

for some time, needing for its removal firm bandaging, 
;e, and cold douchin^- 

he HflTTM of a limb may be injured at two different periods. 
nediate injury is due to laceration or rupture, either of the 
trunk, or, as is more common, of the nerve fibrillae, without 

continuity of the sheath. Paralytic and anaesthetic pheno- 
follow, but are usually recovered from. (*) Secondary 
5ms result from the nerve becoming included in the callus, 
»nip>ressed, as ossification ensues. It may also arise from 
jous splint pressure. Irritative symptoms in the shape of 
gia and muscular spasms are first manifested, followed by 
^s and anaesthesia. This usually occurs about three or 
'eeks after the accident, and may persist or disappear in 
iih or two- Tmtment is always of the expectant type 
time, so as to ascertain whether Nature will be able to 

the damage; and even when the paralysis is immediate, 
^urse should be followed, since total rupture of a nerv* 
-. When, however, the symptoms persist, the parts must 
d open, the nerve freed from adhesions, or exuberant 

removed, and such measures taken as will be^^t secure 
rrve frooi further compression and favour the process of 



366 A MANUAL OF SUltGERY 



Dnlcm of Fimctures- 

The union of fractures is brought about by a series of d 
exactly analt^ous to those which we hav-e ^Uready seen oo 

other wounds, except that they do not terminate in the fan 
of cicatricial tissue, but go on to the further de\'e]o[HBi 
bone. The minute details of the process are evet> dov ott 
undersloodf although the main outUnes can be readily tndkl 

When a fracture has occurred, the broken ends of the boi 
left rough, spiculated, and more or less separated one ta 
other : the periosteum is torn, the muscles and neighba 
tissues lacerated, and a varying amount of blood is extrava 
In the course of a few hours after the parts ha\'e been ira* 
ized, the process of repair is inaugurated by the bkn 
becoming invaded by leucocytes, and after a time il is absc 
the haemoglobin passing through various stages of degener 
and thereby staining the surrounding tissues. At the same 
a rarefying int^ammation occurs in all the injured and laa 
structures, as a result of which the damaged parts are rem 
connective- tissue corpuscles are set free and proliferate^ aoc 
a cell ulo- plastic exudation forms around and between the lact 
tissues and broken ends of the bone, which gradually b( 
smooth^ rounded, and devoid of spicules. This exudati 
transformed into granulation tissue by vascularization fro) 
cumjacent vessels. Calcification of this material follows, pre 
or not by a cartilaginous or fibrous change, and this ai 
material is in its turn replaced by bone, which, at first sd 
spongy, becomes after a time firm and sclerosed. In ai 
where the limb is not immobilized, a stage of cartilage foni 
always occurs l>efore the final bony deposit, and this ma} 
l^ met with in the human subject under similar circumsD 
viz., in fractured ribs and not unfrequently in children, wha 
difficult to keep the parts absolutely at rest. 

This new cell ulo -plastic material known as raZ/ni, ex 
around the ends of the bone, which are, as it were, implan 
it and thus held together. In the early stages it is termo 
visional or tnshenthin^, and the amount present is determin 
the relativf^ position of the fragments and the amount of nK 
possiNe between them. 

Where :he brokf^n ends are accurately apposed and the 
absolutely immohiM/ed, but little callus is formed (Fig- iff 
and that equally and evenly all round the site of the fra 
Ossification commences in that part of the ensheaihing call 
which is farthest remo\ed from the broken surfaces — i^,, i 
angle between the stripped-up periosteum and the bout 
gradually extends throughout the mass until the whole is co 
dated, and thus the continuity of the trane is restored. A 
same time, or a little later, the granulation tissue betwee 



litjvniEs OF SOSES 



3fiT 



«idB, which vxtoode for a short way Into (he mc^idUrv 

ty iA)» fliso undcgocs £:raditttl o^aificdtiun. commcncim; ui the 

^M^IU aod giaitLuHy iri-a^rjiirj^ doAis litflwecri the end* of ibfi 

toot* Id jain niih t»ie titw Kiny tissue which is forititfd from outside. 

Bj thit menu U dcrdop&d a Um<'i],i ot now bimu of variable 

ih wfaa j s . wluch cKtciids ncross tlic innlLilUry taiial ami clavr-s iK 

Ulibo between tht compricl liisyi- [jn riihcr •iiilt of it- Tha 

Ikimntdulhry ptjrtion is somofimes caiW ihe mUtKai ^eitns, 
nd in b\'Ourah1e ca^s is subsequently removni, thus tc-Qpcii* 
kt, the mcJuJliuy cnnal; that pLnccd Ix-Iwwtij liie cumjiart 
laocof Uit fiaj-mciits k^Ji'^^'''"''>' Iwr^timr-s mnrp iind mem* nrai, 
.ad k somrtimfs Lnoxvn ;l« the ddfimUtv ctiHut (a), and jn mnny 




M» -Pijm;«41c to itxnu>K:fr Uhiort tiv FnACTCasa. A. W>b TIP: 
lULLT APhmKO. Aim Ct vriimK thm FftAcn^itflfr SevTACiK amx bbot rv 

CMITfCT AT ALU 

piuvlsioiui] cjJIgA- 



thi'- 1^ the only pf)rtii]n iJ tht new li^suc wlutb fiimlly 
fvrsl^i. tnJcvd, it is 1>)' no rnearr^ uncutnmtni for the bone to 
h« fio al«cLutely restortd as to fltiow no si^ns of tliri« having 
M«icn 4 feactuic/ 

H \Micvp thr vn\\^ (if thr lKvn<<4 panta.l1y uvuildii (Fi^- ion, li], 
^■v sUTMMim <tf efi«hrhlhirg rallun [f) it conrespontfiii^ly mcrr.'iKc^d, 
^M6U»up:(]| ih^-:(>.ii:u!il>rft by ihoover-Lfippini; of ihc fin^mcnts. 
^Bm projectiiii; iiiAitfiii^ «.if Lir^nc arc rouQflcJ olT, mid the mcdul- 
^py CH^ilTJLs rliitiMl fiy plnrr-s of inrrmal ralhi^ {b); ihsamiiuni tjf 
^MniilK«CAUiiK M) U uELially tm-iU, btii vAtiuit in utnount wltlt 
»e actual conditions pr:-r«::iit. The hiaiti bond at iiniuti K tht 
IcaibiDc nuu>. A ccn<iia nmpunt of dclomiiiy i» ware (u 




^ 



A MASVAL OFSunGairr 



Trmain nffn «iirh nn AcndrnV. fmii >1 k vnuctnl [nr (Ik noM 
tiiry c^haI to be rcKiorcd ; frctjuci^tl^ ime or more pUtcs of b«t 
Arc foiind cTof^infir ii. 

II dicfnictL^icil rniUEin^not pljiccd In contact Al oJI iFifi. iTO.()t 
no ilt-finilivr axWu-s- cun he fmrncdn hul ihp rmtullar)' rarkj rf 
each (nipmenl ir- doiwl by *-i pUlc of intcrniii tallus (4j, jtod oiifl 
IB sccxifcd hy n Iftr^c ^nls^ tif cnaht:athinK tiiHua *f J- 

Whctc comminulicHi biin cxtutTHl, tiic iplmtcTKl Oa^ruefiUtft 

which ta *iub!«qu«ntly tran!^forni«d irio callu^- 

Tlic removal of tbr tJot and the formaltop (i iL^r ulftlion tmv 
usuiilly inkE uLiutil a wpfK lii ceii days, ami Ldl^iriLatiuu^uiiuncscti 
aboi.)t f h^ end of the iecond woeUn Hy iln- f.^jrih (>r sivlh wiA 
Acoordini^ to the size and vascularity of the honcnnJ thorDcupm 
tiv^ power of the indiviUudJ, tbc fracture will Xtc conKtlldABnl. Irjj 
in ihf lower limb ii is often ^ieht w«;k* l»fforr the jMticuiui 
hear any w^i^ht upon it. Mcnibii may, hou^fr\'«r, piXK« bri^rt t^ 
final staifc of complete icpnir i^ nitaincd. 

Tbr nwitmBnt of ^mi>1e frai^liirtfft i% tiKually a mailer at 1u& 
little difficulty, although when the IvniM are mvich divpbCM] cr 
comminuted, il may not be caay to correct tbc ildonmlyaf In 
nuiintai:! the fiiignicnl^ in appuftiiir.Ti. CctuiitKlmiaitf^ all thai * 
prpd^d i^ lo sumewhai rpstrici tlic tlirl, rhminatinK all *tinra- 
Uting and utMt&cGs&ary arti^cti, At ibc t^imc ttm« att«ndnig m 
the MAlc of the bowcU. I^hi^i IK c^tpccinily needed tn fractures 
fif ibf InWE-r curwmity, whcic thn piitirnt i» Lnnttnod to bed fw 
sonif time. In elderly people th« ^(emer;!] b«allb is vtiy likelj i" 
sufter, partly Irom the r.hixk of iho ncddeot, partly Iram itm ■ 
Enforced and sudden chance of habit, nece^ilatm^' n HXncvibl 
Tgriieruns diet and the ^ulniini'titaliun uf a critam amuitfit (J 
itimulant. Tli« Two ^reat dan£«n thrvaiening okl (Mopk itfc 
UypOdCatic pneumonin and bedsores* Any len^htncy to ttw 
fLKiiivr is prevented by falling tiuch pnticnE^into a salting poeiUf*i 
and a]li>vi'iTi|; iliecTi t^ut nf lied on crulcbcs «s soon a&poutlih. 
llcdKore^ must be prevenced by ihe strictest ftUtntioo to clMtifi- 
n«s (p. 7b)- 

The Loc&l Tieataient of a ^tiniplc fTaclut^econsi»i», fust, la utti% 
thti limli — ih;tT \\. m rr-dncin^ the rif'fnrmily nnd Fn>ioring the 
fractured end*: to n normnl position — and then in ^ruv* il so ftK 10 
m^iintain it in the dcsireii pcnilicot. 

Flnt Aid. — If ihr patieiLt ]ixt to lie mowd from llic >|kOt 
where the accident hapfwned, it ii Deceuary to tcmpunmly 
secure the hmb in us ^fM>d a position as pottilJe; tplims have 
often to be improxiKd frotn sticks, umbrellas nevr^papers, 
aitd H> (urth. Ml a^ lo ptevi^tt any risk ii( the leMun lieooinanK 
rompo-und. In a railway acddenf Ihe splintered dH)fis of the 
carriage* may be «mplo)ed for ihiA purpo^M, and Ihe 



n^iURtBS OF B0NBS 



3^ 



thi BIBta as pacldinff. If one of the Iq^ b broken, ii may also 
AriDljrlkO Xo the crilicr limb, wfikb in tbuv conrcrtcd iriu> ;i 

rary splint. 

Mttttten of a fracture i& usu^Uly nccompJiahM 1iy a combi- 
Miico of eAtVQsicn upplicd to ttc lower «£incnl of ihc limb, 

«4b nuuiipuLilion nf ihr fiiLctuieil ciicIh^ cuuolei'rKCftivun lieiiig 

EMthnvkme lime ruAinULii^d by .in iisslstiuit, lo «om« <ases it H 
ttosnry lo »lax c«nain mu^clta ia o^d(^^ to (acilii.Lt'.- riHluc-imn ; 
ikBiia ill fracttircsof tbo Ic^, <he lower fidi^inciit u-ii<1a to be 
diMTti up by ihc iiiumIfs AUH^Jied to the iirndo AcIiiIIiSh Aud to 
flbnrte this th« kti«9 ^ould »lway« be flexed by an .isfitKiAnii 
«4»bold> up the JcfC nad maVca count cr-c\ ten *u 011, whilst the 
^neaD reduces ihc defot ii^it> b> trAcETon on ihc Jowrr pan of ihc 
li^r: wctifln of tbr trmlo AcKiUU is tomffiiiupyi rallf d fnr in thrift 
n«i. Tho manipulation is often pAinriil. huC^ if poi^viblc, an 
auithebc should oc dispensed with, as one can never be certain 
thbcibor or aol tltc luEieiit will sirug^-lc! dmin^ il* adminiMrii- 

T^ Tuintenancti of the hmb in its nc^rmal position, when once 
ffi^urd, la provided for by u ^uitublc upplicaliott of \'nriou:» 
9liBl»* Tlie™ Oiiiuat of iJialerlaK sm-b as wund, lir.ilher, xiiic, 

arlaauic, etc., according to thi* r^quli-iteii af the rrtsr. If cif 
p tivc, oc tin. tliay -ire ti^unlly nuid^ ilccotxIii^ to AOtrfd 
||4KTil pMtcxD, diDd fitted to the pariiculax patient by means of 
pta; if formvd ot leather or pDJopliisiic. ihey nifly be -^hapud so 
|*»Jo«if?t »ny pfimlJaritie^i of the p-^ri. A pattern m.^de of paper 
ftkst tiUcd to the bmb, and the splint U then cut to tha desired 
pc; ri ib i^Alciird by iminri^iun in hct ur cold v^aIcj, moulded 
ineniui.tttid rtIlowr»J in dty on it, Wheie b.MThi-i i^ fi'^iployed, 
addition of n Utile ^nnenar lo the water ii^^iet^ in (endeniiij it 
it lod topple. The k^d^c* wid comer* u.it fiuHlly fimiidcdj and 
iaiCTinc p.vlded wlih >^oi.^l v;r liut- The j^ciict^lI iitlrs leldLiiiu 
ibe nf plirAtinn nf liplmts .irf^ nit fnlln^s: (1,) Thi* joints bmh 
d below the iiite ol frncturc ^hoidd nlwj^yt be inimobiiixcd ; 
Tplinin must he sufficiently Urcc lo lirnijy eitcAsic ihc 
', it \\m, lo ptoject .1 little l>eyonrt it, ^a tli;tl the limb amy 
itxtd by ibr -hplini.And not ihe splint by the limb: (iii.) ain'ful 
mua^t be ifiveo toihe podding' i^on^ to prevent irritAlion or 
of the fdnn. In out-patient practice, wht re the patient* 
tou t.^ueful ai Id ^>er^ii:;d (nc.in!iitt-iN, h m ixdvi-iiblt 10 fwid 
lir iplini with some antiseptit [nattriiil. *i[cli a* buraetc lini, in 
rdet IQ prtt\cni llie de%^lrjpinE.'0( of vermin. Il ii somnlimes 
ikle^ tlmi no roller IxiiidAi;? ^luuld 1m; applied next ii.- ihc »kin 
Ibr tpbiii in \hr situation of \\i'^ frariufe, iind thuugh iJii* 
» ^™d K''n*ril nde, U h not nowaday* an invariable practice. 
The I4>liniii may ofl«n with odvanta^'e bo ftt&t f xeJ to the limb 
ttt jiK or tfco iLrn* of ftr^ppini^. iltiU then secured by ordinHry 
«iiia» buii&^e9( ; tbcK« muKt noi be Applied roo tightly, *dncftih* 



370 A MASUAL OF SURGERY 

— — ^^ 

su-ellmg of the limb not unfrequently increases afterward^ 
undue constriction resulting in gangrene may ensue, Mrnco 
limb ensheathed in bandage must never be flexed, but the 
should always l>e made before the bandage is applied ; if 
not attended to, the bandage may cut into the sofi i 
by compression of the vessels cause gangrene. It is 
necessary' to bandage the peripheral parts of the limbi n 
prevent <pdema from the pressure of the apparatus obstn 
the venous return. The patient should always be seen 
day following the application of the splints, and the coch^ 
the fingers or toes carefully examined ; if they look at all bh 
feel numb and cold, the bandages must be slightly relaKed. 

\'arious forms of Fixed Jlppaimtlu are occasionally usedi 
treatment of fractures, especially in the later stages wbd 
swelling has disappeared, and in children. The matenaU 
commonly employed are starch, water-glasSt and plaster of E 

The starch liandage is only utilized in cases when 
strength and rigidity are not required. The limb is can 
padded with cotton wool, and o^'er this are applied thb stri|j 
cardlx>ard soaked in starch so as to fit the limb. This is sea 
by a bandage, the meshes of which are well impregnated wi 
starch solution, and over all may be placed another faandig^ 
under surface of which is also rubbed with starch. Wbci 
dries, it produces a hriii mass, sufficient to immobilize the I 
It should l>e put on fairly tights Che wool padding, if thick eoa 
suflicing to prevent injurious constriction. Some surge<Ki5«i^ 
it even in the early stages of fractures ; under such circumsttf 
when the swelling of the limb diminishes and the boa 
Incomes loose, it must be readjusted by slitting it up and pi 
away a portion on one or both sides. 

The u-atct-ghss bairdage is applied by first swathing the 
with a thick padding of cotton wool, or bandaging it with bo 
lint ; around this a coarse canvas bandage soaked in a scA 
of silicate of soda, strong enough to tie of the consisiem 
treacle, is applied; several thicknesses of the tiandage ui 
quired in order to give it the necessary strength. The \ 
advant^ige of this material is that it is lights easily applied 
makt'S but little mess: the chief objection to it is that it 
but slowly, taking fully twenty-four hours to become IhoroB 
hard and firm. 

Plaitft of Paris, though tatlier messy and increasing 
siderably the weight of the limb, is one of the best men 
securing prolonged immobilization. It may be applied (^ 
to the outside t>f a layer of cotton wool or boracic buM 
hut freq^iently a coarse canvas bandage or a suitable pie 
house-fiannel is employed as a foundation on which to pb 
(r7) The dried plaster may l>e rublwd into a coarse can\'as ban 
which prior to use is soaked for a few moments in cold i 



i^yVRtRS OF BOSES 



JH 



wmcli nlitUc salt niAy he added to pccvcni the pUsFcr setting 
■lUKkt^ ; ji i>, ilicii wuuiiJ luxiiid lliu li[iib, which \ias Ikwu 
UmiouUy pLtddoil U'iih httnc lim or wonJ, and on iho Pil(»rior of 

tbttCieamof the ri£:hl strength, the dncd powder is cHst in spooB' 

fcd^orio a Uml <jf uilO iv^iirr unlil it no Ioeij^ce sinks iiLimt^Lliatfily, 

bm a porliofi r«?tnaiitfi floating on the i;L]rf;iec^ Th<? mixtures if^ 

te nirred with an iron Ttpoon, And i& rcndy for ii^< |A) 'i^c 

fMall«d Bmvman ipiint is m.idc by ^litchjng tngcther two pieces 

ofco«r« bouuT-flsiiael sufficarntly kiti^e to <<t]L-:i^ thr linibn ihe 

jnM being nude «*> a* lo be liluiied d'jwn the baek of the limb 

jftiiithv nutUlk Of th« lUond. By thrs m^ax^ a dciuhk- cfuint; 

iipnmde<! oa each »;i]c c^f the IJmLii The imicr puitjoii*!^ are 

i(md clowly to lh« purl, and se<:urex] in froni by a tow of 

wt^-plnt; a thkk layer of pbster is tiien spread over tlu«, 

MkAJ[&K a£ tir OS the suuin licbinti find to tht? jimction of the 

1*0 umcr ptccQ^ lu fioul. TIjt ijij1<si Uyei ef llMiiiiel i» now 

dvni ot^rr ihU hefonr it ^*?ts af^d ^\\t *«o a^ jiTti to rovi^r ihe 

pteUr, reaching >« far forwards ns tfie irineT piece- Th« IvlX) 

iid(» arc dealt vftxh in this way scpanilcLy, and when the whole 

«6niL, by rcnko\u^L' the safciy-piii^ the splii^l c^in be uker off. 

Etetevn at the twck forming a hinpn, {c) Pb^tor of Paris m;iy 

ika be (tiled lo nnv pari of ihe body ftccorriitip to a melhod intio- 

ted by Mr. Crofi, of St. Thomas's Uo^piul. M required for a 

&nh, piccei^ of llHiineJ atc rui into The sb^i^Kr of Uicriil splint?^, Iwo 

^nA udc,;ind sufEdcciily latg;c lo encase it comfortabiy. After 

pTO«Ctins tbe limb with wool or Iml, ooe of ihc lateral r-cf;;menls^, 

footer skle of which \h well si^ikrd with plaster, U plaoed iu 

pottlioo. aiMl tlie ftooind ponion, \vhich h;is been l(>i;illy immiirmd 

o ihe plail^. it tl»en placed o\xr it, u little extra plaster lidng 

F^T^pfi rubbed in; the two arc now secured by a muslin banduj^. 

i!t'f thi^ h^s 5Ct, the opp^Mie side tif ibe limb is Jcail with in 

tutiJy thi? same w:iy» and when thf- whole is solid the inu<dio 

bindan is cut through in front, biit is Jefc untouched behind so 

«* to Eorm a hin^. U it is oon^idored necev^ry, thin BCnp*> of 

vood or oietfi) iikiy be In<xKp(Ji4teJ iti Hny of the^M! diiniui^'eit^eulii. 

10 Gt to Mid in ihHr ur^ngth, 

Euly immobih/uiton by n^cAEis of plaster of Pfltis hft« be^n 
•dvocuod by certain Continental «nd American authoriticu, and so 
■ocL ooa£(ience have they in \\ \hi<\ ever fracluies of the femur 
■irdrall u'ilh in thi"; »-ay u-ithin a fpw days of ihp arddeni, nnd 
Ihc patient allowed lo walk aUiut. Such amhuiatory treatmeul has 
DCt rQcci^Td much support in thiis country. Mihou^h we titc 
Wffphipy iQ rcali/e that ihe oiti coiiKrr native plou of ptoluiiife^l 
■ftiiKiUlifaiicn in splints i« not alw^iys deginible^ The pfaeiict? 
fcUoMd IS to sc^nire ihrt limb on l>oth Eides of the fracture for 
(C<M coo^dcrable distance, incorpotacio]^ metal supports in the 
ptuicr ca^in^. To alluw hit the Hhtiuluug ftod aUupby of tJjc 



J71 A MANUAL OF SURGERY 

limb which necessarily follows, the splint is early divided so; 
allow of its frequent removal, and it can then be pared dowBl 
reJitted to the limb; if this is not attended to> the endsdi 
fragments become loose, and are likely to move one on tbe 
possibly giving rise to non-union. 

Another modification which has been recently adii 
especially by Lucas- Championnifere — is the treatment of. 
by Maaaage, It has long been recognised that after aa 
of this nature the hmb is likely to remain for some ci 
period weak and stiff, owing partly to atrophy of muscles, 
to cicatricial adhesions between various divided structures, 
part to contraction of ligaments in neighbouring joints, 
vent this, it has been proposed that splints ^ould be 
discarded, except in cases where displacement of the 
cannot be otherwise prevented. The limb is allowed to 
soft sand-bag or pillow, or, in the case of the upper exti 
supported in a suitable sling. Massage is commenced 
few days of the accident, being at first limited to mere 
mo^'ements. but subsequently including more forcible 
and also pas^ve exercise to the neighbouring joints; the 
are repeated daily, and gradually increase in length- A 
amount of pain is noticed at first, but this rapidly disappears,! 
indeed, a sensation of comfort is induced by the exerciser 
claimed that by this means the period of treatment is 
reduced, and that there is much less subsequent stiffness and 
ability- It must not be foreotten, however* that in tbe 
stages, where blood-clot is still present, it is possible to 
thrombus lying in a lar^e vein, and certainly one fatal resoh 
been reported from this cause ; the greatest gentleness must 
fore be used during the first week or ten days. Whether or 
this plan of treatment is advisable in dealing with fractures trf' 
shafts of long bones is still doubtful, but as Co its value in 
tures involving the articular ends there can l>e no question. R 
such injuries as fracture of the anatomical neck of the humcn 
Colles's or Pott's fracture, and for fracture-dislocations in d 
neighbourhood of the elbow, it has been already proved to bt< 
the greEitcTit service. In one case of the first mentioned of tU 
lesions, which we treated by this means at hospital, the «■ 
was most gratifying ; the limb was merely kept in a slingt M 
massape was commenced within three days of the acoM 
within a fortnight the patient was able to raise his arm uiAo 
help to ;i rit(ht an^le, and he went out subsequently wftb 
limb the movements of which were almost perfect, Simibd 
in the simpler cases of Pott's fracture, all that is needed 
daily ma^sa^-f and the fixation of the foot by strapping; in til 
weeks the palitnil can usually get about with the help of a stki 

OompUcationa arising during TreatmAnt. — (i) If an elde 
patient is kept in bed for any length of lime in the recumbi 



INJURIES OF BONES 373 

hypostatic pncumtmut is very likely to ensue. It occurs 
nmooly after intracapsular fractures of the cervix femorts, 
ig to this cause non-union often results, since the patients 
he allowed to get about on crutches at an early date, the 
ng fixed in a Thomas's splint, (2) Bft^sowsare very liable 
vene in old people with fractures which need treatment in 
umbent posture. (3) Crutch palsy is the result of com- 
1 of the brachial nerves between the head of the humerus 
^ pad of a crutch. It may affect all the nerves of the upper 
ity, or may pick out any one of them, and then most 
■nly the musculo^ spiral. It can usually be prevented by 
r of spring padded crutches with cross-pieces for the hands, 

aUow the patient to partially relieve the axillary pressure 
porting the weight of the body by means of the arms. When 

occurred, the use of crutches must be discontinued, and 
sm and massage employed to the affected muscles. (4) Gnn- 
nay arise from fractures in a variety of ways : (i.) From the 
diate effects of the injury, either by its direct action on the 
s, or by causing arterial thrombosis in a limb with athero- 
os vessels, or from rupture of the artery with consequent 
IS thrombosis, owing to the pressure of the extravasation ; 
7f the supervention of spreading gangrene in a compound 
jre ; (iii-) from errors in the course of trealmenl, as by 
aging the limb too tightly, so as to constrict the vessels ; or 
le bandage becoming unduly tight, owing to the subsequent 
ing of the limb ; or by flexing a joint after bandaging it, the 
ige cutting into the soft tissues \ or by the localized pressure 
ipJint which has been insufficiently padded. Moist gangrene 

1 type met with in all cases, except when the limb has been 
ously drained of its fluids by an atheromatous condition of its 
Is. (For rules of treatment, see Chapter IV.) 

Oompoutid FnctuTM. 

compound fracture is one in which there is a communication 
een the external air and the site of injury. It may be pro- 
i by direct or indirect injury, and any of the compiications or 
ficatioDs met with in simple fractures may be present. The 
s may be but little displaced, or may protrude through the 
ing in the skin, and under such circumstances may be much 
«d or comminuted, and even contaminated with dirt or mud. 
\t chief dangers of compjound fractures are, firstly, h^inoyrhage, 
h, instead 01 collecting within the tissues of the limb. Is able 
cape externally, although subcutaneous extravasation is not 
mmon ; and secondly, the advent of sepsis. The latler is the 
important, and may lead to the most serious consequences. 
ODS of muscle and periosteum, which in a simple fracture 
d be removed or incorporated in the new formation of callus, 



J74 ^ itfANUAL OF SURGERY 



may in septic cases become inflamed, and even slougfa. 
isolated fragments of bone are almost certain to DecEt>ae if 
puration ensues, whilst the severest forms of septic 
may occur, endangering the patient's life by pyxmia. 
results are exceedingly prone to follow when the exteraal 
is small and insufficient provision has been made for 
Immense advances in the treatment of these conditions have 
made since the introduction of antiseptic surf^ery, and wben 
IS regularly and efficiently practised, these dangerous 
lions are rarely seen. 

The Method of Union of a compound fracture is practicil^ 
same as that occurring in simple fractures. If the wouod 
rendered aseptic, and there be not much bruising, it imj 
closed by suture except at the spot where a drainage-tabe » 
serted. Primary union may thus be obtained, and tben 
according to the details already described will result- It 
ever, suppuration occurs, it will probably be attended 
greater or less amount of necrosis, and possibly diffiise 
tion in the soft parts ; the wound will therefore remain open 
time, varying with tlie acuteness of the local phenomena- U 
gradually closed by granulations, which extend upwanis 
l:)elow, and the deepest part of this granulation tissue, vhicb 
derived from the bone and periosteum, and contains os: 
elements, will be transformed into callus, and finally into 
osseous tissue. 

The Oonatitntion&l Iteactdon follow-ing compound tiactuttf 
always more marked than in simple cases. Even where 
prevented by efficient treatment^ a certain amount of 
traumatic fever is almost certain lo supervene for a few 
whilst, if sepsis occurs, there may be a period of marked 
disturbance for a week or ten days, similar to that which is 
in all septic lacerated wounds (p. 90). 

In the Treatment of compound fractures, the main object old 
surgeon is to render the wound aseptic and to gi\e efficient eadll 
tht discharges. For this purpose the patient should in manyc""^ 
be ana-sthelized, the wound enlarged and thoroughly wa^ed 
with some potent antiseptic, such as carl>olic lotion (i in 
Where dirt has been ground into the soft tissues, or even ioto^ 
bone, the surgeon nt-ed not be afraid of scrubbing the parts *■ 
soap and an antiseptic solution by means of a nail-brush- Lo* 
fragments of bone are removed, and portions denuded of tiM* 
periosteum may he taken away lest necrosis should ensue; l*t 
as a ruk', where fragments retain any considerable coonedii 
w ith the soft parts, they may lie left without fear. When a shtf| 
end of one of the fragments is protruding through a small opeoiil 
in the skin, it is first thorouj;hly purified liefore attempting^ 
reduction, and is then either replaced, after enlarging the wound' 
the skin, or a portion s^twu off. Hemorrhage from definite spot 



INJURIES OF BONES 375 

itb in the usual way, and the fragments placed as nearly 
le in their Qormal position- If there is no comminution 
ragments can be brought accurately into position, they 
lire fixation by the insertion of silver wire, when it is 
that asepsis has been attained ; but where the ends of 
i are commmutedt the small portions must be arranged 
m as well as possible, and no attempt made to wire them. 
sized drainage-tube is inserted, and, if need be, counter^ 
: made ; the limb is then placed on appropriate splints, 
external wound may be closed or not according to circum- 
Under such a regime the majority of uncomplicated cases 
veil- Immoveable apparatus may he applied after a time. 
; being left in the plaster casing to allow any wounds to 
ed. 

mpound fractures which have been attended with com* 
LS directed to vessels, nerves, and neighbouring soft parts 
., the prognosis and course of the case may l>e consider- 
M:ted ; treatment suitable to each of these conditions must 
ted (p. 364}. 

question of Ampntation will necessarily be raised m the 
rious cases ; but it is unnecessary to add anything here to 
s already been stated in Chapter VII. (p. iMi). 

Unnuited FractoreB. 

: varieties of ununited fracture have been descril>ed : 
ttute non-unian is said to be present when no attempt at 
i made. This rarely occurs except when some definite 
ease, such as sarcoma or osteo-malacia, exists, or when in 
lebilitated patient there has been no attempt to Ek the 
'2) Fibrous uttim consists in the development of a more or 
I mass of connective tissue, which serves as the only bond 
. between the ends of the bones, which are either rounded 
sed by a thin plate of bone or cartilage, or sometimes 

and atrophied. {3) A false joint, or pseudarthrosis. is a 
n in which the ends of the bones are covered either by bone 
age, and more or less altered in shape, so as to Kirm a 

ball-and-socket joint, the capsule being represented l>y 

ounding tibrous tissue, and the synovial cavity by an 

ions bursa, which forms as the result of the friction of the 

s (Fig. ioi)» 

nost common situations for ununited fractures are project- 

cesses of bone to which powerful muscles are attached. 

the patella, olecranon, coracoid process, posterior ha]f of 

atcis, etc. ; whilst in long bones the middle of tht; shaft of 

lerus and the upper and lower thirds of the femur are the 

e sites. 

' different OftUWi may be associated in determining the 



JT6 



A MANUAL OF SURGERY 



defective union of fractures, but the following are the 
important : (i) Want of apposition of the bony en6s, tmi 
muscular action — e,g., in the patella, where the two fnif 
may be widely separated, or in the femur, where they maf 
lap; (2) the interposition of foreign bodies, such as musc^ 
aponeurotic tissue ; (3) want of rest, one of the most cot 
causes, as in the middle of the shaft of the humerus, whcTM 
the elbow is well supported, complete immobility cam 
obtained, and non-union is likely to result; (4) defective 1 
supply to one or both fragments, as by injury to the m 




Fici roi ■ -Uju'mteh Fracture with False Tojnt, (Frosi Coll 
ScpCEONS" MusauM.) 



artery, £ir as in intracapsular fracture of the cei^-ix femoris, 
the on]\' sovirce of supply to the opper fragment is a smal 
derived from the obturator artery running along the ligam 
teres ; (5) local affections of the bone, such as malignant tui 
destruction of the periosteum by inflammation, or the 
pressure of pads upon the newly-formed callus; (6) genefi 
disease, as osteo-malacia ■ and (7) general constitutional ^"C 
01 debility, sometimes due to definite diseases, as scun"y or 
syphilis, sometinics to general asthenia or alcohohsm. 
been defmitely proved that senihty, pregnancy, and the can 
cachexia do not, as used formerly to be stated, predispose 1 
condition. 



litJUniES OF B0SB5 



m 



HcSliifofAriunuoitcxlErscturoarep^foctlyobvious, n&nniic, 

viriwnn nvpioif- 

Tbt ftdffiosli >^ uffunlly f;ocd il -^utlahlo irc^tincnt U A^1opt«d, 
k tfcfi cftM of children* however, the coailtcion b oflcn niAintnittod 
nfn*fin ojirTiilnt- rmiliTifnit. and. in fn^ t, niwy Iff JiKi;rA\Alcd 
in h, iho ecils of llw bcirie bec-^minif aircphlc, roumW^ and 
cn««dl>y cftniUice: in such the fiwil reeori is not unfrequoidy 
kttHUioa. 

iIk TnMaMBt of unurirefl fraclure^. i'^ nriw roiulucted on pci- 
lecilf <Mbuie lines, (i) The pirts .iit< rcfixed in ;in tiiunoxeabtv 
aVfmtiV, prcferuhly planter at I^aris. for ?h1Ji vrct^kTS wbiUt mouif 
mAdo(4e<l to impruM^ llic ^ehfiiE Le^lllj> ith 
kiiuy Ai the 4Ki»I(I«jindtb« inlmtriTiitrAtion 
aioeicjt. (3) Kaihng this, tlie ^ntAa of th« 
KiWa ni»y be well ftililHrtl logethcr, no as to 
tuikkxJil Artinnn And th<* pari^.iyiiin fixeil. 
(iJ ShffliW thU b*T ijni.-iicc«s8fu!, operative 
■■uaufifi muM hv untfcvtaltcn. H the honu 
vbdcnbly (xipcrfKial, And llit- «uds not teiy 
Bi jput. th^'v KhonM h** etprr^ed, u^ti inro 
*igit. fcuwl ingcllMrr tpreferabJy hy a dove- 
'lUBi; moccm), (Uid »ccurv<1 by slout mN^r 
'nrT.tttich may lie left in titu pciiiii^nc^Uly, 
*W if uq)Cir hicwniMi fur^ptxjlrcl- If, how- 
r^- rhe boocK xrc deeply plnccd, no tti:4t the 
<^>vil]0n to expOM Ibc ends and fti tijcni 
|<Cnt«T t>ccoi]ie« a very severe obv, il is often 
■Wet pracdcr to l«ftW ihem in Ih^ir Inil 
Wbee, ftftd mftrdy fist Ihcm by the m*<f lion 
^ 'Wf pe(r> or nickel' plated screwrs- Tlius. 
4 tfe opp^r <^*>d of the ffmiiit nrtn-immn i>^ 
umiy awocbted i^ilh o\'irrlAppiDE( of the 
*>dfiof tbe booc to a coiuidcTnbie extent. To 
*>P3e« And fit clie^e loc<''<^>|^^ would nerew- 
^1 tery exienM\« operation : il U wiiipr in 
■ch caseA merely to cut down in front upnn 
^f* upper .interior fmjrmcnt. drill two holes 
'J^TOitli lurth fi^i^tijvms. iiiu! into Ihrw maert 
XdUhk ivory peg*. T'^'O holeB »;houl<1 A.lw4y« 
>• en^toyed. lo pre\-cni Hlipping ol the fra^' 
(Wk during ihc nuny ncooaoary nianlpuU- 
^6«>: whil^ oii4r drill is i«inov«d for the 
■Mnidn of ihi« peg, the other hoM^i the bonc^ 
*wly. A& d rate, the M*;3 may he allovred to remain ppi inaiienHy, 
*t octuiottally ihuy Womt loose in three or four wcolo. and 
■wJ rcnMH'aJ. Thetr pie*(C[wf < anses iL lariat amouul uf c;i»llu^ to 
^< tnd by this meains the frndtire U consolidaied. 




TUMI OF Fiifm 
WITH VlClACH 



3T« 



A MANUAL OF SUHGEtty 



Dfmintted Ttacttm is ili» i«Tm apiplM la a rare condiiioi, in 
which a fruciure which h^d l>e«& Appwemly ftrmJy uc^ 
becomes ^pAratcd agam. It ia only ni£t with wh«n the «6 
vidual d^volops sonic txiremely (ti^hiliutEinc tliscnw. «ucl u 
KCLirx-y ; ii mxy be rocovMcd from under Kuiiahte mAlnvnl 
dircccod to the cav^e, Jind by fixalion of ilv p^tt^^ 

TlclouA Union of fracimc* rcsitUs cither from impcrfact tt 
nLljiislnirrii iif thf c-iiiK of ihr lunm- prior i^ i^lAcinjC tUr Kmb«L 
an]n]niDVc.tMc;(pparAiu(;. or from th^ pnrti^tioi twing keplatrf&u 
and hence bcrojnin;; si]h'iGiiiL<:iiily di^pliucd- X'nnoud kindsd^ 
Cormtty ami Uisrii^Lifcmcnt.^^oinpaiuod i>r ngt hy k>5» of fLSCtiCA- 
may rescdl frtim ihis acddwit. In Mime raws il nuv Up adtmbMS 
to IcaviT ihinRii ;tloiie, but whvrv th{? dcfbrmil)' or fancttOMl di^ 
turbnncc i^ .tcHous, meAUfi must Im: taken to remedy nultort- 1' 
obseivcd early. It U noi dilTicuJt la iGu!ju>t tbc |Mirt5 by ^mp^' 
pre^urr^ under an ima'slhetit, ii ncce-vmry re-fractuntik^ t^ 
hon^l hut this tJiould cmly Ins undertaken whilst the callus <* 
8oft, i,£„ within three or' four week* *jf ibc Jrixi4cfit> _ Son« 
SLtr^cuii«upply ihis method nt o^UocUiia cxv%i vihett cotaWjlidatu» 
has h**n neccimplished, us\7\^ for th« purpow levers and pwrfi" 
eJamps; but in our upinioi^ i^uch trc^aEnivnl la moM uad««ifftl:^ 
And nii^lily itnMicntilic Aince it h diflicuJi La a(.i:uTatcK ^t^sg^ 
tbr amoimi of (damage conctiTfenily mflfirtud au thr sod pirt*- 
\\> much prefer the offji method, cutting down ott ih« bone, r^ 
dividing it, rcmovjnj; uanecv&sary cnllua, nnd facing the tm*,T»>cnt» 
by hilver wites. pegfl. or screwa. 



Special rractnreK. 

Bones of tho Fneo. IIk Nasal l)onr» are aln^y^ brokceD a^ * 
rrMjll ti/ dirm.: ^ iirlr:irE-, 1>> ilir: iitf, ^ cnckctWI. itick. etc. f*^^ 
frnctiire i^ ^^enerjilly tmn^vt'i^c. and sitinled jii« ;iIh>v« the £»"^* 
margin of the bones; otc:isioQnl[y. when gr*yier fofc^ U *t*^~ 
they Rive wjLy close to the root of the DO»e, aad may ihta ^f 
ci^mplkaEcd with fiivciuic if the frontal bone or Ixis* ot the sk***'' 
In young peoplt tht caiTrlnj^ alone nv*y bo ^'parated. T**^*^ 
i& uwuilly a ffootl deal of deformity from deprvtwoo or latf ^^ 
displacement of thf (raj^mcnts. allhoujjh it m^yat hrsl be "»***^^ 
hy the: ^niouiii uf hrniiiu^ y(ev.'nt- Scvcic cpi«taxis» siuai^^ 
«mphyaema, and cer^bml symptoms, aro sometime* met wit b * ^ 
ccmplieationi of these cabes. The fraetiitc ^'cry rradily b*cor*»^ 
conwIidflteLl, ^iid ihr dfrformity is thus often irremediably ft* *^' 
It i* niDf^t inipoitatil, thneforir, to drtcrmiiir iht presence or >**? 
oi a fiacttiie at one*, and this can only br tn^d** cn;i wh^n ""V^f! 
^wdlini- is prc^nt b^ icra^pin^ the orn*n and movirn; it (rem «>*? 
Id ^deioclitit ciepitus. Tlic twtom is wimclimes broken «»" 
drprp^w'd in asfinriarion ivith thr abovp injury, bm it mayctO^'' 
alone in olhcr inttanc«({t j^vin^ rit^: to lateral di%pl;iecment- Thi^ 




INJURIES OF BONES 379 



not result in obvious deformity, but may lead lo consider- 

nasal obstruction and discomfort. The Treatment of these 
5 consists in imniedtate replacement of the bones, advisably 
er an anesthetic ; this may be accomplished by the pressure 
aome blunt instrument, such as a pair of padded dressing 
:eps, the blades of which are introduced within the nostril, or 
^stension of a suitable indiarubber bag with air or water. A 
1 of Unl or gauze soaked in carbolic oil is then inserted to main- 
Q the position, and a guttapercha or zinc splint moulded to tit 
i bridge applied externally- In old-standing cases, where there 
much depression of the bridge, t)ut little can be done, although 
is possible to divide the septum by Rouge's operation {p. 693), 
dtbeu forcibly elevate the parts, maintaining them in position 

suitable plugs or \-uIcanite supports. Lateral deformity can 
ully be remedied by mechanical appliances or operation. 
The lAchiTinAl bone has been broken by direct violence, the 
LCture usually extending from the nasal bone lo the lateral mass 
the ethmoid. Interference with the flow of tears and surgical 
iphysema are the two most marked symptoms. 
The HaIat bone is but rarely fractured without the other bones 
the face being involved. When it does occur, it is almost always 
vciated with damage to the anterior wall of the antrum, and con- 
Iciable depression 1^ the fragments results- An attempt should 
i made to replace the parts by pressure from within the mouth. 
The EygomA may be fractured by direct violence applied from 
ithout ; the broken portion may be depressed below the surface, 
LI xerlical displacement is limited by the attachment of the mas- 
ter below and of the temporal fascia above. Reposition, either 
' manipulation from w^tthin the mouth, or even by operation, is 
sential in order to prevent interference w^ith the subsequent 
obillty of the jaw. 

The SnpeiiOT HaslllA is invariably broken as a result of direct 
jury, such as a gunshot wound or a blow ; it is almost always 
imtKnind, and often bilateral. The alveolar portion is either 
utially or entirely detached, or a transverse fissure, extending 
i fsa as the pterygoid processes on each side, may render the 
'bole palate and lower part of the facial skeleton moveable. 
lOt unnrequently all the bones of the face are smashed and com- 
unuted, severe hemorrhage from the internal maxillary artery or 
ts tenninal branches sometimes resulting. As a rule. Treatment 
muista in merely keeping the patient quiet and applying* cooling 
oiions; union occurs with great readiness, but is sometimes 
wsociated with necrosis and suppuration. The patient must Ite 
fed by a tube, and a carefully fitted dental plate should l>e applied 
to i broken alveolus. 

The InfBorior HudlU is usually fractured by direct violence, but 
occasionally by force applied indirectly, as when a carriai^e passes 
*^"*r the hone, laterally compressing the two sidt-s, and leading to 



3to 



A CASUAL OF SaaGEȴ 



a (niciiire In the middle 11n«<. Mo<ii often the 4lie of ibi^ irs^it 
a liiile in troux ot the in^jntul forameti (I'l^- loj), ihtc b«B^t 
vcftk spot at the jiinclioii of two Miong pvCft. si^*. tttc sjraf^w 
menu attil ihr :ilv'>r4jUt>% tarrying ll^e molar tirrlli ; iHr teat v 
fiinhf-r wcAk^n^d by th« long narrow alveolus lodgiag ibvoan 
tooch. ThrsfrActuromrLy aomeftimes be dOLbIc whoo gTctl violaw 
has been applied to ihc &rnipbvab> A solution of coBtbtuitr «i9 
cKxiiTN cTnsi- to thr niigV Iwhind ihf? mnlnr tcrlh, mliii^tf Ae 
coronoid ptoccu and condyle hftve occasionally boon broken, tit 
former nnly ar n result of ^tiki force, f j:,. a f^vinsbot vnxckdL ->• 
latter from cilWr direct or iiidirctt violence^ 

The UgHA of thi^ frartiiTP arr. \vry evident if thr I«rui; n 
sitUAied Anteriorly : b;it when hohind the teeth, doglM 
may he much more (liflicull. The common variety in winail 
(dA\Ay^ compoiind. ow'm^ lo the firm Hll^tchrnmt of the nmco- 
periosreum to the slvrolur bordtr. I^cctstinn irf the gum^ l^ 
Hood' stained sn]i\a fioon hccoming f<ctid, the inufiuUrity >* 

the line of the tocth. sod tiK 
cAKily rhcited crepitus, jlH cot 
«iliUe a typical picture, Th^ 

□uiiig riuiuty to the toriafi^ 
Ihe mucous iiinnbrBiWh \f 
po«»ib1y due to imptinCi* 
of the inietior dic^Ul oe*^'" 
The Mijiii) trunk, houc^*- 
^trnerAliy tv:ap«, oum^ i** ^ 
positic^n of iImt fracture in fg"^ 
of the mental foriimcB, »t^*^ 
111 Llkciae In^liiud there is ^ 
liiile dlspUcemeni. Si^ '^i' 
hai^morthdlgv »om«liiiMi ttim ~^ 
froci laceration of the ikccompanytn^ ivricry. Tine ^tcriof (=^^' 
mcnt is uhLially f^mc^shal ral»^, whllM the anterior p<iriio "^^ 
deprcKRed by inr miction of the hycid mustltH;, afl<l may o\ei — ^ 
the former, owiqj^ to the direction of the frncture, the ODlt 
f»lfitkeni uRludlij^- inuie of the outer sudaccof lUe bone th< 
posterior, Th«* dironirin of the dispUrement is Tever>ed m 
COMS. When situated at the angle or h the PtrHc^ ntnun, t' 
l» such equal muscuUr support on the two »deii that but I 
dUplaeemenc rcsulls. \M)en tJie ftnclurc pa^vs ihvtiih fir 
tf//Atf rt»«f)/p, that process is 4l]«plac«1 fiiirvard^ ^nd inwards H 
Uie esilcrnfil piervKnid. whilst the body of the bone ii ft"**? 
^afcOvxablcantcnvpnstcriorly, find dravfTi o^-cr lowartl.i the opp*;^*''' 
4lde, Wbrn lUrfproninJ f^riH^a [^ drf^LcheJ. it ih (lr;if[ged upwfS*^ 
i>y the lempornl imdoTi. but no ^eat dt^pl.-n^ement can occur* 
'Ovrid^ to the extc^bive atlAcl'tmpnt of the tenitiriouK hlve^. 

In tliosG ca»e» cf fr.icture which ore coinpo«tod (aad Uii* 




Fw laj— LowKn Jaw, iKbiCAllNCTfrR 
Srre o? tmb Hoar CoHho-tf Tvac- 







INJURIES OF BONES 



381 



les the great majority of those ordinarily seen), a septic 
unatioQ of the ends of the bone often ensues, leading to 
zed necrosis, and sometimes to septic pneumonia, or even 
Qcral py^mia- 

lC Tieatmant of a fractured mandible is frequently a matter 
ifBculty, owing partly to the septic element present, and 
y to the difficulty of fixing the jaw without interfering with 
patient's nutrition. A great variety of methods have been 
iorc suggested, but of these the following are the more 
irtajit : 

Id simple cases, without much displacement of the frag- 
ts, all that is needed is an efficient four-tailed bandage, 
. is made by taking a piece of calico 4 inches wide 

t yard in length, and splitting each end into two, leaving 
It 8 inches undivided, and in the centre of this a small 
itudinal cut is made, into which 
)oint of the chin is inserted. The 

lower tails are then drawn up 

lied over the vertex, whilst the 

upper ends are secured behind 
Kciput, and then, to prevent slip- 
. are knotted to the ends of the 
er (Fig- 104). If the lower knot 
ronght below the protuberance, 
ward displacement of the anterior 
lent may be produced, and sub- 
mt deformity. This apparatus 
Id be maintained iirmty in position 
^ree weeks, the patient being fed 
iiids passed between the teeth or 
igh the gap behind the last molar, 
[dl talking and attempts at move- 
prohibited. The mouth should 
Oc frequently syringed out with some antiseptic lotion. 
1 is usually secured in five weeks. 

If patients are inclined to be unrulyi or if the above 
ratus fails to maintain the fragments in position, a moulded 
Lpercha or leather splint may be applied, made in the shape 
ated in Fig. 105, the upper portion being folded back, and 
3wer portion drawn up around the bone- It is lined with lint, 
secured by bandages or tapes passed through holes, and tied as 
H-n in Fig. 106. 

Where there is much displacement, the fragments must be 
L Wire sutures passed around or between the teeth and lied 
listinctly objectionable, causing the teeth to become loose, and 
aps diseased. Hammond's win splint has been much praised, 
we cannot speak of it from personal experience, ll consists 

firm wire collar or framework, which encircles the whole series 




Fig. 104-—- Application of 

FOURTAlLED BaNDAI'.I^ F<m 

Fracture ov Lower Jaw 



Firm 



3S3 A MANUAL OF SCRGEHr 



of teeth in the lower jaw. It is accurately fitted, firstly, to t 
of the jaw, subsequently to the jaw itselft and is fixed by «i 
wires passing from one half to the other between the teeth. 

4, iVirittg of the fragments together may be required in 1 
cases. The wires must be passed either through the bow fa 
the teeth — a task not easy to accomplish without an eill 
wound — or through the empty alveoli of neighbouring 
which are extracted for the purpose. 

When septic inflammation occurs of such severity as lo 
necrosis, it is often best to delay all operative treatment untl 
sequestrum has been detached, and the parts are more haJi 
the patient's mouth in the meantime being frequently dad 
with antiseptic lotions. Wiring of the fragments may tbdj 
necessary, be undertaken with good hope of success. 




FiCr 105- Leather Splint 
FOR LowtH Ja^v 




Fig. loC — Leathkh SplihT 

A PPL [ED. 



Fracture of the Hyoid Bone is uncommon^ arising usually t 
direct violence, such as a forcible grasp or the constriction of 
neck in hanging. Either the body may be broken, or one d 
cornua separated. The symptoms produced are : Pain on att« 
ing movements of the tongue, jaw, or neck ; a husky ^-oice; 
deformity, which can sometimes be detected from without. 
sionally the mucous membrane is perforated, and bleeding into 
mouth may occur, whilst oedema of the glottis may subseqne 
supervene. The fragments should be approximated as wel 

Eossible by manipulation lx;tween one finger in the moutb and 
and outside, and the neck then fixed by a poroplastic collaT' 

rmeture of the Elba may arise in two distinct wa>;s: (i) 
direct violence, as by blows or stabs^ the fragments beine dr 
inwards, and damage to the underlying pleura, lungs, ii^^ 



nfycufEs OF bct^es 



fi^ 



^^^HBirajtm, bring vttr MUtAy ic occur ; or {3) hy indir^r \ iolence 
^^^BncxlcfMl prc^un;, a^ ^I'hcn Xhc chtst is comprc^ised between 
r ican^vrbecl wid llw ^rrmnd. or l*clucen a wall und the end of « 
I nnpn. The t«ii (ti«1« t^ the nl> ;atr ttirti nppTOKimated f>eyand 
I 1M uniu of natunti da^iicily. and it gives way at the most convex 
^L pad- i>-» acir ibc nni^lc- Diimajct! to the ^'iscem may nrise from 
^1 ccoTUfjoa, t>ui is \c'Vi coiniiiuii llun in the former c1*lnv, Alllmii^li 
^^ bM}Dl>icint3i frori mptiirr of the p:irtctitl pleura. U not imcommon. 
^M Ov« teverai rib* may he broken, but the dispiaccmcnt ii; mrciy 
^1 flBftihed, csicepi in cusc^ due to dirvcl violence nhere MVcrnl rihi* 
^1 luwtcm 'ftia^td ill,' The fthU Icj thn^eigbth ribsatPthrwmnvt 
^H Tmcnnly injiirt-d. Mn^ mor« prommeni u»d fixed ut both ends ; 
^H tt« frn AAd sifcond ribf. nre so vV(>d protc^LteU by the clckviclc av 
^H IftW >efdam Eirokcn. and <hen only by diicct violence, whiUl the 
^H bstr libn ufteii CiVLipc ijii iiiii'iiiil uf llieii giealcr mohiliiy, 
^H EUrly u^Bwn and pvr^n? tLitfering from gvnerxil pur;i]yf i« are 
^H ^(cally prone lo ihie ^iccidenl- 

^U Thr Srioptoms Aicr usually to[crvibly ob^loiiA. vU-, u scn^ttimi 
^H •fscrarlliii)^ stiiipiJini; or Rixinf: \^Hy, a shaip Icfalitei! t;ilchirg 
^V pain ai rbc tiitc of ihr injury, incrc^^E^d on deep breitthin^- :ind 
^B Coq^ainj-, ftnd po^hly wimo loccl exiTnvtLfAtion tmd s^vclling* 
H J^r i,ii;i m-ty dil»i> be elicited by conjoined pfcs>uic u^ii the 
^ sternum iinl ^iital cnhimti, uhiUt tbr fr;ictiirr may hflrvid^^ni on 
r Pnlpution, or crepitus delected ubcn the paii«nt cougha or on 
I **t»culutioti» When several rib^nrc driwn in, ix marked dcprc9- 

?**5 m*y result. uhiiM if llxe Kme 

'** ftcft^m-er^d with ht or iini^de Ihe 

*£ji£i>atis ni-ny bo evtrcmely obscure, 
^^^^ ^ clinical hi^totj' of c-tw:* com 
^K^biied by lesioti*^ of ihr hinf^s i>i 

■fcliM. tee Ch-npter X WII. 
^t_^nie Trefttmcat ir; tolernhly Hmple. 
^*^ aflcctcd side i» lo be wcurcly 
^^^oppifdvith broad siriiJ^of ^idheM^e 
t»li5t«, so us lo bmit ihc tnovcmcm^i 
•*4much a^ poswWc. Tht- stripji, 
' i 1c 1 UK:lie% ftide. !vhtmld project 
_^^^ind the middle line, l^tb fioni 
■^^£d tiacfc, and are applied (rom Ws>w 
^^l^mrds whilst ihc cnesi i<i in a stale 
H^^'^^lile opiiatJuutCMcli nliipo^er- 
•*winj; the precepting one (l^lti. [07)- 
^Wtt woollen banda^'e ^'houTd then 
J^*pplicdo*^AlL If the rnd% of Ihc 
™»e«c driven itiw'anJ^, ^u*:h Mrfti>- 
I pnjg cin r*rely tie horn*, a*' 11 tends ttill further lo irtttalr ia 
\ *^'*pe«s the liinir- I'nder such drcumsiancp.i ;ill confctririinn of 
1 ^l*<bertsh 




Fio, i07,"MeTUao or ktsav- 
pivi^ Brchdn Kim. 



^^ <bert fhoidd l*e avoided, but ihc patient should 1^ confined lo 



fl^ 



4 MANUAL OF SUBGE/tT 



b«d with ft undba£ b«tA<o«a the fihouM^rs. ruid ibA torn boail» 
ihc Mdc- When tlic lo^ct rib» &ro brokicr. ti^'ht appGcilkmi 

irrilAlrd, And trQiih]csoni4^ hlrcougli m^iy rvsitll, Rihs,umniltH 
unite rt^dily, bui a ccinsiior:tl]lt' Jiinount of callu^j U EortiwJcmaj 
to th<- HifhcLiltv of sAiisbf toriiy Ux'tDe; ihc bfokeo cnds- 

Baporation of a OoDtfJ Oartilaco ,iomctt(»eji txcurs, Kiviac rtie Ifl 
liifi Mint Hyi j[Jluiii.% ;i[ul leiiiiiin^ iht? iani« li^^lmrfit 4% a biciea 
rlK Occnsioii^lly the cmtibgt^ ii»;lf imiy be fmctuiiyl- lauiii 
<:a£« the reeuUinj; bond oi union is omcouu. 



m 



motnre oftbo 8t«miim is; nimcwt ft3way« due to direct 
although it hnr< hven liTiown to yidd &om crtcouSrc fleKico of 
the Irnly ^tftr^r finclcic of tho spmCt or from mii'vuUr ikiTroce 
riuring p.irturilion- THp lini* nf fmcliire ii; nnully ir*ni\pfw,t'* 
bone pving way dthct bct^veH!n the m^mubnuni and ^Udiolufi, 
Of a little below lhi» line. The btiDcs rrw> tcnuin fV niu at lh< 
up;»cr friitr^neni be di^pbcrd li;ickwiinJ>. ihr tlcftirmiiy in *ucii 
c.n^es being very evident, and firent dytpntt-a rc«u3ting. \* =■ 
hitur tilet:l, mituntjn oi the nrch oi tbe aorta may occur. 

Tre&bmeitt. — ^Tbc patient should be kept in liod will] a pitlo* 
Wlween tlie ^hlHItl1«■^s» am] llie rbest iirAf^ped «« for trictuctd 
nbs^ H tho p;ilitfnc cannot t>eat lliJs p<M)lioii, li« diouH be 
uJlovrcd to »it up with Ihe body lenmng fonr^rcb- Repwiuon 
oin aometimcn l>tr effected by miuupubtioo And cMcn^n of tb* 
spini: ; :iT preser^t no opemilve tncasur** h»\'e l»een underukfj* 
Willi ih\6 motive, although iher« ia no ab^lut« rvas^m wDt ■' 
fllioiild not bt attempted. 

rractutta of Xhut Vp'^t £xt»aUtT' 

FrMture of ths 01i.vlc]«,— No bone in th<.^ kxly. i^ith tlw cs*" 
ccpik>]i isf ihi; JAilJuSt is tirnkdi more fici|iirnily tb^vi ibt ^ 
davicle; thU ifi dnr ta it« cxpoAMl positit^u -"Utd it« btittrect'lib 
action in heepitiie out the point of the lUwulder, %o that *>v^ 
»iiock to the asxn \i tran^tmiitMl thiou^b it to the tnuik. Mcnc*, | 
4Uhuu|^b fiHCLuieH (tiini dirct:l viulcnti; d» ocnn, it is mm 
n^iually bTr>ki*n -^^ the result of forfie directed lo Ihe hand or 
shoulder, such nn a. lull from a liorve. The injtiry ta very com^ 
mon in cbLldren, bein^ then often of a igreeiistkk lUiCure, and 
more fre(]uent in men ihAit \i\ wurnen. The bone may yielA^H 
four dllTereiit «pois, vir, ; ^^M 

t. At tb« VMnuU BdA, »n uncomrnoD occtutoDo^. Aod oH^^ 
of the nature of a sepamtion of «n cpiphy&is, and beikce tfenesaUy 
Sfirn in childnr*. 'I hf* tflispUrpmr-.m is v*«ry sHchl, a* tne outer 
rraf{m«nt is alm^Et inimove.ibly tivod by lh« rhoml^id bf^MneoL 

2. Througb tho Qr«ftUr Convexity, tho comntoneft situation* 
Ihc Eh^elc yields ,^1>0LK il^ centre, iind ihu tine of ftat^turc 





INJURIES OF BONES 



3«5 



j^blique, running from without backwards and inwards, 
placement that occurs is quite characteristic, and is 
n any fracture situated between the rhomboid ligament 
ner side and the coraco-clavicular ligaments on the outer, 
ss marked, however, when the fracture is nearer the 
ies than the centre of this space. The patient presents 
with a history of injury and severe pain, supporting the 
:\th the other hand, the head bent over to the affected 
as to reia\ the muscles of the neck, and the arm power- 
>n closer examination, one finds that the point of the 
r is less prominent than usual, l>eing approximated to 
num, and on a lower level than the other, whilst at the 

site of fracture is a shghtbony 
projection. This deformity is 
accounted for by a displace- 
ment of the whole outer frag- 
ment downwards, forwards, 
and inwards (Fig. io8); the 
outer end. however, is more 
displaced than the inner, so 
that the latter looks upwards, 
inwards, and l>ackwaTds. al- 
though it is placed imme- 
diately below the inner frag- 
ment. Such deformity 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 
venter of the scapula to em- 
brace the curved thoracic 
wall, from which it is usually 
kept separated. The action 
of the muscles passing from 
ink to the upper arm may have some effect, but can only 
ked on as an accessory, and not the main cause of the 
:ement. The position of the inner fragment is probably but 
diered, since it is held in place by the rhomboid ligament ; 
parent projection of its outer end is due rather to the depres- 
'f the outer fragment than to elevation of the inner by the 
i-mastoid- 

Bfltween UMOonco-clATicnlaxLlgamentA, usually arising from 
violence, and with but little displacement, owing to the 
m of the ligaments. The signs of local trauma and crepitus 
lowever, present. 

At the AcromiAl End, external to the triipezoid )ig;imL^nt, 
agam, usually produced by direct violence. The inner fraR- 

25 




k*j — Fhacil'pk of Clavicle 
.v;h Gheateh Convexity (Till- 

no- mastoid . S, subclavius : Tmi, 
nits minor: Sm. serraius m^nEis 



jS6 A MANUAL OF SURCERY 



ment here retains its position unalteredf hut the outer 
is dragged down by the weight of the arm, and forwards bj 
action of the muscles, so that it lies at right angles to the ntt 
the bone, 

OoznplicaUonj} arise most frequently in cases produced by 
violence. The subclavian vein may be injured, or the 
plexus ; and even the dome of the pleura and the subjacent 
have been injured. Gangrene of^ the arm has resulted 
obstruction to the \'esse^s. 

Tre&tment. — In the ^rst and third of the above-mettti 
varieties, all that is needed is to immobilize the aim in a 
and to keep the patient quiet. In the last form a ligut 
bandage is required around the shoulders to keep the outer 
ment back, and an elbow sling to keep it up. 

For the ordinary type of fracture many different plaaa 
treatment have been adopted. In order to replace the 
or to set the fracture, the surgeo