Sat, Apr 13, 2024, 10:02 PM -07:00

author: Fudgerboy <91767657+Fudgerboy@users.noreply.github.com> 2024-04-14 05:02:38 +0000
committer: Fudgerboy <91767657+Fudgerboy@users.noreply.github.com> 2024-04-14 05:02:38 +0000
commit: 248d296234dc7ce76294c677bf2ca5e76c2f50d1 (patch)
tree: 5a38d5a5eb4cd6075e10de1583fde289c144cc91 /wk5/pset/speller/texts/surgery.txt
parent: ba93a5dca5f93fe7b5761c251037d4f1860f9a43 (diff)
1 files changed, 24335 insertions, 0 deletions
diff --git a/wk5/pset/speller/texts/surgery.txt b/wk5/pset/speller/texts/surgery.txt
new file mode 100644
index 0000000..dd5917e
--- /dev/null
+++ b/wk5/pset/speller/texts/surgery.txt
@@ -0,0 +1,24335 @@
+Project Gutenberg's Manual of Surgery, by Alexis Thomson and Alexander Miles
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: Manual of Surgery
+       Volume First: General Surgery. Sixth Edition.
+
+Author: Alexis Thomson and Alexander Miles
+
+Release Date: March 4, 2006 [EBook #17921]
+
+Language: English
+
+Character set encoding: ASCII
+
+*** START OF THIS PROJECT GUTENBERG EBOOK MANUAL OF SURGERY ***
+
+
+
+
+Produced by Jonathan Ingram, Laura Wisewell and the Online
+Distributed Proofreading Team at http://www.pgdp.net
+
+
+
+
+
++--------------------------------------------------------------------+
+|                                                                    |
+| Transcriber's note: The original text used the Greek letter mu,    |
+| which has here been rendered as [micron], and the apothecaries'    |
+| symbols here rendered as [ounce] and [dram]. The degrees symbol in |
+| temperatures has been omitted altogether, since the C or F makes   |
+| it clear. The substitutions used for other special characters,     |
+| such as the ae ligature, are standard. All the special characters  |
+| are preserved in the UTF-8 and HTML versions of this text.         |
+|                                                                    |
+| In addition, a number of printing errors have been corrected.      |
+| These are marked in the HTML version only.                         |
+|                                                                    |
++--------------------------------------------------------------------+
+
+
+
+
+                     OXFORD MEDICAL PUBLICATIONS
+
+
+
+                          MANUAL OF SURGERY
+
+
+
+                                  BY
+
+                     ALEXIS THOMSON, F.R.C.S.Ed.
+           _PROFESSOR OF SURGERY, UNIVERSITY OF EDINBURGH_
+                  SURGEON EDINBURGH ROYAL INFIRMARY
+
+                                 AND
+
+                     ALEXANDER MILES, F.R.C.S.Ed.
+                  SURGEON EDINBURGH ROYAL INFIRMARY
+
+
+                             VOLUME FIRST
+                           GENERAL SURGERY
+
+
+                       _SIXTH EDITION REVISED_
+                       _WITH 169 ILLUSTRATIONS_
+
+
+
+                                LONDON
+                 HENRY FROWDE and HODDER & STOUGHTON
+                        THE _LANCET_ BUILDING
+                 1 & 2 BEDFORD STREET, STRAND, W.C.2
+
+
+
+
+
+
+    First Edition                                             1904
+    Second Edition                                            1907
+    Third Edition                                             1909
+    Fourth Edition                                            1911
+      "       "    Second Impression                          1913
+    Fifth Edition                                             1915
+      "       "    Second Impression                          1919
+    Sixth Edition                                             1921
+
+
+
+                     PRINTED IN GREAT BRITAIN BY
+                  MORRISON AND GIBB LTD., EDINBURGH
+
+
+
+
+PREFACE TO SIXTH EDITION
+
+
+Much has happened since this Manual was last revised, and many surgical
+lessons have been learned in the hard school of war. Some may yet have
+to be unlearned, and others have but little bearing on the problems
+presented to the civilian surgeon. Save in its broadest principles, the
+surgery of warfare is a thing apart from the general surgery of civil
+life, and the exhaustive literature now available on every aspect of it
+makes it unnecessary that it should receive detailed consideration in a
+manual for students. In preparing this new edition, therefore, we have
+endeavoured to incorporate only such additions to our knowledge and
+resources as our experience leads us to believe will prove of permanent
+value in civil practice.
+
+For the rest, the text has been revised, condensed, and in places
+rearranged; a number of old illustrations have been discarded, and a
+greater number of new ones added. Descriptions of operative procedures
+have been omitted from the _Manual_, as they are to be found in the
+companion volume on _Operative Surgery_, the third edition of which
+appeared some months ago.
+
+We have retained the Basle anatomical nomenclature, as extended
+experience has confirmed our preference for it. For the convenience of
+readers who still employ the old terms, these are given in brackets
+after the new.
+
+This edition of the _Manual_ appears in three volumes; the first being
+devoted to General Surgery, the other two to Regional Surgery. This
+arrangement has enabled us to deal in a more consecutive manner than
+hitherto with the surgery of the Extremities, including Fractures and
+Dislocations.
+
+We have once more to express our thanks to colleagues in the Edinburgh
+School and to other friends for aiding us in providing new
+illustrations, and for other valuable help, as well as to our publishers
+for their generosity in the matter of illustrations.
+
+EDINBURGH,
+    _March_ 1921.
+
+
+
+
+CONTENTS
+
+
+                                                                   PAGE
+    CHAPTER I
+    REPAIR                                                            1
+
+    CHAPTER II
+    CONDITIONS WHICH INTERFERE WITH REPAIR                           17
+
+    CHAPTER III
+    INFLAMMATION                                                     31
+
+    CHAPTER IV
+    SUPPURATION                                                      45
+
+    CHAPTER V
+    ULCERATION AND ULCERS                                            68
+
+    CHAPTER VI
+    GANGRENE                                                         86
+
+    CHAPTER VII
+    BACTERIAL AND OTHER WOUND INFECTIONS                            107
+
+    CHAPTER VIII
+    TUBERCULOSIS                                                    133
+
+    CHAPTER IX
+    SYPHILIS                                                        146
+
+    CHAPTER X
+    TUMOURS                                                         181
+
+    CHAPTER XI
+    INJURIES                                                        218
+
+    CHAPTER XII
+    METHODS OF WOUND TREATMENT                                      241
+
+    CHAPTER XIII
+    CONSTITUTIONAL EFFECTS OF INJURIES                              249
+
+    CHAPTER XIV
+    THE BLOOD VESSELS                                               258
+
+    CHAPTER XV
+    THE LYMPH VESSELS AND GLANDS                                    321
+
+    CHAPTER XVI
+    THE NERVES                                                      342
+
+    CHAPTER XVII
+    SKIN AND SUBCUTANEOUS TISSUES                                   376
+
+    CHAPTER XVIII
+    THE MUSCLES, TENDONS, AND TENDON SHEATHS                        405
+
+    CHAPTER XIX
+    THE BURSAE                                                      426
+
+    CHAPTER XX
+    DISEASES OF BONE                                                434
+
+    CHAPTER XXI
+    DISEASES OF JOINTS                                              501
+
+    INDEX                                                           547
+
+
+
+
+LIST OF ILLUSTRATIONS
+
+
+  FIG.                                                             PAGE
+
+    1. Ulcer of Back of Hand grafted from Abdominal Wall             15
+
+    2. Staphylococcus aureus in Pus from case of Osteomyelitis       25
+
+    3. Streptococci in Pus from case of Diffuse Cellulitis           26
+
+    4. Bacillus coli communis in Pus from Abdominal Abscess          27
+
+    5. Fraenkel's Pneumococci in Pus from Empyema following          28
+       Pneumonia
+
+    6. Passive Hyperaemia of Hand and Forearm induced by Bier's      37
+       Bandage
+
+    7. Passive Hyperaemia of Finger induced by Klapp's Suction       38
+       Bell
+
+    8. Passive Hyperaemia induced by Klapp's Suction Bell for        39
+       Inflammation of Inguinal Gland
+
+    9. Diagram of various forms of Whitlow                           56
+
+   10. Charts of Acute Sapraemia                                     61
+
+   11. Chart of Hectic Fever                                         62
+
+   12. Chart of Septicaemia followed by Pyaemia                      63
+
+   13. Chart of Pyaemia following on Acute Osteomyelitis             65
+
+   14. Leg Ulcers associated with Varicose Veins                     71
+
+   15. Perforating Ulcers of Sole of Foot                            74
+
+   16. Bazin's Disease in a girl aet. 16                             75
+
+   17. Syphilitic Ulcers in region of Knee                           76
+
+   18. Callous Ulcer showing thickened edges                         78
+
+   19. Tibia and Fibula, showing changes due to Chronic Ulcer of     80
+       Leg
+
+   20. Senile Gangrene of the Foot                                   89
+
+   21. Embolic Gangrene of Hand and Arm                              92
+
+   22. Gangrene of Terminal Phalanx of Index-Finger                 100
+
+   23. Cancrum Oris                                                 103
+
+   24. Acute Bed Sores over right Buttock                           104
+
+   25. Chart of Erysipelas occurring in a wound                     108
+
+   26. Bacillus of Tetanus                                          113
+
+   27. Bacillus of Anthrax                                          120
+
+   28. Malignant Pustule third day after infection                  122
+
+   29. Malignant Pustule fourteen days after infection              122
+
+   30. Colony of Actinomyces                                        126
+
+   31. Actinomycosis of Maxilla                                     128
+
+   32. Mycetoma, or Madura Foot                                     130
+
+   33. Tubercle bacilli                                             134
+
+   34. Tuberculous Abscess in Lumbar Region                         141
+
+   35. Tuberculous Sinus injected through its opening in the        144
+       Forearm with Bismuth Paste
+
+   36. Spirochaete pallida                                          147
+
+   37. Spirochaeta refrigerans from scraping of Vagina              148
+
+   38. Primary Lesion on Thumb, with Secondary Eruption on          154
+       Forearm
+
+   39. Syphilitic Rupia                                             159
+
+   40. Ulcerating Gumma of Lips                                     169
+
+   41. Ulceration in inherited Syphilis                             170
+
+   42. Tertiary Syphilitic Ulceration in region of Knee and on      171
+       both Thumbs
+
+   43. Facies of Inherited Syphilis                                 174
+
+   44. Facies of Inherited Syphilis                                 175
+
+   45. Subcutaneous Lipoma                                          185
+
+   46. Pedunculated Lipoma of Buttock                               186
+
+   47. Diffuse Lipomatosis of Neck                                  187
+
+   48. Zanthoma of Hands                                            188
+
+   49. Zanthoma of Buttock                                          189
+
+   50. Chondroma growing from Infra-Spinous Fossa of Scapula        190
+
+   51. Chondroma of Metacarpal Bone of Thumb                        190
+
+   52. Cancellous Osteoma of Lower End of Femur                     192
+
+   53. Myeloma of Shaft of Humerus                                  195
+
+   54. Fibro-myoma of Uterus                                        196
+
+   55. Recurrent Sarcoma of Sciatic Nerve                           198
+
+   56. Sarcoma of Arm fungating                                     199
+
+   57. Carcinoma of Breast                                          206
+
+   58. Epithelioma of Lip                                           209
+
+   59. Dermoid Cyst of Ovary                                        213
+
+   60. Carpal Ganglion in a woman aet. 25                           215
+
+   61. Ganglion on lateral aspect of Knee                           216
+
+   62. Radiogram showing pellets embedded in Arm                    228
+
+   63. Cicatricial Contraction following Severe Burn                236
+
+   64. Genealogical Tree of Haemophilic Family                      278
+
+   65. Radiogram showing calcareous degeneration of Arteries        284
+
+   66. Varicose Vein with Thrombosis                                289
+
+   67. Extensive Varix of Internal Saphena System on Left Leg       291
+
+   68. Mixed Naevus of Nose                                         296
+
+   69. Cirsoid Aneurysm of Forehead                                 299
+
+   70. Cirsoid Aneurysm of Orbit and Face                           300
+
+   71. Radiogram of Aneurysm of Aorta                               303
+
+   72. Sacculated Aneurysm of Abdominal Aorta                       304
+
+   73. Radiogram of Innominate Aneurysm after Treatment by          309
+       Moore-Corradi method
+
+   74. Thoracic Aneurysm threatening to rupture                     313
+
+   75. Innominate Aneurysm in a woman                               315
+
+   76. Congenital Cystic Tumour or Hygroma of Axilla                328
+
+   77. Tuberculous Cervical Gland with Abscess formation            331
+
+   78. Mass of Tuberculous Glands removed from Axilla               333
+
+   79. Tuberculous Axillary Glands                                  335
+
+   80. Chronic Hodgkin's Disease in boy aet. 11                     337
+
+   81. Lymphadenoma in a woman aet. 44                              338
+
+   82. Lympho Sarcoma removed from Groin                            339
+
+   83. Cancerous Glands in Neck, secondary to Epithelioma of Lip    341
+
+   84. Stump Neuromas of Sciatic Nerve                              345
+
+   85. Stump Neuromas, showing changes at ends of divided Nerves    354
+
+   86. Diffuse Enlargement of Nerves in generalised                 356
+       Neuro-Fibromatosis
+
+   87. Plexiform Neuroma of small Sciatic Nerve                     357
+
+   88. Multiple Neuro-Fibromas of Skin (Molluscum fibrosum)         358
+
+   89. Elephantiasis Neuromatosa in a woman aet. 28                 359
+
+   90. Drop-Wrist following Fracture of Shaft of Humerus            365
+
+   91. To illustrate the Loss of Sensation produced by Division     367
+       of the Median Nerve
+
+   92. To illustrate Loss of Sensation produced by Complete         368
+       Division of Ulnar Nerve
+
+   93. Callosities and Corns on Sole of Foot                        377
+
+   94. Ulcerated Chilblains on Fingers                              378
+
+   95. Carbuncle on Back of Neck                                    381
+
+   96. Tuberculous Elephantiasis                                    383
+
+   97. Elephantiasis in a woman aet. 45                             387
+
+   98. Elephantiasis of Penis and Scrotum                           388
+
+   99. Multiple Sebaceous Cysts or Wens                             390
+
+  100. Sebaceous Horn growing from Auricle                          392
+
+  101. Paraffin Epithelioma                                         394
+
+  102. Rodent Cancer of Inner Canthus                               395
+
+  103. Rodent Cancer with destruction of contents of Orbit          396
+
+  104. Diffuse Melanotic Cancer of Lymphatics of Skin               398
+
+  105. Melanotic Cancer of Forehead with Metastasis in Lymph        399
+       Glands
+
+  106. Recurrent Keloid                                             401
+
+  107. Subungual Exostosis                                          403
+
+  108. Avulsion of Tendon                                           410
+
+  109. Volkmann's Ischaemic Contracture                             414
+
+  110. Ossification in Tendon of Ilio-psoas Muscle                  417
+
+  111. Radiogram of Calcification and Ossification in Biceps and    418
+       Triceps
+
+  112. Ossification in Muscles of Trunk in generalised Ossifying    419
+       Myositis
+
+  113. Hydrops of Prepatellar Bursa                                 427
+
+  114. Section through Gouty Bursa                                  428
+
+  115. Tuberculous Disease of Sub-Deltoid Bursa                     429
+
+  116. Great Enlargement of the Ischial Bursa                       431
+
+  117. Gouty Disease of Bursae                                      432
+
+  118. Shaft of the Femur after Acute Osteomyelitis                 444
+
+  119. Femur and Tibia showing results of Acute Osteomyelitis       445
+
+  120. Segment of Tibia resected for Brodie's Abscess               449
+
+  121. Radiogram of Brodie's Abscess in Lower End of Tibia          451
+
+  122. Sequestrum of Femur after Amputation                         453
+
+  123. New Periosteal Bone on Surface of Femur from Amputation      454
+       Stump
+
+  124. Tuberculous Osteomyelitis of Os Magnum                       456
+
+  125. Tuberculous Disease of Tibia                                 457
+
+  126. Diffuse Tuberculous Osteomyelitis of Right Tibia             458
+
+  127. Advanced Tuberculous Disease in Region of Ankle              459
+
+  128. Tuberculous Dactylitis                                       460
+
+  129. Shortening of Middle Finger of Adult, the result of          461
+       Tuberculous Dactylitis in Childhood
+
+  130. Syphilitic Disease of Skull                                  463
+
+  131. Syphilitic Hyperostosis and Sclerosis of Tibia               464
+
+  132. Sabre-blade Deformity of Tibia                               467
+
+  133. Skeleton of Rickety Dwarf                                    470
+
+  134. Changes in the Skull resulting from Ostitis Deformans        474
+
+  135. Cadaver, illustrating the alterations in the Lower Limbs     475
+       resulting from Ostitis Deformans
+
+  136. Osteomyelitis Fibrosa affecting Femora                       476
+
+  137. Radiogram of Upper End of Femur in Osteomyelitis Fibrosa     478
+
+  138. Radiogram of Right Knee showing Multiple Exostoses           482
+
+  139. Multiple Exostoses of Limbs                                  483
+
+  140. Multiple Cartilaginous Exostoses                             484
+
+  141. Multiple Cartilaginous Exostoses                             486
+
+  142. Multiple Chondromas of Phalanges and Metacarpals             488
+
+  143. Skiagram of Multiple Chondromas                              489
+
+  144. Multiple Chondromas in Hand                                  490
+
+  145. Radiogram of Myeloma of Humerus                              492
+
+  146. Periosteal Sarcoma of Femur                                  493
+
+  147. Periosteal Sarcoma of Humerus                                493
+
+  148. Chondro-Sarcoma of Scapula                                   494
+
+  149. Central Sarcoma of Femur invading Knee Joint                 495
+
+  150. Osseous Shell of Osteo-Sarcoma of Femur                      495
+
+  151. Radiogram of Osteo-Sarcoma of Femur                          496
+
+  152. Radiogram of Chondro-Sarcoma of Humerus                      497
+
+  153. Epitheliomatus Ulcer of Leg invading Tibia                   499
+
+  154. Osseous Ankylosis of Femur and Tibia                         503
+
+  155. Osseous Ankylosis of Knee                                    504
+
+  156. Caseating focus in Upper End of Fibula                       513
+
+  157. Arthritis Deformans of Elbow                                 525
+
+  158. Arthritis Deformans of Knee                                  526
+
+  159. Hypertrophied Fringes of Synovial Membrane of Knee           527
+
+  160. Arthritis Deformans of Hands                                 529
+
+  161. Arthritis Deformans of several Joints                        530
+
+  162. Bones of Knee in Charcot's Disease                           533
+
+  163. Charcot's Disease of Left Knee                               534
+
+  164. Charcot's Disease of both Ankles: front view                 535
+
+  165. Charcot's Disease of both Ankles: back view                  536
+
+  166. Radiogram of Multiple Loose Bodies in Knee-joint             540
+
+  167. Loose Body from Knee-joint                                   541
+
+  168. Multiple partially ossified Chondromas of Synovial           542
+       Membrane from Shoulder-joint
+
+  169. Multiple Cartilaginous Loose Bodies from Knee-joint          543
+
+
+
+
+MANUAL OF SURGERY
+
+
+
+
+CHAPTER I
+
+REPAIR
+
+
+Introduction--Process of repair--Healing by primary union--Granulation
+    tissue--Cicatricial tissue--Modifications of process of
+    repair--Repair in individual tissues--Transplantation or grafting
+    of tissues--Conditions--Sources of grafts--Grafting of individual
+    tissues--Methods.
+
+
+INTRODUCTION
+
+To prolong human life and to alleviate suffering are the ultimate
+objects of scientific medicine. The two great branches of the healing
+art--Medicine and Surgery--are so intimately related that it is
+impossible to draw a hard-and-fast line between them, but for
+convenience Surgery may be defined as "the art of treating lesions and
+malformations of the human body by manual operations, mediate and
+immediate." To apply his art intelligently and successfully, it is
+essential that the surgeon should be conversant not only with the normal
+anatomy and physiology of the body and with the various pathological
+conditions to which it is liable, but also with the nature of the
+process by which repair of injured or diseased tissues is effected.
+Without this knowledge he is unable to recognise such deviations from
+the normal as result from mal-development, injury, or disease, or
+rationally to direct his efforts towards the correction or removal of
+these.
+
+
+PROCESS OF REPAIR
+
+The process of repair in living tissue depends upon an inherent power
+possessed by vital cells of reacting to the irritation caused by injury
+or disease. The cells of the damaged tissues, under the influence of
+this irritation, undergo certain proliferative changes, which are
+designed to restore the normal structure and configuration of the part.
+The process by which this restoration is effected is essentially the
+same in all tissues, but the extent to which different tissues can carry
+the recuperative process varies. Simple structures, such as skin,
+cartilage, bone, periosteum, and tendon, for example, have a high power
+of regeneration, and in them the reparative process may result in almost
+perfect restitution to the normal. More complex structures, on the other
+hand, such as secreting glands, muscle, and the tissues of the central
+nervous system, are but imperfectly restored, simple cicatricial
+connective tissue taking the place of what has been lost or destroyed.
+Any given tissue can be replaced only by tissue of a similar kind, and
+in a damaged part each element takes its share in the reparative process
+by producing new material which approximates more or less closely to the
+normal according to the recuperative capacity of the particular tissue.
+The normal process of repair may be interfered with by various
+extraneous agencies, the most important of which are infection by
+disease-producing micro-organisms, the presence of foreign substances,
+undue movement of the affected part, and improper applications and
+dressings. The effect of these agencies is to delay repair or to prevent
+the individual tissues carrying the process to the furthest degree of
+which they are capable.
+
+In the management of wounds and other diseased conditions the main
+object of the surgeon is to promote the natural reparative process by
+preventing or eliminating any factor by which it may be disturbed.
+
+#Healing by Primary Union.#--The most favourable conditions for the
+progress of the reparative process are to be found in a clean-cut wound
+of the integument, which is uncomplicated by loss of tissue, by the
+presence of foreign substances, or by infection with disease-producing
+micro-organisms, and its edges are in contact. Such a wound in virtue of
+the absence of infection is said to be _aseptic_, and under these
+conditions healing takes place by what is called "primary union"--the
+"healing by first intention" of the older writers.
+
+#Granulation Tissue.#--The essential and invariable medium of repair in
+all structures is an elementary form of new tissue known as _granulation
+tissue_, which is produced in the damaged area in response to the
+irritation caused by injury or disease. The vital reaction induced by
+such irritation results in dilatation of the vessels of the part,
+emigration of leucocytes, transudation of lymph, and certain
+proliferative changes in the fixed tissue cells. These changes are
+common to the processes of inflammation and repair; no hard-and-fast
+line can be drawn between these processes, and the two may go on
+together. It is, however, only when the proliferative changes have come
+to predominate that the reparative process is effectively established by
+the production of healthy granulation tissue.
+
+_Formation of Granulation Tissue._--When a wound is made in the
+integument under aseptic conditions, the passage of the knife through
+the tissues is immediately followed by an oozing of blood, which soon
+coagulates on the cut surfaces. In each of the divided vessels a clot
+forms, and extends as far as the nearest collateral branch; and on the
+surface of the wound there is a microscopic layer of bruised and
+devitalised tissue. If the wound is closed, the narrow space between its
+edges is occupied by blood-clot, which consists of red and white
+corpuscles mixed with a quantity of fibrin, and this forms a temporary
+uniting medium between the divided surfaces. During the first twelve
+hours, the minute vessels in the vicinity of the wound dilate, and from
+them lymph exudes and leucocytes migrate into the tissues. In from
+twenty-four to thirty-six hours, the capillaries of the part adjacent to
+the wound begin to throw out minute buds and fine processes, which
+bridge the gap and form a firmer, but still temporary, connection
+between the two sides. Each bud begins in the wall of the capillary as a
+small accumulation of granular protoplasm, which gradually elongates
+into a filament containing a nucleus. This filament either joins with a
+neighbouring capillary or with a similar filament, and in time these
+become hollow and are filled with blood from the vessels that gave them
+origin. In this way a series of young _capillary loops_ is formed.
+
+The spaces between these loops are filled by cells of various kinds, the
+most important being the _fibroblasts_, which are destined to form
+cicatricial fibrous tissue. These fibroblasts are large irregular
+nucleated cells derived mainly from the proliferation of the fixed
+connective-tissue cells of the part, and to a less extent from the
+lymphocytes and other mononuclear cells which have migrated from the
+vessels. Among the fibroblasts, larger multi-nucleated cells--_giant
+cells_--are sometimes found, particularly when resistant substances,
+such as silk ligatures or fragments of bone, are embedded in the
+tissues, and their function seems to be to soften such substances
+preliminary to their being removed by the phagocytes. Numerous
+_polymorpho-nuclear leucocytes_, which have wandered from the vessels,
+are also present in the spaces. These act as phagocytes, their function
+being to remove the red corpuscles and fibrin of the original clot, and
+this performed, they either pass back into the circulation in virtue of
+their amoeboid movement, or are themselves eaten up by the growing
+fibroblasts. Beyond this phagocytic action, they do not appear to play
+any direct part in the reparative process. These young capillary loops,
+with their supporting cells and fluids, constitute granulation tissue,
+which is usually fully formed in from three to five days, after which it
+begins to be replaced by cicatricial or scar tissue.
+
+_Formation of Cicatricial Tissue._--The transformation of this temporary
+granulation tissue into scar tissue is effected by the fibroblasts,
+which become elongated and spindle-shaped, and produce in and around
+them a fine fibrillated material which gradually increases in quantity
+till it replaces the cell protoplasm. In this way white fibrous tissue
+is formed, the cells of which are arranged in parallel lines and
+eventually become grouped in bundles, constituting fully formed white
+fibrous tissue. In its growth it gradually obliterates the capillaries,
+until at the end of two, three, or four weeks both vessels and cells
+have almost entirely disappeared, and the original wound is occupied by
+cicatricial tissue. In course of time this tissue becomes consolidated,
+and the cicatrix undergoes a certain amount of contraction--_cicatricial
+contraction_.
+
+_Healing of Epidermis._--While these changes are taking place in the
+deeper parts of the wound, the surface is being covered over by
+_epidermis_ growing in from the margins. Within twelve hours the cells
+of the rete Malpighii close to the cut edge begin to sprout on to the
+surface of the wound, and by their proliferation gradually cover the
+granulations with a thin pink pellicle. As the epithelium increases in
+thickness it assumes a bluish hue and eventually the cells become
+cornified and the epithelium assumes a greyish-white colour.
+
+_Clinical Aspects._--So long as the process of repair is not complicated
+by infection with micro-organisms, there is no interference with the
+general health of the patient. The temperature remains normal; the
+circulatory, gastro-intestinal, nervous, and other functions are
+undisturbed; locally, the part is cool, of natural colour and free from
+pain.
+
+#Modifications of the Process of Repair.#--The process of repair by
+primary union, above described, is to be looked upon as the type of all
+reparative processes, such modifications as are met with depending
+merely upon incidental differences in the conditions present, such as
+loss of tissue, infection by micro-organisms, etc.
+
+_Repair after Loss or Destruction of Tissue._--When the edges of a wound
+cannot be approximated either because tissue has been lost, for example
+in excising a tumour or because a drainage tube or gauze packing has
+been necessary, a greater amount of granulation tissue is required to
+fill the gap, but the process is essentially the same as in the ideal
+method of repair.
+
+The raw surface is first covered by a layer of coagulated blood and
+fibrin. An extensive new formation of capillary loops and fibroblasts
+takes place towards the free surface, and goes on until the gap is
+filled by a fine velvet-like mass of granulation tissue. This
+granulation tissue is gradually replaced by young cicatricial tissue,
+and the surface is covered by the ingrowth of epithelium from the edges.
+
+This modification of the reparative process can be best studied
+clinically in a recent wound which has been packed with gauze. When the
+plug is introduced, the walls of the cavity consist of raw tissue with
+numerous oozing blood vessels. On removing the packing on the fifth or
+sixth day, the surface is found to be covered with minute, red,
+papillary granulations, which are beginning to fill up the cavity. At
+the edges the epithelium has proliferated and is covering over the newly
+formed granulation tissue. As lymph and leucocytes escape from the
+exposed surface there is a certain amount of serous or sero-purulent
+discharge. On examining the wound at intervals of a few days, it is
+found that the granulation tissue gradually increases in amount till the
+gap is completely filled up, and that coincidently the epithelium
+spreads in and covers over its surface. In course of time the epithelium
+thickens, and as the granulation tissue is slowly replaced by young
+cicatricial tissue, which has a peculiar tendency to contract and so to
+obliterate the blood vessels in it, the scar that is left becomes
+smooth, pale, and depressed. This method of healing is sometimes spoken
+of as "healing by granulation"--although, as we have seen, it is by
+granulation that all repair takes place.
+
+_Healing by Union of two Granulating Surfaces._--In gaping wounds union
+is sometimes obtained by bringing the two surfaces into apposition after
+each has become covered with healthy granulations. The exudate on the
+surfaces causes them to adhere, capillary loops pass from one to the
+other, and their final fusion takes place by the further development of
+granulation and cicatricial tissue.
+
+_Reunion of Parts entirely Separated from the Body._--Small portions of
+tissue, such as the end of a finger, the tip of the nose or a portion of
+the external ear, accidentally separated from the body, if accurately
+replaced and fixed in position, occasionally adhere by primary union.
+
+In the course of operations also, portions of skin, fascia, or bone, or
+even a complete joint may be transplanted, and unite by primary union.
+
+_Healing under a Scab._--When a small superficial wound is exposed to
+the air, the blood and serum exuded on its surface may dry and form a
+hard crust or _scab_, which serves to protect the surface from external
+irritation in the same way as would a dry pad of sterilised gauze. Under
+this scab the formation of granulation tissue, its transformation into
+cicatricial tissue, and the growth of epithelium on the surface, go on
+until in the course of time the crust separates, leaving a scar.
+
+_Healing by Blood-clot._--In subcutaneous wounds, for example tenotomy,
+in amputation wounds, and in wounds made in excising tumours or in
+operating upon bones, the space left between the divided tissues becomes
+filled with blood-clot, which acts as a temporary scaffolding in which
+granulation tissue is built up. Capillary loops grow into the coagulum,
+and migrated leucocytes from the adjacent blood vessels destroy the red
+corpuscles, and are in turn disposed of by the developing fibroblasts,
+which by their growth and proliferation fill up the gap with young
+connective tissue. It will be evident that this process only differs
+from healing by primary union in the _amount_ of blood-clot that is
+present.
+
+_Presence of a Foreign Body._--When an aseptic foreign body is present
+in the tissues, _e.g._ a piece of unabsorbable chromicised catgut, the
+healing process may be modified. After primary union has taken place the
+scar may broaden, become raised above the surface, and assume a
+bluish-brown colour; the epidermis gradually thins and gives way,
+revealing the softened portion of catgut, which can be pulled out in
+pieces, after which the wound rapidly heals and resumes a normal
+appearance.
+
+
+REPAIR IN INDIVIDUAL TISSUES
+
+_Skin and Connective Tissue._--The mode of regeneration of these tissues
+under aseptic conditions has already been described as the type of ideal
+repair. In highly vascular parts, such as the face, the reparative
+process goes on with great rapidity, and even extensive wounds may be
+firmly united in from three to five days. Where the anastomosis is less
+free the process is more prolonged. The more highly organised elements
+of the skin, such as the hair follicles, the sweat and sebaceous glands,
+are imperfectly reproduced; hence the scar remains smooth, dry, and
+hairless.
+
+_Epithelium._--Epithelium is only reproduced from pre-existing
+epithelium, and, as a rule, from one of a similar type, although
+metaplastic transformation of cells of one kind of epithelium into
+another kind can take place. Thus a granulating surface may be covered
+entirely by the ingrowing of the cutaneous epithelium from the margins;
+or islets, originating in surviving cells of sebaceous glands or sweat
+glands, or of hair follicles, may spring up in the centre of the raw
+area. Such islets may also be due to the accidental transference of
+loose epithelial cells from the edges. Even the fluid from a blister, in
+virtue of the isolated cells of the rete Malpighii which it contains, is
+capable of starting epithelial growth on a granulating surface. Hairs
+and nails may be completely regenerated if a sufficient amount of the
+hair follicles or of the nail matrix has escaped destruction. The
+epithelium of a mucous membrane is regenerated in the same way as that
+on a cutaneous surface.
+
+Epithelial cells have the power of living for some time after being
+separated from their normal surroundings, and of growing again when once
+more placed in favourable circumstances. On this fact the practice of
+skin grafting is based (p. 11).
+
+_Cartilage._--When an articular cartilage is divided by incision or by
+being implicated in a fracture involving the articular end of a bone, it
+is repaired by ordinary cicatricial fibrous tissue derived from the
+proliferating cells of the perichondrium. Cartilage being a non-vascular
+tissue, the reparative process goes on slowly, and it may be many weeks
+before it is complete.
+
+It is possible for a metaplastic transformation of connective-tissue
+cells into cartilage cells to take place, the characteristic hyaline
+matrix being secreted by the new cells. This is sometimes observed as an
+intermediary stage in the healing of fractures, especially in young
+bones. It may also take place in the regeneration of lost portions of
+cartilage, provided the new tissue is so situated as to constitute part
+of a joint and to be subjected to pressure by an opposing cartilaginous
+surface. This is illustrated by what takes place after excision of
+joints where it is desired to restore the function of the articulation.
+By carrying out movements between the constituent parts, the fibrous
+tissue covering the ends of the bones becomes moulded into shape, its
+cells take on the characters of cartilage cells, and, forming a matrix,
+so develop a new cartilage.
+
+Conversely, it is observed that when articular cartilage is no longer
+subjected to pressure by an opposing cartilage, it tends to be
+transformed into fibrous tissue, as may be seen in deformities attended
+with displacement of articular surfaces, such as hallux valgus and
+club-foot.
+
+After fractures of costal cartilage or of the cartilages of the larynx
+the cicatricial tissue may be ultimately replaced by bone.
+
+_Tendons._--When a tendon is divided, for example by subcutaneous
+tenotomy, the end nearer the muscle fibres is drawn away from the other,
+leaving a gap which is speedily filled by blood-clot. In the course of a
+few days this clot becomes permeated by granulation tissue, the
+fibroblasts of which are derived from the sheath of the tendon, the
+surrounding connective tissue, and probably also from the divided ends
+of the tendon itself. These fibroblasts ultimately develop into typical
+tendon cells, and the fibres which they form constitute the new tendon
+fibres. Under aseptic conditions repair is complete in from two to three
+weeks. In the course of the reparative process the tendon and its sheath
+may become adherent, which leads to impaired movement and stiffness. If
+the ends of an accidentally divided tendon are at once brought into
+accurate apposition and secured by sutures, they unite directly with a
+minimum amount of scar tissue, and function is perfectly restored.
+
+_Muscle._--Unstriped muscle does not seem to be capable of being
+regenerated to any but a moderate degree. If the ends of a divided
+striped muscle are at once brought into apposition by stitches, primary
+union takes place with a minimum of intervening fibrous tissue. The
+nuclei of the muscle fibres in close proximity to this young cicatricial
+tissue proliferate, and a few new muscle fibres may be developed, but
+any gross loss of muscular tissue is replaced by a fibrous cicatrix. It
+would appear that portions of muscle transplanted from animals to fill
+up gaps in human muscle are similarly replaced by fibrous tissue. When a
+muscle is paralysed from loss of its nerve supply and undergoes complete
+degeneration, it is not capable of being regenerated, even should the
+integrity of the nerve be restored, and so its function is permanently
+lost.
+
+_Secretory Glands._--The regeneration of secretory glands is usually
+incomplete, cicatricial tissue taking the place of the glandular
+substance which has been destroyed. In wounds of the liver, for example,
+the gap is filled by fibrous tissue, but towards the periphery of the
+wound the liver cells proliferate and a certain amount of regeneration
+takes place. In the kidney also, repair mainly takes place by
+cicatricial tissue, and although a few collecting tubules may be
+reformed, no regeneration of secreting tissue takes place. After the
+operation of decapsulation of the kidney a new capsule is formed, and
+during the process young blood vessels permeate the superficial parts
+of the kidney and temporarily increase its blood supply, but in the
+consolidation of the new fibrous tissue these vessels are ultimately
+obliterated. This does not prove that the operation is useless, as the
+temporary improvement of the circulation in the kidney may serve to tide
+the patient over a critical period of renal insufficiency.
+
+_Stomach and Intestine._--Provided the peritoneal surfaces are
+accurately apposed, wounds of the stomach and intestine heal with great
+rapidity. Within a few hours the peritoneal surfaces are glued together
+by a thin layer of fibrin and leucocytes, which is speedily organised
+and replaced by fibrous tissue. Fibrous tissue takes the place of the
+muscular elements, which are not regenerated. The mucous lining is
+restored by ingrowth from the margins, and there is evidence that some
+of the secreting glands may be reproduced.
+
+Hollow viscera, like the oesophagus and urinary bladder, in so far
+as they are not covered by peritoneum, heal less rapidly.
+
+_Nerve Tissues._--There is no trustworthy evidence that regeneration of
+the tissues of the brain or spinal cord in man ever takes place. Any
+loss of substance is replaced by cicatricial tissue.
+
+The repair of _Bone_, _Blood Vessels_, and _Peripheral Nerves_ is more
+conveniently considered in the chapters dealing with these structures.
+
+#Rate of Healing.#--While the rate at which wounds heal is remarkably
+constant there are certain factors that influence it in one direction or
+the other. Healing is more rapid when the edges are in contact, when
+there is a minimum amount of blood-clot between them, when the patient
+is in normal health and the vitality of the tissues has not been
+impaired. Wounds heal slightly more quickly in the young than in the
+old, although the difference is so small that it can only be
+demonstrated by the most careful observations.
+
+Certain tissues take longer to heal than others: for example, a fracture
+of one of the larger long bones takes about six weeks to unite, and
+divided nerve trunks take much longer--about a year.
+
+Wounds of certain parts of the body heal more quickly than others: those
+of the scalp, face, and neck, for example, heal more quickly than those
+over the buttock or sacrum, probably because of their greater
+vascularity.
+
+The extent of the wound influences the rate of healing; it is only
+natural that a long and deep wound should take longer to heal than a
+short and superficial one, because there is so much more work to be
+done in the conversion of blood-clot into granulation tissue, and this
+again into scar tissue that will be strong enough to stand the strain on
+the edges of the wound.
+
+
+THE TRANSPLANTATION OR GRAFTING OF TISSUES
+
+Conditions are not infrequently met with in which healing is promoted
+and restoration of function made possible by the transference of a
+portion of tissue from one part of the body to another; the tissue
+transferred is known as the _graft_ or the _transplant_. The simplest
+example of grafting is the transplantation of skin.
+
+In order that the graft may survive and have a favourable chance of
+"taking," as it is called, the transplanted tissue must retain its
+vitality until it has formed an organic connection with the tissue in
+which it is placed, so that it may derive the necessary nourishment from
+its new bed. When these conditions are fulfilled the tissues of the
+graft continue to proliferate, producing new tissue elements to replace
+those that are lost and making it possible for the graft to become
+incorporated with the tissue with which it is in contact.
+
+Dead tissue, on the other hand, can do neither of these things; it is
+only capable of acting as a model, or, at the most, as a scaffolding for
+such mobile tissue elements as may be derived from, the parent tissue
+with which the graft is in contact: a portion of sterilised marine
+sponge, for example, may be observed to become permeated with
+granulation tissue when it is embedded in the tissues.
+
+A successful graft of living tissue is not only capable of regeneration,
+but it acquires a system of lymph and blood vessels, so that in time it
+bleeds when cut into, and is permeated by new nerve fibres spreading in
+from the periphery towards the centre.
+
+It is instructive to associate the period of survival of the different
+tissues of the body after death, with their capacity of being used for
+grafting purposes; the higher tissues such as those of the central
+nervous system and highly specialised glandular tissues like those of
+the kidney lose their vitality quickly after death and are therefore
+useless for grafting; connective tissues, on the other hand, such as
+fat, cartilage, and bone retain their vitality for several hours after
+death, so that when they are transplanted, they readily "take" and do
+all that is required of them: the same is true of the skin and its
+appendages.
+
+_Sources of Grafts._--It is convenient to differentiate between
+_autoplastic_ grafts, that is those derived from the same individual;
+_homoplastic_ grafts, derived from another animal of the same species;
+and _heteroplastic_ grafts, derived from an animal of another species.
+Other conditions being equal, the prospects of success are greatest with
+autoplastic grafts, and these are therefore preferred whenever possible.
+
+There are certain details making for success that merit attention: the
+graft must not be roughly handled or allowed to dry, or be subjected to
+chemical irritation; it must be brought into accurate contact with the
+new soil, no blood-clot intervening between the two, no movement of the
+one upon the other should be possible and all infection must be
+excluded; it will be observed that these are exactly the same conditions
+that permit of the primary healing of wounds, with which of course the
+healing of grafts is exactly comparable.
+
+_Preservation of Tissues for Grafting._--It was at one time believed
+that tissues might be taken from the operating theatre and kept in cold
+storage until they were required. It is now agreed that tissues which
+have been separated from the body for some time inevitably lose their
+vitality, become incapable of regeneration, and are therefore unsuited
+for grafting purposes. If it is intended to preserve a portion of tissue
+for future grafting, it should be embedded in the subcutaneous tissue of
+the abdominal wall until it is wanted; this has been carried out with
+portions of costal cartilage and of bone.
+
+
+INDIVIDUAL TISSUES AS GRAFTS
+
+#The Blood# lends itself in an ideal manner to transplantation, or, as
+it has long been called, _transfusion_. Being always a homoplastic
+transfer, the new blood is not always tolerated by the old, in which
+case biochemical changes occur, resulting in haemolysis, which
+corresponds to the disintegration of other unsuccessful homoplastic
+grafts. (See article on Transfusion, _Op. Surg._, p. 37.)
+
+#The Skin.#--The skin was the first tissue to be used for grafting
+purposes, and it is still employed with greater frequency than any
+other, as lesions causing defects of skin are extremely common and
+without the aid of grafts are tedious in healing.
+
+Skin grafts may be applied to a raw surface or to one that is covered
+with granulations.
+
+_Skin grafting of raw surfaces_ is commonly indicated after operations
+for malignant disease in which considerable areas of skin must be
+sacrificed, and after accidents, such as avulsion of the scalp by
+machinery.
+
+_Skin grafting of granulating surfaces_ is chiefly employed to promote
+healing in the large defects of skin caused by severe burns; the
+grafting is carried out when the surface is covered by a uniform layer
+of healthy granulations and before the inevitable contraction of scar
+tissue makes itself manifest. Before applying the grafts it is usual to
+scrape away the granulations until the young fibrous tissue underneath
+is exposed, but, if the granulations are healthy and can be rendered
+aseptic, the grafts may be placed on them directly.
+
+If it is decided to scrape away the granulations, the oozing must be
+arrested by pressure with a pad of gauze, a sheet of dental rubber or
+green protective is placed next the raw surface to prevent the gauze
+adhering and starting the bleeding afresh when it is removed.
+
+#Methods of Skin-Grafting.#--Two methods are employed: one in which the
+epidermis is mainly or exclusively employed--epidermis or epithelial
+grafting; the other, in which the graft consists of the whole thickness
+of the true skin--cutis-grafting.
+
+_Epidermis or Epithelial Grafting._--The method introduced by the late
+Professor Thiersch of Leipsic is that almost universally practised. It
+consists in transplanting strips of epidermis shaved from the surface of
+the skin, the razor passing through the tips of the papillae, which
+appear as tiny red points yielding a moderate ooze of blood.
+
+The strips are obtained from the front and lateral aspects of the thigh
+or upper arm, the skin in those regions being pliable and comparatively
+free from hairs.
+
+They are cut with a sharp hollow-ground razor or with Thiersch's
+grafting knife, the blade of which is rinsed in alcohol and kept
+moistened with warm saline solution. The cutting is made easier if the
+skin is well stretched and kept flat and perfectly steady, the
+operator's left hand exerting traction on the skin behind, the hands of
+the assistant on the skin in front, one above and the other below the
+seat of operation. To ensure uniform strips being cut, the razor is kept
+parallel with the surface and used with a short, rapid, sawing movement,
+so that, with a little practice, grafts six or eight inches long by one
+or two inches broad can readily be cut. The patient is given a general
+anaesthetic, or regional anaesthesia is obtained by injections of a
+solution of one per cent. novocain into the line of the lateral and
+middle cutaneous nerves; the disinfection of the skin is carried out on
+the usual lines, any chemical agent being finally got rid of, however,
+by means of alcohol followed by saline solution.
+
+The strips of epidermis wrinkle up on the knife and are directly
+transferred to the surface, for which they should be made to form a
+complete carpet, slightly overlapping the edges of the area and of one
+another; some blunt instrument is used to straighten out the strips,
+which are then subjected to firm pressure with a pad of gauze to express
+blood and air-bells and to ensure accurate contact, for this must be as
+close as that between a postage stamp and the paper to which it is
+affixed.
+
+As a dressing for the grafted area and of that also from which the
+grafts have been taken, gauze soaked in _liquid paraffin_--the patent
+variety known as _ambrine_ is excellent--appears to be the best; the
+gauze should be moistened every other day or so with fresh paraffin, so
+that, at the end of a week, when the grafts should have united, the
+gauze can be removed without risk of detaching them. _Dental wax_ is
+another useful type of dressing; as is also _picric acid_ solution. Over
+the gauze, there is applied a thick layer of cotton wool, and the whole
+dressing is kept in place by a firmly applied bandage, and in the case
+of the limbs some form of splint should be added to prevent movement.
+
+A dressing may be dispensed with altogether, the grafts being protected
+by a wire cage such as is used after vaccination, but they tend to dry
+up and come to resemble a scab.
+
+When the grafts have healed, it is well to protect them from injury and
+to prevent them drying up and cracking by the liberal application of
+lanoline or vaseline.
+
+The new skin is at first insensitive and is fixed to the underlying
+connective tissue or bone, but in course of time (from six weeks
+onwards) sensation returns and the formation of elastic tissue beneath
+renders the skin pliant and movable so that it can be pinched up between
+the finger and thumb.
+
+_Reverdin's_ method consists in planting out pieces of skin not bigger
+than a pin-head over a granulating surface. It is seldom employed.
+
+_Grafts of the Cutis Vera._--Grafts consisting of the entire thickness
+of the true skin were specially advocated by Wolff and are often
+associated with his name. They should be cut oval or spindle-shaped, to
+facilitate the approximation of the edges of the resulting wound. The
+graft should be cut to the exact size of the surface it is to cover;
+Gillies believes that tension of the graft favours its taking. These
+grafts may be placed either on a fresh raw surface or on healthy
+granulations. It is sometimes an advantage to stitch them in position,
+especially on the face. The dressing and the after-treatment are the
+same as in epidermis grafting.
+
+There is a degree of uncertainty about the graft retaining its vitality
+long enough to permit of its deriving the necessary nourishment from its
+new surroundings; in a certain number of cases the flap dies and is
+thrown off as a slough--moist or dry according to the presence or
+absence of septic infection.
+
+The technique for cutis-grafting must be without a flaw, and the asepsis
+absolute; there must not only be a complete absence of movement, but
+there must be no traction on the flap that will endanger its blood
+supply.
+
+Owing to the uncertainty in the results of cutis-grafting the
+_two-stage_ or _indirect method_ has been introduced, and its almost
+uniform success has led to its sphere of application being widely
+extended. The flap is raised as in the direct method but is left
+attached at one of its margins for a period ranging from 14 to 21 days
+until its blood supply from its new bed is assured; the detachment is
+then made complete. The blood supply of the proposed flap may influence
+its selection and the way in which it is fashioned; for example, a flap
+cut from the side of the head to fill a defect in the cheek, having in
+its margin of attachment or pedicle the superficial temporal artery, is
+more likely to take than a flap cut with its base above.
+
+Another modification is to raise the flap but leave it connected at both
+ends like the piers of a bridge; this method is well suited to defects
+of skin on the dorsum of the fingers, hand and forearm, the bridge of
+skin is raised from the abdominal wall and the hand is passed beneath it
+and securely fixed in position; after an interval of 14 to 21 days, when
+the flap is assured of its blood supply, the piers of the bridge are
+divided (Fig. 1). With undermining it is usually easy to bring the
+edges of the gap in the abdominal wall together, even in children; the
+skin flap on the dorsum of the hand appears rather thick and
+prominent--almost like the pad of a boxing-glove--for some time, but
+the restoration of function in the capacity to flex the fingers is
+gratifying in the extreme.
+
+[Illustration: FIG. 1.--Ulcer of back of Hand covered by flap of skin
+raised from anterior abdominal wall. The lateral edges of the flap are
+divided after the graft has adhered.]
+
+The indirect element of this method of skin-grafting may be carried
+still further by transferring the flap of skin first to one part of the
+body and then, after it has taken, transferring it to a third part.
+Gillies has especially developed this method in the remedying of
+deformities of the face caused by gunshot wounds and by petrol burns in
+air-men. A rectangular flap of skin is marked out in the neck and chest,
+the lateral margins of the flap are raised sufficiently to enable them
+to be brought together so as to form a tube of skin: after the
+circulation has been restored, the lower end of the tube is detached and
+is brought up to the lip or cheek, or eyelid, where it is wanted; when
+this end has derived its new blood supply, the other end is detached
+from the neck and brought up to where it is wanted. In this way, skin
+from the chest may be brought up to form a new forehead and eyelids.
+
+Grafts of _mucous membrane_ are used to cover defects in the lip, cheek,
+and conjunctiva. The technique is similar to that employed in
+skin-grafting; the sources of mucous membrane are limited and the
+element of septic infection cannot always be excluded.
+
+_Fat._--Adipose tissue has a low vitality, but it is easily retained and
+it readily lends itself to transplantation. Portions of fat are often
+obtainable at operations--from the omentum, for example, otherwise the
+subcutaneous fat of the buttock is the most accessible; it may be
+employed to fill up cavities of all kinds in order to obtain more rapid
+and sounder healing and also to remedy deformity, as in filling up a
+depression in the cheek or forehead. It is ultimately converted into
+ordinary connective tissue _pari passu_ with the absorption of the fat.
+
+The _fascia lata of the thigh_ is widely and successfully used as a
+graft to fill defects in the dura mater, and interposed between the
+bones of a joint--if the articular cartilage has been destroyed--to
+prevent the occurrence of ankylosis.
+
+The _peritoneum_ of hydrocele and hernial sacs and of the omentum
+readily lends itself to transplantation.
+
+_Cartilage and bone_, next to skin, are the tissues most frequently
+employed for grafting purposes; their sphere of action is so extensive
+and includes so much of technical detail in their employment, that they
+will be considered later with the surgery of the bones and joints and
+with the methods of re-forming the nose.
+
+_Tendons and blood vessels_ readily lend themselves to transplantation
+and will also be referred to later.
+
+_Muscle and nerve_, on the other hand, do not retain their vitality when
+severed from their surroundings and do not functionate as grafts except
+for their connective-tissue elements, which it goes without saying are
+more readily obtainable from other sources.
+
+Portions of the _ovary_ and of the _thyreoid_ have been successfully
+transplanted into the subcutaneous cellular tissue of the abdominal wall
+by Tuffier and others. In these new surroundings, the ovary or thyreoid
+is vascularised and has been shown to functionate, but there is not
+sufficient regeneration of the essential tissue elements to "carry on";
+the secreting tissue is gradually replaced by connective tissue and the
+special function comes to an end. Even such temporary function may,
+however, tide a patient over a difficult period.
+
+
+
+
+CHAPTER II
+
+CONDITIONS WHICH INTERFERE WITH REPAIR
+
+
+SURGICAL BACTERIOLOGY
+
+Want of rest--Irritation--Unhealthy tissues--Pathogenic bacteria.
+    SURGICAL BACTERIOLOGY--General characters of
+    bacteria--Classification of bacteria--Conditions of bacterial
+    life--Pathogenic powers of bacteria--Results of bacterial
+    growth--Death of bacteria--Immunity--Antitoxic sera--Identification
+    of bacteria--Pyogenic bacteria.
+
+In the management of wounds and other surgical conditions it is
+necessary to eliminate various extraneous influences which tend to delay
+or arrest the natural process of repair.
+
+Of these, one of the most important is undue movement of the affected
+part. "The first and great requisite for the restoration of injured
+parts is _rest_," said John Hunter; and physiological and mechanical
+rest as the chief of natural therapeutic agents was the theme of John
+Hilton's classical work--_Rest and Pain_. In this connection it must be
+understood that "rest" implies more than the mere state of physical
+repose: all physiological as well as mechanical function must be
+prevented as far as is possible. For instance, the constituent bones of
+a joint affected with tuberculosis must be controlled by splints or
+other appliances so that no movement can take place between them, and
+the limb may not be used for any purpose; physiological rest may be
+secured to an inflamed colon by making an artificial anus in the caecum;
+the activity of a diseased kidney may be diminished by regulating the
+quantity and quality of the fluids taken by the patient.
+
+Another source of interference with repair in wounds is _irritation_,
+either by mechanical agents such as rough, unsuitable dressings,
+bandages, or ill-fitting splints; or by chemical agents in the form of
+strong lotions or other applications.
+
+An _unhealthy or devitalised condition of the patient's tissues_ also
+hinders the reparative process. Bruised or lacerated skin heals less
+kindly than skin cut with a smooth, sharp instrument; and persistent
+venous congestion of a part, such as occurs, for example, in the leg
+when the veins are varicose, by preventing the access of healthy blood,
+tends to delay the healing of open wounds. The existence of grave
+constitutional disease, such as Bright's disease, diabetes, syphilis,
+scurvy, or alcoholism, also impedes healing.
+
+Infection by disease-producing micro-organisms or _pathogenic bacteria_
+is, however, the most potent factor in disturbing the natural process of
+repair in wounds.
+
+
+SURGICAL BACTERIOLOGY
+
+The influence of micro-organisms in the causation of disease, and the
+role played by them in interfering with the natural process of repair,
+are so important that the science of applied bacteriology has now come
+to dominate every department of surgery, and it is from the standpoint
+of bacteriology that nearly all surgical questions have to be
+considered.
+
+The term _sepsis_ as now used in clinical surgery no longer retains its
+original meaning as synonymous with "putrefaction," but is employed to
+denote all conditions in which bacterial infection has taken place, and
+more particularly those in which pyogenic bacteria are present. In the
+same way the term _aseptic_ conveys the idea of freedom from all forms
+of bacteria, putrefactive or otherwise; and the term _antiseptic_ is
+used to denote a power of counteracting bacteria and their products.
+
+#General Characters of Bacteria.#--A _bacterium_ consists of a finely
+granular mass of protoplasm, enclosed in a thin gelatinous envelope.
+Many forms are motile--some in virtue of fine thread-like flagella, and
+others through contractility of the protoplasm. The great majority
+multiply by simple fission, each parent cell giving rise to two daughter
+cells, and this process goes on with extraordinary rapidity. Other
+varieties, particularly bacilli, are propagated by the formation of
+_spores_. A spore is a minute mass of protoplasm surrounded by a dense,
+tough membrane, developed in the interior of the parent cell. Spores are
+remarkable for their tenacity of life, and for the resistance they offer
+to the action of heat and chemical germicides.
+
+Bacteria are most conveniently classified according to their shape. Thus
+we recognise (1) those that are globular--_cocci_; (2) those that
+resemble a rod--_bacilli_; (3) the spiral or wavy forms--_spirilla_.
+
+_Cocci_ or _micrococci_ are minute round bodies, averaging about 1 [micron]
+in diameter. The great majority are non-motile. They multiply by fission;
+and when they divide in such a way that the resulting cells remain in
+pairs, are called _diplococci_, of which the bacteria of gonorrhoea and
+pneumonia are examples (Fig. 5). When they divide irregularly, and form
+grape-like bunches, they are known as _staphylococci_, and to this
+variety the commonest pyogenic or pus-forming organisms belong (Fig. 2).
+When division takes place only in one axis, so that long chains are
+formed, the term _streptococcus_ is applied (Fig. 3). Streptococci are
+met with in erysipelas and various other inflammatory and suppurative
+processes of a spreading character.
+
+_Bacilli_ are rod-shaped bacteria, usually at least twice as long as
+they are broad (Fig. 4). Some multiply by fission, others by
+sporulation. Some forms are motile, others are non-motile. Tuberculosis,
+tetanus, anthrax, and many other surgical diseases are due to different
+forms of bacilli.
+
+_Spirilla_ are long, slender, thread-like cells, more or less spiral or
+wavy. Some move by a screw-like contraction of the protoplasm, some by
+flagellae. The spirochaete associated with syphilis (Fig. 36) is the most
+important member of this group.
+
+#Conditions of Bacterial Life.#--Bacteria require for their growth and
+development a suitable food-supply in the form of proteins,
+carbohydrates, and salts of calcium and potassium which they break up
+into simpler elements. An alkaline medium favours bacterial growth; and
+moisture is a necessary condition; spores, however, can survive the want
+of water for much longer periods than fully developed bacteria. The
+necessity for oxygen varies in different species. Those that require
+oxygen are known as _aerobic bacilli_ or _aerobes_; those that cannot
+live in the presence of oxygen are spoken of as _anaerobes_. The great
+majority of bacteria, however, while they prefer to have oxygen, are
+able to live without it, and are called _facultative anaerobes_.
+
+The most suitable temperature for bacterial life is from 95 to 102 F.,
+roughly that of the human body. Extreme or prolonged cold paralyses but
+does not kill micro-organisms. Few, however, survive being raised to a
+temperature of 134.5 F. Boiling for ten to twenty minutes will kill all
+bacteria, and the great majority of spores. Steam applied in an
+autoclave under a pressure of two atmospheres destroys even the most
+resistant spores in a few minutes. Direct sunlight, electric light, or
+even diffuse daylight, is inimical to the growth of bacteria, as are
+also Rontgen rays and radium emanations.
+
+#Pathogenic Properties of Bacteria.#--We are now only concerned with
+pathogenic bacteria--that is, bacteria capable of producing disease in
+the human subject. This capacity depends upon two sets of factors--(1)
+certain features peculiar to the invading bacteria, and (2) others
+peculiar to the host. Many bacteria have only the power of living upon
+dead matter, and are known as _saphrophytes_. Such as do nourish in
+living tissue are, by distinction, known as _parasites_. The power a
+given parasitic micro-organism has of multiplying in the body and giving
+rise to disease is spoken of as its _virulence_, and this varies not
+only with different species, but in the same species at different times
+and under varying circumstances. The actual number of organisms
+introduced is also an important factor in determining their pathogenic
+power. Healthy tissues can resist the invasion of a certain number of
+bacteria of a given species, but when that number is exceeded, the
+organisms get the upper hand and disease results. When the organisms
+gain access directly to the blood-stream, as a rule they produce their
+effects more certainly and with greater intensity than when they are
+introduced into the tissues.
+
+Further, the virulence of an organism is modified by the condition of
+the patient into whose tissues it is introduced. So long as a person is
+in good health, the tissues are able to resist the attacks of moderate
+numbers of most bacteria. Any lowering of the vitality of the
+individual, however, either locally or generally, at once renders him
+more susceptible to infection. Thus bruised or torn tissue is much more
+liable to infection with pus-producing organisms than tissues clean-cut
+with a knife; also, after certain diseases, the liability to infection
+by the organisms of diphtheria, pneumonia, or erysipelas is much
+increased. Even such slight depression of vitality as results from
+bodily fatigue, or exposure to cold and damp, may be sufficient to turn
+the scale in the battle between the tissues and the bacteria. Age is an
+important factor in regard to the action of certain bacteria. Young
+subjects are attacked by diphtheria, tuberculosis, acute osteomyelitis,
+and some other diseases with greater frequency and severity than those
+of more advanced years.
+
+In different races, localities, environment, and seasons, the pathogenic
+powers of certain organisms, such as those of erysipelas, diphtheria,
+and acute osteomyelitis, vary considerably.
+
+There is evidence that a _mixed infection_--that is, the introduction of
+more than one species of organism, for example, the tubercle bacillus
+and a pyogenic staphylococcus--increases the severity of the resulting
+disease. If one of the varieties gain the ascendancy, the poisons
+produced by the others so devitalise the tissue cells, and diminish
+their power of resistance, that the virulence of the most active
+organisms is increased. On the other hand, there is reason to believe
+that the products of certain organisms antagonise one another--for
+example, an attack of erysipelas may effect the cure of a patch of
+tuberculous lupus.
+
+Lastly, in patients suffering from chronic wasting diseases, bacteria
+may invade the internal organs by the blood-stream in enormous numbers
+and with great rapidity, during the period of extreme debility which
+shortly precedes death. The discovery of such collections of organisms
+on post-mortem examination may lead to erroneous conclusions being drawn
+as to the cause of death.
+
+#Results of Bacterial Growth.#--Some organisms, such as those of tetanus
+and erysipelas, and certain of the pyogenic bacteria, show little
+tendency to pass far beyond the point at which they gain an entrance to
+the body. Others, on the contrary--for example, the tubercle bacillus
+and the organism of acute osteomyelitis--although frequently remaining
+localised at the seat of inoculation, tend to pass to distant parts,
+lodging in the capillaries of joints, bones, kidney, or lungs, and there
+producing their deleterious effects.
+
+In the human subject, multiplication in the blood-stream does not occur
+to any great extent. In some general acute pyogenic infections, such as
+osteomyelitis, cellulitis, etc., pure cultures of staphylococci or of
+streptococci may be obtained from the blood. In pneumococcal and typhoid
+infections, also, the organisms may be found in the blood.
+
+It is by the vital changes they bring about in the parts where they
+settle that micro-organisms disturb the health of the patient. In
+deriving nourishment from the complex organic compounds in which they
+nourish, the organisms evolve, probably by means of a ferment, certain
+chemical products of unknown composition, but probably colloidal in
+nature, and known as _toxins_. When these poisons are absorbed into the
+general circulation they give rise to certain groups of symptoms--such
+as rise of temperature, associated circulatory and respiratory
+derangements, interference with the gastro-intestinal functions and also
+with those of the nervous system--which go to make up the condition
+known as blood-poisoning, toxaemia, or _bacterial intoxication_. In
+addition to this, certain bacteria produce toxins that give rise to
+definite and distinct groups of symptoms--such as the convulsions of
+tetanus, or the paralyses that follow diphtheria.
+
+_Death of Bacteria._--Under certain circumstances, it would appear that
+the accumulation of the toxic products of bacterial action tends to
+interfere with the continued life and growth of the organisms
+themselves, and in this way the natural cure of certain diseases is
+brought about. Outside the body, bacteria may be killed by starvation,
+by want of moisture, by being subjected to high temperature, or by the
+action of certain chemical agents of which carbolic acid, the
+perchloride and biniodide of mercury, and various chlorine preparations
+are the most powerful.
+
+#Immunity.#--Some persons are insusceptible to infection by certain
+diseases, from which they are said to enjoy a _natural immunity_. In
+many acute diseases one attack protects the patient, for a time at
+least, from a second attack--_acquired immunity_.
+
+_Phagocytosis._--In the production of immunity the leucocytes and
+certain other cells play an important part in virtue of the power they
+possess of ingesting bacteria and of destroying them by a process of
+intra-cellular digestion. To this process Metchnikoff gave the name of
+_phagocytosis_, and he recognised two forms of _phagocytes_: (1) the
+_microphages_, which are the polymorpho-nuclear leucocytes of the blood;
+and (2) the _macrophages_, which include the larger hyaline leucocytes,
+endothelial cells, and connective-tissue corpuscles.
+
+During the process of phagocytosis, the polymorpho-nuclear leucocytes in
+the circulating blood increase greatly in numbers (_leucocytosis_), as
+well as in their phagocytic action, and in the course of destroying the
+bacteria they produce certain ferments which enter the blood serum.
+These are known as _opsonins_ or _alexins_, and they act on the bacteria
+by a process comparable to narcotisation, and render them an easy prey
+for the phagocytes.
+
+_Artificial or Passive Immunity._--A form of immunity can be induced by
+the introduction of protective substances obtained from an animal which
+has been actively immunised. The process by which passive immunity is
+acquired depends upon the fact that as a result of the reaction between
+the specific virus of a particular disease (the _antigen_) and the
+tissues of the animal attacked, certain substances--_antibodies_--are
+produced, which when transferred to the body of a susceptible animal
+protect it against that disease. The most important of these antibodies
+are the _antitoxins_. From the study of the processes by which immunity
+is secured against the effects of bacterial action the serum and vaccine
+methods of treating certain infective diseases have been evolved. The
+_serum treatment_ is designed to furnish the patient with a sufficiency
+of antibodies to neutralise the infection. The anti-diphtheritic and the
+anti-tetanic act by neutralising the specific toxins of the
+disease--_antitoxic serums_; the anti-streptcoccic and the serum for
+anthrax act upon the bacteria--_anti-bacterial serums_.
+
+A _polyvalent_ serum, that is, one derived from an animal which has been
+immunised by numerous strains of the organism derived from various
+sources, is much more efficacious than when a single strain has been
+used.
+
+_Clinical Use of Serums._--Every precaution must be taken to prevent
+organismal contamination of the serum or of the apparatus by means of
+which it is injected. Syringes are so made that they can be sterilised
+by boiling. The best situations for injection are under the skin of the
+abdomen, the thorax, or the buttock, and the skin should be purified at
+the seat of puncture. If the bulk of the full dose is large, it should
+be divided and injected into different parts of the body, not more than
+20 c.c. being injected at one place. The serum may be introduced
+directly into a vein, or into the spinal canal, _e.g._ anti-tetanic
+serum. The immunity produced by injections of antitoxic sera lasts only
+for a comparatively short time, seldom longer than a few weeks.
+
+_"Serum Disease" and Anaphylaxis._--It is to be borne in mind that some
+patients exhibit a supersensitiveness with regard to protective sera, an
+injection being followed in a few days by the appearance of an
+urticarial or erythematous rash, pain and swelling of the joints, and a
+variable degree of fever. These symptoms, to which the name _serum
+disease_ is applied, usually disappear in the course of a few days.
+
+The term _anaphylaxis_ is applied to an allied condition of
+supersensitiveness which appears to be induced by the injection of
+certain substances, including toxins and sera, that are capable of
+acting as antigens. When a second injection is given after an interval
+of some days, if anaphylaxis has been established by the first dose, the
+patient suddenly manifests toxic symptoms of the nature of profound
+shock which may even prove fatal. The conditions which render a person
+liable to develop anaphylaxis and the mechanism by which it is
+established are as yet imperfectly understood.
+
+_Vaccine Treatment._--The vaccine treatment elaborated by A. E. Wright
+consists in injecting, while the disease is still active, specially
+prepared dead cultures of the causative organisms, and is based on the
+fact that these "vaccines" render the bacteria in the tissues less able
+to resist the attacks of the phagocytes. The method is most successful
+when the vaccine is prepared from organisms isolated from the patient
+himself, _autogenous vaccine_, but when this is impracticable, or takes
+a considerable time, laboratory-prepared polyvalent _stock vaccines_ may
+be used.
+
+_Clinical Use of Vaccines._--Vaccines should not be given while a
+patient is in a negative phase, as a certain amount of the opsonin in
+the blood is used up in neutralising the substances injected, and this
+may reduce the opsonic index to such an extent that the vaccines
+themselves become dangerous. As a rule, the propriety of using a vaccine
+can be determined from the general condition of the patient. The initial
+dose should always be a small one, particularly if the disease is acute,
+and the subsequent dosage will be regulated by the effect produced. If
+marked constitutional disturbance with rise of temperature follows the
+use of a vaccine, it indicates a negative phase, and calls for a
+diminution in the next dose. If, on the other hand, the local as well as
+the general condition of the patient improves after the injection, it
+indicates a positive phase, and the original dose may be repeated or
+even increased. Vaccines are best introduced subcutaneously, a part
+being selected which is not liable to pressure, as there is sometimes
+considerable local reaction. Repeated doses may be necessary at
+intervals of a few days.
+
+The vaccine treatment has been successfully employed in various
+tuberculous lesions, in pyogenic infections such as acne, boils,
+sycosis, streptococcal, pneumococcal, and gonococcal conditions, in
+infections of the accessory air sinuses, and in other diseases caused by
+bacteria.
+
+
+PYOGENIC BACTERIA
+
+From the point of view of the surgeon the most important varieties of
+micro-organisms are those that cause inflammation and suppuration--the
+_pyogenic bacteria_. This group includes a great many species, and these
+are so widely distributed that they are to be met with under all
+conditions of everyday life.
+
+The nature of the inflammatory and suppurative processes will be
+considered in detail later; suffice it here to say that they are brought
+about by the action of one or other of the organisms that we have now to
+consider.
+
+It is found that the _staphylococci_, which cluster into groups, tend to
+produce localised lesions; while the chain-forms--_streptococci_--give
+rise to diffuse, spreading conditions. Many varieties of pyogenic
+bacteria have now been differentiated, the best known being the
+staphylococcus aureus, the streptococcus, and the bacillus coli
+communis.
+
+[Illustration: FIG. 2.--Staphylococcus aureus in Pus from case of
+Osteomyelitis. x 1000 diam. Gram's stain.]
+
+_Staphylococcus Aureus._--This is the commonest organism found in
+localised inflammatory and suppurative conditions. It varies greatly in
+its virulence, and is found in such widely different conditions as skin
+pustules, boils, carbuncles, and some acute inflammations of bone. As
+seen by the microscope it occurs in grape-like clusters, fission of the
+individual cells taking place irregularly (Fig. 2). When grown in
+artificial media, the colonies assume an orange-yellow colour--hence the
+name _aureus_. It is of high vitality and resists more prolonged
+exposure to high temperatures than most non-sporing bacteria. It is
+capable of lying latent in the tissues for long periods, for example, in
+the marrow of long bones, and of again becoming active and causing a
+fresh outbreak of suppuration. This organism is widely distributed: it
+is found on the skin, in the mouth, and in other situations in the body,
+and as it is present in the dust of the air and on all objects upon
+which dust has settled, it is a continual source of infection unless
+means are taken to exclude it from wounds.
+
+The _staphylococcus albus_ is much less common than the aureus, but has
+the same properties and characters, save that its growth on artificial
+media assumes a white colour. It is the common cause of stitch
+abscesses, the skin being its normal habitat.
+
+[Illustration: FIG. 3.--Streptococci in Pus from an acute abscess in
+subcutaneous tissue. x 1000 diam. Gram's stain.]
+
+_Streptococcus Pyogenes._--This organism also varies greatly in its
+virulence; in some instances--for example in erysipelas--it causes a
+sharp attack of acute spreading inflammation, which soon subsides
+without showing any tendency to end in suppuration; under other
+conditions it gives rise to a generalised infection which rapidly proves
+fatal. The streptococcus has less capacity of liquefying the tissues
+than the staphylococcus, so that pus formation takes place more slowly.
+At the same time its products are very potent in destroying the tissues
+in their vicinity, and so interfering with the exudation of leucocytes
+which would otherwise exercise their protective influence. Streptococci
+invade the lymph spaces, and are associated with acute spreading
+conditions such as phlegmonous or erysipelatous inflammations and
+suppurations, lymphangitis and suppuration in lymph glands, and
+inflammation of serous and synovial membranes, also with a form of
+pneumonia which is prone to follow on severe operations in the mouth and
+throat. Streptococci are also concerned in the production of spreading
+gangrene and pyaemia.
+
+Division takes place in one axis, so that chains of varying length are
+formed (Fig. 3). It is less easily cultivated by artificial media than
+the staphylococcus; it forms a whitish growth.
+
+[Illustration: FIG. 4.--Bacillus coli communis in Urine, from a case of
+Cystitis. x 1000 diam. Leishman's stain.]
+
+_Bacillus Coli Communis._--This organism, which is a normal inhabitant
+of the intestinal tract, shows a great tendency to invade any organ or
+tissue whose vitality is lowered. It is causatively associated with such
+conditions as peritonitis and peritoneal suppuration resulting from
+strangulated hernia, appendicitis, or perforation in any part of the
+alimentary canal. In cystitis, pyelitis, abscess of the kidney,
+suppuration in the bile-ducts or liver, and in many other abdominal
+conditions, it plays a most important part. The discharge from wounds
+infected by this organism has usually a foetid, or even a faecal odour,
+and often contains gases resulting from putrefaction.
+
+It is a small rod-shaped organism with short flagellae, which render it
+motile (Fig. 4). It closely resembles the typhoid bacillus, but is
+distinguished from it by its behaviour in artificial culture media.
+
+[Illustration: FIG. 5.--Fraenkel's Pneumococci in Pus from Empyema
+following Pneumonia. x 100 diam. Stained with Muir's capsule stain.]
+
+_Pneumo-bacteria._--Two forms of organism associated with
+pneumonia--_Fraenkel's pneumococcus_ (one of the diplococci) (Fig. 5)
+and _Friedlander's pneumo-bacillus_ (a short rod-shaped form)--are
+frequently met with in inflammations of the serous and synovial
+membranes, in suppuration in the liver, and in various other
+inflammatory and suppurative conditions.
+
+_Bacillus Typhosus._--This organism has been found in pure culture in
+suppurative conditions of bone, of cellular tissue, and of internal
+organs, especially during convalescence from typhoid fever. Like the
+staphylococcus, it is capable of lying latent in the tissues for long
+periods.
+
+_Other Pyogenic Bacteria._--It is not necessary to do more than name
+some of the other organisms that are known to be pyogenic, such as the
+bacillus pyocyaneus, which is found in green and blue pus, the
+micrococcus tetragenus, the gonococcus, actinomyces, the glanders
+bacillus, and the tubercle bacillus. Most of these will receive further
+mention in connection with the diseases to which they give rise.
+
+#Leucocytosis.#--Most bacterial diseases, as well as certain other
+pathological conditions, are associated with an increase in the number
+of leucocytes in the blood throughout the circulatory system. This
+condition of the blood, which is known as _leucocytosis_, is believed to
+be due to an excessive output and rapid formation of leucocytes by the
+bone marrow, and it probably has as its object the arrest and
+destruction of the invading organisms or toxins. To increase the
+resisting power of the system to pathogenic organisms, an artificial
+leucocytosis may be induced by subcutaneous injection of a solution of
+nucleinate of soda (16 minims of a 5 per cent. solution).
+
+The _normal_ number of leucocytes per cubic millimetre varies in
+different individuals, and in the same individual under different
+conditions, from 5000 to 10,000: 7500 is a normal average, and anything
+above 12,000 is considered abnormal. When leucocytosis is present, the
+number may range from 12,000 to 30,000 or even higher; 40,000 is looked
+upon as a high degree of leucocytosis. According to Ehrlich, the
+following may be taken as the standard proportion of the various forms
+of leucocytes in normal blood: polynuclear neutrophile leucocytes, 70 to
+72 per cent.; lymphocytes, 22 to 25 per cent.; eosinophile cells, 2 to 4
+per cent.; large mononuclear and transitional leucocytes, 2 to 4 per
+cent.; mast-cells, 0.5 to 2 per cent.
+
+In estimating the clinical importance of a leucocytosis, it is not
+sufficient merely to count the aggregate number of leucocytes present. A
+differential count must be made to determine which variety of cells is
+in excess. In the majority of surgical affections it is chiefly the
+granular polymorpho-nuclear neutrophile leucocytes that are in excess
+(_ordinary leucocytosis_). In some cases, and particularly in parasitic
+diseases such as trichiniasis and hydatid disease, the eosinophile
+leucocytes also show a proportionate increase (_eosinophilia_). The term
+_lymphocytosis_ is applied when there is an increase in the number of
+circulating lymphocytes, as occurs, for example, in lymphatic leucaemia,
+and in certain cases of syphilis.
+
+Leucocytosis is met with in nearly all acute infective diseases, and in
+acute pyogenic inflammatory affections, particularly in those attended
+with suppuration. In exceptionally acute septic conditions the extreme
+virulence of the toxins may prevent the leucocytes reacting, and
+leucocytosis may be absent. The absence of leucocytosis in a disease in
+which it is usually present is therefore to be looked upon as a grave
+omen, particularly when the general symptoms are severe. In some cases
+of malignant disease the number of leucocytes is increased to 15,000 or
+20,000. A few hours after a severe haemorrhage also there is usually a
+leucocytosis of from 15,000 to 30,000, which lasts for three or four
+days (Lyon). In cases of haemorrhage the leucocytosis is increased by
+infusion of fluids into the circulation. After all operations there is
+at least a transient leucocytosis (_post-operative leucocytosis_)
+(F. I. Dawson).
+
+The leucocytosis begins soon after the infection manifests itself--for
+example, by shivering, rigor, or rise of temperature. The number of
+leucocytes rises somewhat rapidly, increases while the condition is
+progressing, and remains high during the febrile period, but there is no
+constant correspondence between the number of leucocytes and the height
+of the temperature. The arrest of the inflammation and its resolution
+are accompanied by a fall in the number of leucocytes, while the
+occurrence of suppuration is attended with a further increase in their
+number.
+
+In interpreting the "blood count," it is to be kept in mind that a
+_physiological leucocytosis_ occurs within three or four hours of taking
+a meal, especially one rich in proteins, from 1500 to 2000 being added
+to the normal number. In this _digestion leucocytosis_ the increase is
+chiefly in the polynuclear neutrophile leucocytes. Immediately before
+and after delivery, particularly in primiparae, there is usually a
+moderate degree of leucocytosis. If the labour is normal and the
+puerperium uncomplicated, the number of leucocytes regains the normal in
+about a week. Lactation has no appreciable effect on the number of
+leucocytes. In new-born infants the leucocyte count is abnormally high,
+ranging from 15,000 to 20,000. In children under one year of age, the
+normal average is from 10,000 to 20,000.
+
+_Absence of Leucocytosis--Leucopenia._--In certain infective diseases
+the number of leucocytes in the circulating blood is abnormally
+low--3000 or 4000--and this condition is known as _leucopenia_. It
+occurs in typhoid fever, especially in the later stages of the disease,
+in tuberculous lesions unaccompanied by suppuration, in malaria, and in
+most cases of uncomplicated influenza. The occurrence of leucocytosis in
+any of these conditions is to be looked upon as an indication that a
+mixed infection has taken place, and that some suppurative process is
+present.
+
+The absence of leucocytosis in some cases of virulent septic poisoning
+has already been referred to.
+
+It will be evident that too much reliance must not be placed upon a
+single observation, particularly in emergency cases. Whenever possible,
+a series of observations should be made, the blood being examined about
+four hours after meals, and about the same hour each day.
+
+The clinical significance of the blood count in individual diseases will
+be further referred to.
+
+_The Iodine or Glycogen Reaction._--The leucocyte count may be
+supplemented by staining films of the blood with a watery solution of
+iodine and potassium iodide. In all advancing purulent conditions, in
+septic poisonings, in pneumonia, and in cancerous growths associated
+with ulceration, a certain number of the polynuclear leucocytes are
+stained a brown or reddish-brown colour, due to the action of the iodine
+on some substance in the cells of the nature of glycogen. This reaction
+is absent in serous effusions, in unmixed tuberculous infections, in
+uncomplicated typhoid fever, and in the early stages of cancerous
+growths.
+
+
+
+
+CHAPTER III
+
+INFLAMMATION
+
+
+Definition--Nature of inflammation from surgical point of
+    view--Sequence of changes in bacterial inflammation--Clinical
+    aspects of inflammation--General principles of treatment--Chronic
+    inflammation.
+
+Inflammation may be defined as the series of vital changes that occurs
+in the tissues in response to irritation. These changes represent the
+reaction of the tissue elements to the irritant, and constitute the
+attempt made by nature to arrest or to limit its injurious effects, and
+to repair the damage done by it.
+
+The phenomena which characterise the inflammatory reaction can be
+induced by any form of irritation--such, for example, as mechanical
+injury, the application of heat or of chemical substances, or the action
+of pathogenic bacteria and their toxins--and they are essentially
+similar in kind whatever the irritant may be. The extent to which the
+process may go, however, and its effects on the part implicated and on
+the system as a whole, vary with different irritants and with the
+intensity and duration of their action. A mechanical, a thermal, or a
+chemical irritant, acting alone, induces a degree of reaction directly
+proportionate to its physical properties, and so long as it does not
+completely destroy the vitality of the part involved, the changes in the
+tissues are chiefly directed towards repairing the damage done to the
+part, and the inflammatory reaction is not only compatible with the
+occurrence of ideal repair, but may be looked upon as an integral step
+in the reparative process.
+
+The irritation caused by infection with bacteria, on the other hand, is
+cumulative, as the organisms not only multiply in the tissues, but in
+addition produce chemical poisons (toxins) which aggravate the
+irritative effects. The resulting reaction is correspondingly
+progressive, and has as its primary object the expulsion of the irritant
+and the limitation of its action. If the natural protective effort is
+successful, the resulting tissue changes subserve the process of repair,
+but if the bacteria gain the upper hand in the struggle, the
+inflammatory reaction becomes more intense, certain of the tissue
+elements succumb, and the process for the time being is a destructive
+one. During the stage of bacterial inflammation, reparative processes
+are in abeyance, and it is only after the inflammation has been allayed,
+either by natural means or by the aid of the surgeon, that repair takes
+place.
+
+In applying the antiseptic principle to the treatment of wounds, our
+main object is to exclude or to eliminate the bacterial factor, and so
+to prevent the inflammatory reaction going beyond the stage in which it
+is protective, and just in proportion as we succeed in attaining this
+object, do we favour the occurrence of ideal repair.
+
+#Sequence of Changes in Bacterial Inflammation.#--As the form of
+inflammation with which we are most concerned is that due to the action
+of bacteria, in describing the process by which the protective influence
+of the inflammatory reaction is brought into play, we shall assume the
+presence of a bacterial irritant.
+
+The introduction of a colony of micro-organisms is quickly followed by
+an accumulation of wandering cells, and proliferation of
+connective-tissue cells in the tissues at the site of infection. The
+various cells are attracted to the bacteria by a peculiar chemical or
+biological power known as _chemotaxis_, which seems to result from
+variations in the surface tension of different varieties of cells,
+probably caused by some substance produced by the micro-organisms.
+Changes in the blood vessels then ensue, the arteries becoming dilated
+and the rate of the current in them being for a time increased--_active
+hyperaemia_. Soon, however, the rate of the blood flow becomes slower
+than normal, and in course of time the current may cease (_stasis_), and
+the blood in the vessels may even coagulate (_thrombosis_). Coincidently
+with these changes in the vessels, the leucocytes in the blood of the
+inflamed part rapidly increase in number, and they become viscous and
+adhere to the vessel wall, where they may accumulate in large numbers.
+In course of time the leucocytes pass through the vessel
+wall--_emigration of leucocytes_--and move towards the seat of
+infection, giving rise to a marked degree of _local leucocytosis_.
+Through the openings by which the leucocytes have escaped from the
+vessels, red corpuscles may be passively extruded--_diapedesis of red
+corpuscles_. These processes are accompanied by changes in the
+endothelium of the vessel walls, which result in an increased formation
+of lymph, which transudes into the meshes of the connective tissue
+giving rise to an _inflammatory oedema_, or, if the inflammation is on a
+free surface, forming an _inflammatory exudate_. The quantity and
+characters of this exudate vary in different parts of the body, and
+according to the nature, virulence, and location of the organisms
+causing the inflammation. Thus it may be _serous_, as in some forms of
+synovitis; _sero-fibrinous_, as in certain varieties of peritonitis, the
+fibrin tending to limit the spread of the inflammation by forming
+adhesions; _croupous_, when it coagulates on a free surface and forms a
+false membrane, as in diphtheria; _haemorrhagic_ when mixed with blood;
+or _purulent_, when suppuration has occurred. The protective effects of
+the inflammatory reaction depend for the most part upon the transudation
+of lymph and the emigration of leucocytes. The lymph contains the
+opsonins which act on the bacteria and render them less able to resist
+the attack of the phagocytes, as well as the various protective
+antibodies which neutralise the toxins. The polymorph leucocytes are the
+principal agents in the process of phagocytosis (p. 22), and together
+with the other forms of phagocytes they ingest and destroy the bacteria.
+
+If the attempt to repel the invading organisms is successful, the
+irritant effects are overcome, the inflammation is arrested, and
+_resolution_ is said to take place.
+
+Certain of the vascular and cellular changes are now utilised to restore
+the condition to the normal, and _repair_ ensues after the manner
+already described. In certain situations, notably in tendon sheaths, in
+the cavities of joints, and in the interior of serous cavities, for
+example the pleura and peritoneum, the restoration to the normal is not
+perfect, adhesions forming between the opposing surfaces.
+
+If, however, the reaction induced by the infection is insufficient to
+check the growth and spread of the organisms, or to inhibit their toxin
+production, local necrosis of tissue may take place, either in the form
+of suppuration or of gangrene, or the toxins absorbed into the
+circulation may produce blood-poisoning, which may even prove fatal.
+
+#Clinical Aspects of Inflammation.#--It must clearly be understood that
+inflammation is not to be looked upon as a disease in itself, but rather
+as an evidence of some infective process going on in the tissues in
+which it occurs, and of an effort on the part of these tissues to
+overcome the invading organisms and their products. The chief danger to
+the patient lies, not in the reactive changes that constitute the
+inflammatory process, but in the fact that he is liable to be poisoned
+by the toxins of the bacteria at work in the inflamed area.
+
+Since the days of Celsus (first century A.D.), heat, redness, swelling,
+and pain have been recognised as cardinal signs of inflammation, and to
+these may be added, interference with function in the inflamed part, and
+general constitutional disturbance. Variations in these signs and
+symptoms depend upon the acuteness of the condition, the nature of the
+causative organism and of the tissue attacked, the situation of the part
+in relation to the surface, and other factors.
+
+The _heat_ of the inflamed part is to be attributed to the increased
+quantity of blood present in it, and the more superficial the affected
+area the more readily is the local increase of temperature detected by
+the hand. This clinical point is best tested by placing the palm of the
+hand and fingers for a few seconds alternately over an uninflamed and an
+inflamed area, otherwise under similar conditions as to coverings and
+exposure. In this way even slight differences may be recognised.
+
+_Redness_, similarly, is due to the increased afflux of blood to the
+inflamed part. The shade of colour varies with the stage of the
+inflammation, being lighter and brighter in the early, hyperaemic stages,
+and darker and duskier when the blood flow is slowed or when stasis has
+occurred and the oxygenation of the blood is defective. In the
+thrombotic stage the part may assume a purplish hue.
+
+The _swelling_ is partly due to the increased amount of blood in the
+affected part and to the accumulation of leucocytes and proliferated
+tissue cells, but chiefly to the exudate in the connective
+tissue--_inflammatory oedema_. The more open the structure of the tissue
+of the part, the greater is the amount of swelling--witness the marked
+degree of oedema that occurs in such parts as the scrotum or the eyelids.
+
+_Pain_ is a symptom seldom absent in inflammation. _Tenderness_--that
+is, pain elicited on pressure--is one of the most valuable diagnostic
+signs we possess, and is often present before pain is experienced by the
+patient. That the area of tenderness corresponds to the area of
+inflammation is almost an axiom of surgery. Pain and tenderness are due
+to the irritation of nerve filaments of the part, rendered all the more
+sensitive by the abnormal conditions of their blood supply. In
+inflammatory conditions of internal organs, for example the abdominal
+viscera, the pain is frequently referred to other parts, usually to an
+area supplied by branches from the same segment of the cord as that
+supplying the inflamed part.
+
+For purposes of diagnosis, attention should be paid to the terms in
+which the patient describes his pain. For example, the pain caused by
+an inflammation of the skin is usually described as of a _burning_ or
+_itching_ character; that of inflammation in dense tissues like
+periosteum or bone, or in encapsuled organs, as _dull_, _boring_, or
+_aching_. When inflammation is passing on to suppuration the pain
+assumes a _throbbing_ character, and as the pus reaches the surface, or
+"points," as it is called, sharp, _darting_, or _lancinating_ pains are
+experienced. Inflammation involving a nerve-trunk may cause a _boring_
+or a _tingling_ pain; while the implication of a serous membrane such as
+the pleura or peritoneum gives rise to a pain of a sharp, _stabbing_
+character.
+
+_Interference with the function_ of the inflamed part is always present
+to a greater or less extent.
+
+#Constitutional Disturbances.#--Under the term constitutional
+disturbances are included the presence of fever or elevation of
+temperature; certain changes in the pulse rate and the respiration;
+gastro-intestinal and urinary disturbances; and derangements of the
+central nervous system. These are all due to the absorption of toxins
+into the general circulation.
+
+_Temperature._--A marked rise of temperature is one of the most constant
+and important concomitants of acute inflammatory conditions, and the
+temperature chart forms a fairly reliable index of the state of the
+patient. The toxins interfere with the nerve-centres in the medulla that
+regulate the balance between the production and the loss of body heat.
+
+Clinically the temperature is estimated by means of a self-registering
+thermometer placed, for from one to five minutes, in close contact with
+the skin in the axilla, or in the mouth. Sometimes the thermometer is
+inserted into the rectum, where, however, the temperature is normally
+3/4 F. higher than in the axilla.
+
+_In health_ the temperature of the body is maintained at a mean of about
+98.4 F. (37 C.) by the heat-regulating mechanism. It varies from hour
+to hour even in health, reaching its maximum between four and eight in
+the evening, when it may rise to 99 F., and is at its lowest between
+four and six in the morning, when it may be about 97 F.
+
+The temperature is more easily disturbed in children than in adults, and
+may become markedly elevated (104 or 105 F.) from comparatively slight
+causes; in the aged it is less liable to change, so that a rise to 103
+or 104 F. is to be looked upon as indicating a high state of fever.
+
+A sudden rise of temperature is usually associated with a feeling of
+chilliness down the back and in the limbs, which may be so marked that
+the patient shivers violently, while the skin becomes cold, pale, and
+shrivelled--_cutis anserina_. This is a nervous reaction due to a want
+of correspondence between the internal and the surface temperature of
+the body, and is known clinically as a _rigor_. When the temperature
+rises gradually the chill is usually slight and may be unobserved. Even
+during the cold stage, however, the internal temperature is already
+raised, and by the time the chill has passed off its maximum has been
+reached.
+
+The _pulse_ is always increased in frequency, and usually varies
+directly with the height of the temperature. _Respiration_ is more
+active during the progress of an inflammation; and bronchial catarrh is
+common apart from any antecedent respiratory disease.
+
+_Gastro-intestinal disturbances_ take the form of loss of appetite,
+vomiting, diminished secretion of the alimentary juices, and weakening
+of the peristalsis of the bowel, leading to thirst, dry, furred tongue,
+and constipation. Diarrhoea is sometimes present. The _urine_ is usually
+scanty, of high specific gravity, rich in nitrogenous substances,
+especially urea and uric acid, and in calcium salts, while sodium
+chloride is deficient. Albumin and hyaline casts may be present in cases
+of severe inflammation with high temperature. The significance of
+general _leucocytosis_ has already been referred to.
+
+#General Principles of Treatment.#--The capacity of the inflammatory
+reaction for dealing with bacterial infections being limited, it often
+becomes necessary for the surgeon to aid the natural defensive
+processes, as well as to counteract the local and general effects of the
+reaction, and to relieve symptoms.
+
+The ideal means of helping the tissues is by removing the focus of
+infection, and when this can be done, as for example in a carbuncle or
+an anthrax pustule, the infected area may be completely excised. When
+the focus is not sufficiently limited to admit of this, the infected
+tissue may be scraped away with the sharp spoon, or destroyed by
+caustics or by the actual cautery. If this is inadvisable, the organisms
+may be attacked by strong antiseptics, such as pure carbolic acid.
+
+Moist dressings favour the removal of bacteria by promoting the escape
+of the inflammatory exudate, in which they are washed out.
+
+#Artificial Hyperaemia.#--When such direct means as the above are
+impracticable, much can be done to aid the tissues in their struggle by
+improving the condition of the circulation in the inflamed area, so as
+to ensure that a plentiful supply of fresh arterial blood reaches it.
+The beneficial effects of _hot fomentations and poultices_ depend on
+their causing a dilatation of the vessels, and so inducing a hyperaemia
+in the affected area. It has been shown experimentally that repeated,
+short applications of moist heat (not exceeding 106 F.) are more
+efficacious than continuous application. It is now believed that the
+so-called _counter-irritants_--mustard, iodine, cantharides, actual
+cautery--act in the same way; and the method of treating erysipelas by
+applying a strong solution of iodine around the affected area is based
+on the same principle.
+
+[Illustration: FIG. 6.--Passive Hyperaemia of Hand and Forearm induced by
+Bier's Bandage.]
+
+While these and similar methods have long been employed in the treatment
+of inflammatory conditions, it is only within comparatively recent years
+that their mode of action has been properly understood, and to August
+Bier belongs the credit of having put the treatment of inflammation on a
+scientific and rational basis. Recognising the "beneficent intention" of
+the inflammatory reaction, and the protective action of the leucocytosis
+which accompanies the hyperaemic stages of the process, Bier was led to
+study the effects of increasing the hyperaemia by artificial means. As a
+result of his observations, he has formulated a method of treatment
+which consists in inducing an artificial hyperaemia in the inflamed area,
+either by obstructing the venous return from the part (_passive
+hyperaemia_), or by stimulating the arterial flow through it (_active
+hyperaemia_).
+
+_Bier's Constricting Bandage._--To induce a _passive hyperaemia_ in a
+limb, an elastic bandage is applied some distance above the inflamed
+area sufficiently tightly to obstruct the venous return from the distal
+parts without arresting in any way the inflow of arterial blood (Fig. 6).
+If the constricting band is correctly applied, the parts beyond
+become swollen and oedematous, and assume a bluish-red hue, but they
+retain their normal temperature, the pulse is unchanged, and there is no
+pain. If the part becomes blue, cold, or painful, or if any existing
+pain is increased, the band has been applied too tightly. The hyperaemia
+is kept up from twenty to twenty-two hours out of the twenty-four, and
+in the intervals the limb is elevated to get rid of the oedema and to
+empty it of impure blood, and so make room for a fresh supply of healthy
+blood when the bandage is re-applied. As the inflammation subsides, the
+period during which the band is kept on each day is diminished; but the
+treatment should be continued for some days after all signs of
+inflammation have subsided.
+
+This method of treating acute inflammatory conditions necessitates
+close supervision until the correct degree of tightness of the band has
+been determined.
+
+[Illustration: FIG. 7.--Passive Hyperaemia of Finger induced by Klapp's
+Suction Bell.]
+
+_Klapp's Suction Bells._--In inflammatory conditions to which the
+constricting band cannot be applied, as for example an acute mastitis, a
+bubo in the groin, or a boil on the neck, the affected area may be
+rendered hyperaemic by an appropriately shaped glass bell applied over it
+and exhausted by means of a suction-pump, the rarefaction of the air in
+the bell determining a flow of blood into the tissues enclosed within it
+(Figs. 7 and 8). The edge of the bell is smeared with vaseline, and the
+suction applied for from five to ten minutes at a time, with a
+corresponding interval between the applications. Each sitting lasts for
+from half an hour to an hour, and the treatment may be carried out once
+or twice a day according to circumstances. This apparatus acts in the
+same way as the old-fashioned _dry cup_, and is more convenient and
+equally efficacious.
+
+[Illustration: FIG. 8.--Passive Hyperaemia induced by Klapp's Suction
+Bell for Inflammation of Inguinal Gland.]
+
+_Active hyperaemia_ is induced by the local application of heat,
+particularly by means of hot air. It has not proved so useful in acute
+inflammation as passive hyperaemia, but is of great value in hastening
+the absorption of inflammatory products and in overcoming adhesions and
+stiffness in tendons and joints.
+
+_General Treatment._--The patient should be kept at rest, preferably in
+bed, to diminish the general tissue waste; and the diet should be
+restricted to fluids, such as milk, beef-tea, meat juices or gruel, and
+these may be rendered more easily assimilable by artificial digestion if
+necessary. To counteract the general effect of toxins absorbed into
+the circulation, specific antitoxic sera are employed in certain forms
+of infection, such as diphtheria, streptococcal septicaemia, and tetanus.
+In other forms of infection, vaccines are employed to increase the
+opsonic power of the blood. When such means are not available, the
+circulating toxins may to some extent be diluted by giving plenty of
+bland fluids by the mouth or normal salt solution by the rectum.
+
+The elimination of the toxins is promoted by securing free action of the
+emunctories. A saline purge, such as half an ounce of sulphate of
+magnesium in a small quantity of water, ensures a free evacuation of the
+bowels. The kidneys are flushed by such diluent drinks as equal parts of
+milk and lime water, or milk with a dram of liquor calcis saccharatus
+added to each tumblerful. Barley-water and "Imperial drink," which
+consists of a dram and a half of cream of tartar added to a pint of
+boiling water and sweetened with sugar after cooling, are also useful
+and non-irritating diuretics. The skin may be stimulated by Dover's
+powder (10 grains) or liquor ammoniae acetatis in three-dram doses every
+four hours.
+
+Various drugs administered internally, such as quinine, salol,
+salicylate of iron, and others, have a reputation, more or less
+deserved, as internal antiseptics.
+
+Weakness of the heart, as indicated by the condition of the pulse, is
+treated by the use of such drugs as digitalis, strophanthus, or
+strychnin, according to circumstances.
+
+Gastro-intestinal disturbances are met by ordinary medical means.
+Vomiting, for example, can sometimes be checked by effervescing drinks,
+such as citrate of caffein, or by dilute hydrocyanic acid and bismuth.
+In severe cases, and especially when the vomited matter resembles
+coffee-grounds from admixture with altered blood--the so-called
+post-operative haematemesis--the best means of arresting the vomiting is
+by washing out the stomach. Thirst is relieved by rectal injections of
+saline solution. The introduction of saline solution into the veins or
+by the rectum is also useful in diluting and hastening the elimination
+of circulating toxins.
+
+In surgical inflammations, as a rule, nothing is gained by lowering the
+temperature, unless at the same time the cause is removed. When severe
+or prolonged pyrexia becomes a source of danger, the use of hot or cold
+sponging, or even the cold bath, is preferable to the administration of
+drugs.
+
+_Relief of Symptoms._--For the relief of _pain_, rest is essential. The
+inflamed part should be placed in a splint or other appliance which will
+prevent movement, and steps must be taken to reduce its functional
+activity as far as possible. Locally, warm and moist dressings, such as
+a poultice or fomentation, may be used. To make a fomentation, a piece
+of flannel or lint is wrung out of very hot water or antiseptic lotion
+and applied under a sheet of mackintosh. Fomentations should be renewed
+as often as they cool. An ordinary india-rubber bag filled with hot
+water and fixed over the fomentation, by retaining the heat, obviates
+the necessity of frequently changing the application. The addition of a
+few drops of laudanum sprinkled on the flannel has a soothing effect.
+Lead and opium lotion is a useful, soothing application employed as a
+fomentation. We prefer the application of lint soaked in a 10 per cent.
+aqueous or glycerine solution of ichthyol, or smeared with ichthyol
+ointment (1 in 3). Belladonna and glycerine, equal parts, may be used.
+
+Dry cold obtained by means of icebags, or by Leiter's lead tubes through
+which a continuous stream of ice-cold water is kept flowing, is
+sometimes soothing to the patient, but when the vessels in the inflamed
+part are greatly congested its use is attended with considerable risk,
+as it not only contracts the arterioles supplying the part, but also
+diminishes the outflow of venous blood, and so may determine gangrene of
+tissues already devitalised.
+
+A milder form of employing cold is by means of evaporating lotions: a
+thin piece of lint or gauze is applied over the inflamed part and kept
+constantly moist with the lotion, the dressing being left freely exposed
+to allow of continuous evaporation. A useful evaporating lotion is made
+up as follows: take of chloride of ammonium, half an ounce; rectified
+spirit, one ounce; and water, seven ounces.
+
+The administration of opiates may be necessary for the relief of pain.
+
+The accumulation of an excessive amount of inflammatory exudate may
+endanger the vitality of the tissues by pressing on the blood vessels to
+such an extent as to cause stasis, and by concentrating the local action
+of the toxins. Under such conditions the tension should be relieved and
+the exudate with its contained toxins removed by making an incision into
+the inflamed tissues, and applying a suction bell. When the exudate has
+collected in a synovial cavity, such as a joint or bursa, it may be
+withdrawn by means of a trocar and cannula. There are other methods of
+withdrawing blood and exudate from an inflamed area, for example by
+leeches or wet-cupping, but they are seldom employed now.
+
+Before applying leeches the part must be thoroughly cleansed, and if
+the leech is slow to bite, may be smeared with cream. The leech is
+retained in position under an inverted wine-glass or wide test-tube till
+it takes hold. After it has sucked its fill it usually drops off, having
+withdrawn a dram or a dram and a half of blood. If it be desirable to
+withdraw more blood, hot fomentations should be applied to the bite. As
+it is sometimes necessary to employ considerable pressure to stop the
+bleeding, leeches should, if possible, be applied over a bone which will
+furnish the necessary resistance. The use of styptics may be called for.
+
+_Wet-cupping_ has almost entirely been superseded by the use of Klapp's
+suction bells.
+
+_General blood-letting_ consists in opening a superficial vein
+(venesection) and allowing from eight to ten ounces of blood to flow
+from it. It is seldom used in the treatment of surgical forms of
+inflammation.
+
+_Counter-irritants._--In deep-seated inflammations, counter-irritants
+are sometimes employed in the form of mustard leaves or blisters,
+according to the degree of irritation required. A mustard leaf or
+plaster should not be left on longer than ten or fifteen minutes, unless
+it is desired to produce a blister. Blistering may be produced by a
+_cantharides plaster_, or by painting with _liquor epispasticus_. The
+plaster should be left on from eight to ten hours, and if it has failed
+to raise a blister, a hot fomentation should be applied to the part.
+_Liquor epispasticus_, alone or mixed with equal parts of collodion, is
+painted on the part with a brush. Several paintings are often required
+before a blister is raised. The preliminary removal of the natural
+grease from the skin favours the action of these applications.
+
+The treatment of inflammation in special tissues and organs will be
+considered in the sections devoted to regional surgery.
+
+#Chronic Inflammation.#--A variety of types of chronic and subacute
+inflammation are met with which, owing to ignorance of their causations,
+cannot at present be satisfactorily classified.
+
+The best defined group is that of the _granulomata_, which includes such
+important diseases as tuberculosis and syphilis, and in which different
+types of chronic inflammation are caused by infection with a specific
+organism, all having the common character, however, that abundant
+granulation tissue is formed in which cellular changes are more in
+evidence than changes in the blood vessels, and in which the subsequent
+degeneration and necrosis of the granulation tissue results in the
+breaking down and destruction of the tissue in which it is formed.
+Another group is that in which chronic inflammation is due to mild or
+attenuated forms of pyogenic infection affecting especially the lymph
+glands and the bone marrow. In the glands of the groin, for example,
+associated with various forms of irritation about the external genitals,
+different types of _chronic lymphadenitis_ are met with; they do not
+frankly suppurate as do the acute types, but are attended with a
+hyperplasia of the tissue elements which results in enlargement of the
+affected glands of a persistent, and sometimes of a relapsing character.
+Similar varieties of _osteomyelitis_ are met with that do not, like the
+acute forms, go on to suppuration or to death of bone, but result in
+thickening of the bone affected, both on the surface and in the
+interior, resulting in obliteration of the medullary canal.
+
+A third group of chronic inflammations are those that begin as an acute
+pyogenic inflammation, which, instead of resolving completely, persists
+in a chronic form. It does so apparently because there is some factor
+aiding the organisms and handicapping the tissues, such as the presence
+of a foreign body, a piece of glass or metal, or a piece of dead bone;
+in these circumstances the inflammation persists in a chronic form,
+attended with the formation of fibrous tissue, and, in the case of bone,
+with the formation of new bone in excess. It will be evident that in
+this group, chronic inflammation and repair are practically
+interchangeable terms.
+
+There are other groups of chronic inflammation, the origin of which
+continues to be the subject of controversy. Reference is here made to
+the chronic inflammations of the synovial membrane of joints, of tendon
+sheaths and of bursae--_chronic synovitis_, _teno-synovitis_ and
+_bursitis_; of the fibrous tissues of joints--chronic forms of
+_arthritis_; of the blood vessels--chronic forms of _endarteritis_ and
+of _phlebitis_ and of the peripheral nerves--_neuritis_. Also in the
+breast and in the prostate, with the waning of sexual life there may
+occur a formation of fibrous tissue--chronic _interstitial mastitis_,
+_chronic prostatitis_, having analogies with the chronic interstitial
+inflammations of internal organs like the kidney--_chronic interstitial
+nephritis_; and in the breast and prostate, as in the kidney, the
+formation of fibrous tissue leads to changes in the secreting epithelium
+resulting in the formation of cysts.
+
+Lastly, there are still other types of chronic inflammation attended
+with the formation of fibrous tissue on such a liberal scale as to
+suggest analogies with new growths. The best known of these are the
+systematic forms of fibromatosis met with in the central nervous system
+and in the peripheral nerves--_neuro-fibromatosis_; in the submucous
+coat of the stomach--_gastric fibromatosis_; and in the
+colon--_intestinal fibromatosis_.
+
+These conditions will be described with the tissues and organs in which
+they occur.
+
+In the _treatment of chronic inflammations_, pending further knowledge
+as to their causation, and beyond such obvious indications as to help
+the tissues by removing a foreign body or a piece of dead bone, there
+are employed--empirically--a number of procedures such as the induction
+of hyperaemia, exposure to the X-rays, and the employment of blisters,
+cauteries, and setons. Vaccines may be had recourse to in those of
+bacterial origin.
+
+
+
+
+CHAPTER IV
+
+SUPPURATION
+
+
+Definition--Pus--_Varieties_--Acute circumscribed abscess--_Acute
+    suppuration in a wound_--_Acute Suppuration in a mucous
+    membrane_--Diffuse cellulitis and diffuse suppuration--
+    _Whitlow_--_Suppurative cellulitis in different situations_--Chronic
+    suppuration--Sinus, Fistula--Constitutional manifestations of
+    pyogenic infection--_Sapraemia_--_Septicaemia_--_Pyaemia_.
+
+Suppuration, or the formation of pus, is one of the results of the
+action of bacteria on the tissues. The invading organism is usually one
+of the staphylococci, less frequently a streptococcus, and still less
+frequently one of the other bacteria capable of producing pus, such as
+the bacillus coli communis, the gonococcus, the pneumococcus, or the
+typhoid bacillus.
+
+So long as the tissues are in a healthy condition they are able to
+withstand the attacks of moderate numbers of pyogenic bacteria of
+ordinary virulence, but when devitalised by disease, by injury, or by
+inflammation due to the action of other pathogenic organisms,
+suppuration ensues.
+
+It would appear, for example, that pyogenic organisms can pass through
+the healthy urinary tract without doing any damage, but if the pelvis of
+the kidney, the ureter, or the bladder is the seat of stone, they give
+rise to suppuration. Similarly, a calculus in one of the salivary ducts
+frequently results in an abscess forming in the floor of the mouth. When
+the lumen of a tubular organ, such as the appendix or the Fallopian tube
+is blocked also, the action of pyogenic organisms is favoured and
+suppuration ensues.
+
+#Pus.#--The fluid resulting from the process of suppuration is known
+as _pus_. In its typical form it is a yellowish creamy substance, of
+alkaline reaction, with a specific gravity of about 1030, and it has a
+peculiar mawkish odour. If allowed to stand in a test-tube it does not
+coagulate, but separates into two layers: the upper, transparent,
+straw-coloured fluid, the _liquor puris_ or pus serum, closely
+resembling blood serum in its composition, but containing less protein
+and more cholestrol; it also contains leucin, tyrosin, and certain
+albumoses which prevent coagulation.
+
+The layer at the bottom of the tube consists for the most part of
+polymorph leucocytes, and proliferated connective tissue and endothelial
+cells (_pus corpuscles_). Other forms of leucocytes may be present,
+especially in long-standing suppurations; and there are usually some red
+corpuscles, dead bacteria, fat cells and shreds of tissue, cholestrol
+crystals, and other detritus in the deposit.
+
+If a film of fresh pus is examined under the microscope, the pus cells
+are seen to have a well-defined rounded outline, and to contain a finely
+granular protoplasm and a multi-partite nucleus; if still warm, the
+cells may exhibit amoeboid movement. In stained films the nuclei take the
+stain well. In older pus cells the outline is irregular, the protoplasm
+coarsely granular, and the nuclei disintegrated, no longer taking the
+stain.
+
+_Variations from Typical Pus._--Pus from old-standing sinuses is often
+watery in consistence (ichorous), with few cells. Where the granulations
+are vascular and bleed easily, it becomes sanious from admixture with
+red corpuscles; while, if a blood-clot be broken down and the debris
+mixed with the pus, it contains granules of blood pigment and is said to
+be "grumous." The _odour_ of pus varies with the different bacteria
+producing it. Pus due to ordinary pyogenic cocci has a mawkish odour;
+when putrefactive organisms are present it has a putrid odour; when it
+forms in the vicinity of the intestinal canal it usually contains the
+bacillus coli communis and has a faecal odour.
+
+The _colour_ of pus also varies: when due to one or other of the
+varieties of the bacillus pyocyaneus, it is usually of a blue or green
+colour; when mixed with bile derivatives or altered blood pigment, it
+may be of a bright orange colour. In wounds inflicted with rough iron
+implements from which rust is deposited, the pus often presents the same
+colour.
+
+The pus may form and collect within a circumscribed area, constituting a
+localised _abscess_; or it may infiltrate the tissues over a wide
+area--_diffuse suppuration_.
+
+
+ACUTE CIRCUMSCRIBED ABSCESS
+
+Any tissue of the body may be the seat of an acute abscess, and there
+are many routes by which the bacteria may gain access to the affected
+area. For example: an abscess in the integument or subcutaneous
+cellular tissue usually results from infection by organisms which have
+entered through a wound or abrasion of the surface, or along the ducts
+of the skin; an abscess in the breast from organisms which have passed
+along the milk ducts opening on the nipple, or along the lymphatics
+which accompany these. An abscess in a lymph gland is usually due to
+infection passing by way of the lymph channels from the area of skin or
+mucous membrane drained by them. Abscesses in internal organs, such as
+the kidney, liver, or brain, usually result from organisms carried in
+the blood-stream from some focus of infection elsewhere in the body.
+
+A knowledge of the possible avenues of infection is of clinical
+importance, as it may enable the source of a given abscess to be traced
+and dealt with. In suppuration in the Fallopian tube (pyosalpynx), for
+example, the fact that the most common origin of the infection is in the
+genital passage, leads to examination for vaginal discharge; and if none
+is present, the abscess is probably due to infection carried in the
+blood-stream from some primary focus about the mouth, such as a gumboil
+or an infective sore throat.
+
+The exact location of an abscess also may furnish a key to its source;
+in axillary abscess, for example, if the suppuration is in the lymph
+glands the infection has come through the afferent lymphatics; if in the
+cellular tissue, it has spread from the neck or chest wall; if in the
+hair follicles, it is a local infection through the skin.
+
+#Formation of an Abscess.#--When pyogenic bacteria are introduced into
+the tissue there ensues an inflammatory reaction, which is characterised
+by dilatation of the blood vessels, exudation of large numbers of
+leucocytes, and proliferation of connective-tissue cells. These
+wandering cells soon accumulate round the focus of infection, and form a
+protective barrier which tends to prevent the spread of the organisms
+and to restrict their field of action. Within the area thus
+circumscribed the struggle between the bacteria and the phagocytes takes
+place, and in the process toxins are formed by the organisms, a certain
+number of the leucocytes succumb, and, becoming degenerated, set free
+certain proteolytic enzymes or ferments. The toxins cause
+coagulation-necrosis of the tissue cells with which they come in
+contact, the ferments liquefy the exudate and other albuminous
+substances, and in this way _pus_ is formed.
+
+If the bacteria gain the upper hand, this process of liquefaction which
+is characteristic of suppuration, extends into the surrounding tissues,
+the protective barrier of leucocytes is broken down, and the
+suppurative process spreads. A fresh accession of leucocytes, however,
+forms a new barrier, and eventually the spread is arrested, and the
+collection of pus so hemmed in constitutes an _abscess_.
+
+Owing to the swelling and condensation of the parts around, the pus thus
+formed is under considerable pressure, and this causes it to burrow
+along the lines of least resistance. In the case of a subcutaneous
+abscess the pus usually works its way towards the surface, and "points,"
+as it is called. Where it approaches the surface the skin becomes soft
+and thin, and eventually sloughs, allowing the pus to escape.
+
+An abscess forming in the deeper planes is prevented from pointing
+directly to the surface by the firm fasciae and other fibrous structures.
+The pus therefore tends to burrow along the line of the blood vessels
+and in the connective-tissue septa, till it either finds a weak spot or
+causes a portion of fascia to undergo necrosis and so reaches the
+surface. Accordingly, many abscess cavities resulting from deep-seated
+suppuration are of irregular shape, with pouches and loculi in various
+directions--an arrangement which interferes with their successful
+treatment by incision and drainage.
+
+The relief of tension which follows the bursting of an abscess, the
+removal of irritation by the escape of pus, and the casting off of
+bacteria and toxins, allow the tissues once more to assert themselves,
+and a process of repair sets in. The walls of the abscess fall in;
+granulation tissue grows into the space and gradually fills it; and
+later this is replaced by cicatricial tissue. As a result of the
+subsequent contraction of the cicatricial tissue, the scar is usually
+depressed below the level of the surrounding skin surface.
+
+If an abscess is prevented from healing--for example, by the presence of
+a foreign body or a piece of necrosed bone--a sinus results, and from it
+pus escapes until the foreign body is removed.
+
+#Clinical Features of an Acute Circumscribed Abscess.#--In the initial
+stages the usual symptoms of inflammation are present. Increased
+elevation of temperature, with or without a rigor, progressive
+leucocytosis, and sweating, mark the transition between inflammation and
+suppuration. An increasing leucocytosis is evidence that a suppurative
+process is spreading.
+
+The local symptoms vary with the seat of the abscess. When it is
+situated superficially--for example, in the breast tissue--the affected
+area is hot, the redness of inflammation gives place to a dusky purple
+colour, with a pale, sometimes yellow, spot where the pus is near the
+surface. The swelling increases in size, the firm brawny centre becomes
+soft, projects as a cone beyond the level of the rest of the swollen
+area, and is usually surrounded by a zone of induration.
+
+By gently palpating with the finger-tips over the softened area, a fluid
+wave may be detected--_fluctuation_--and when present this is a certain
+indication of the existence of fluid in the swelling. Its recognition,
+however, is by no means easy, and various fallacies are to be guarded
+against in applying this test clinically. When, for example, the walls
+of the abscess are thick and rigid, or when its contents are under
+excessive tension, the fluid wave cannot be elicited. On the other hand,
+a sensation closely resembling fluctuation may often be recognised in
+oedematous tissues, in certain soft, solid tumours such as fatty tumours
+or vascular sarcomata, in aneurysm, and in a muscle when it is palpated
+in its transverse axis.
+
+When pus has formed in deeper parts, and before it has reached the
+surface, oedema of the overlying skin is frequently present, and the skin
+pits on pressure.
+
+With the formation of pus the continuous burning or boring pain of
+inflammation assumes a throbbing character, with occasional sharp,
+lancinating twinges. Should doubt remain as to the presence of pus,
+recourse may be had to the use of an exploring needle.
+
+_Differential Diagnosis of Acute Abscess._--A practical difficulty which
+frequently arises is to decide whether or not pus has actually formed.
+It may be accepted as a working rule in practice that when an acute
+inflammation has lasted for four or five days without showing signs of
+abatement, suppuration has almost certainly occurred. In deep-seated
+suppuration, marked oedema of the skin and the occurrence of rigors and
+sweating may be taken to indicate the formation of pus.
+
+There are cases on record where rapidly growing sarcomatous and
+angiomatous tumours, aneurysms, and the bruises that occur in
+haemophylics, have been mistaken for acute abscesses and incised, with
+disastrous results.
+
+#Treatment of Acute Abscesses.#--The dictum of John Bell, "Where there
+is pus, let it out," summarises the treatment of abscess. The extent and
+situation of the incision and the means taken to drain the cavity,
+however, vary with the nature, site, and relations of the abscess. In a
+superficial abscess, for example a bubo, or an abscess in the breast or
+face where a disfiguring scar is undesirable, a small puncture should be
+made where the pus threatens to point, and a Klapp's suction bell be
+applied as already described (p. 39). A drain is not necessary, and in
+the intervals between the applications of the bell the part is covered
+with a moist antiseptic dressing.
+
+In abscesses deeply placed, as for example under the gluteal or pectoral
+muscles, one or more incisions should be made, and the cavity drained by
+glass or rubber tubes or by strips of rubber tissue.
+
+The wound should be dressed the next day, and the tube shortened, in the
+case of a rubber tube, by cutting off a portion of its outer end. On the
+second day or later, according to circumstances, the tube is removed,
+and after this the dressing need not be repeated oftener than every
+second or third day.
+
+Where pus has formed in relation to important structures--as, for
+example, in the deeper planes of the neck--_Hilton's method_ of opening
+the abscess may be employed. An incision is made through the skin and
+fascia, a grooved director is gently pushed through the deeper tissues
+till pus escapes along its groove, and then the track is widened by
+passing in a pair of dressing forceps and expanding the blades. A tube,
+or strip of rubber tissue, is introduced, and the subsequent treatment
+carried out as in other abscesses. When the drain lies in proximity to a
+large blood vessel, care must be taken not to leave it in position long
+enough to cause ulceration of the vessel wall by pressure.
+
+In some abscesses, such as those in the vicinity of the anus, the cavity
+should be laid freely open in its whole extent, stuffed with iodoform or
+bismuth gauze, and treated by the open method.
+
+It is seldom advisable to wash out an abscess cavity, and squeezing out
+the pus is also to be avoided, lest the protective zone be broken down
+and the infection be diffused into the surrounding tissues.
+
+The importance of taking precautions against further infection in
+opening an abscess can scarcely be exaggerated, and the rapidity with
+which healing occurs when the access of fresh bacteria is prevented is
+in marked contrast to what occurs when such precautions are neglected
+and further infection is allowed to take place.
+
+_Acute Suppuration in a Wound._--If in the course of an operation
+infection of the wound has occurred, a marked inflammatory reaction soon
+manifests itself, and the same changes as occur in the formation of an
+acute abscess take place, modified, however, by the fact that the pus
+can more readily reach the surface. In from twenty-four to forty-eight
+hours the patient is conscious of a sensation of chilliness, or may
+even have a rigor. At the same time he feels generally out of sorts,
+with impaired appetite, headache, and it may be looseness of the bowels.
+His temperature rises to 100 or 101 F., and the pulse quickens to 100
+or 110.
+
+On exposing the wound it is found that the parts for some distance
+around are red, glazed, and oedematous. The discoloration and swelling
+are most intense in the immediate vicinity of the wound, the edges of
+which are everted and moist. Any stitches that may have been introduced
+are tight, and the deep ones may be cutting into the tissues. There is
+heat, and a constant burning or throbbing pain, which is increased by
+pressure. If the stitches be cut, pus escapes, the wound gapes, and its
+surfaces are found to be inflamed and covered with pus.
+
+The open method is the only safe means of treating such wounds. The
+infected surface may be sponged over with pure carbolic acid, the excess
+of which is washed off with absolute alcohol, and the wound either
+drained by tubes or packed with iodoform gauze. The practice of scraping
+such surfaces with the sharp spoon, squeezing or even of washing them
+out with antiseptic lotions, is attended with the risk of further
+diffusing the organisms in the tissue, and is only to be employed under
+exceptional circumstances. Continuous irrigation of infected wounds or
+their immersion in antiseptic baths is sometimes useful. The free
+opening up of the wound is almost immediately followed by a fall in the
+temperature. The surrounding inflammation subsides, the discharge of pus
+lessens, and healing takes place by the formation of granulation
+tissue--the so-called "healing by second intention."
+
+Wound infection may take place from _catgut_ which has not been
+efficiently prepared. The local and general reactions may be slight,
+and, as a rule, do not appear for seven or eight days after the
+operation, and, it may be, not till after the skin edges have united.
+The suppuration is strictly localised to the part of the wound where
+catgut was employed for stitches or ligatures, and shows little tendency
+to spread. The infected part, however, is often long of healing. The
+irritation in these cases is probably due to toxins in the catgut and
+not to bacteria.
+
+When suppuration occurs in connection with buried sutures of
+unabsorbable materials, such as silk, silkworm gut, or silver wire, it
+is apt to persist till the foreign material is cast off or removed.
+
+Suppuration may occur in the track of a skin stitch, producing a _stitch
+abscess_. The infection may arise from the material used, especially
+catgut or silk, or, more frequently perhaps, from the growth of
+staphylococcus albus from the skin of the patient when this has been
+imperfectly disinfected. The formation of pus under these conditions may
+not be attended with any of the usual signs of suppuration, and beyond
+some induration around the wound and a slight tenderness on pressure
+there may be nothing to suggest the presence of an abscess.
+
+_Acute Suppuration of a Mucous Membrane._--When pyogenic organisms gain
+access to a mucous membrane, such as that of the bladder, urethra, or
+middle ear, the usual phenomena of acute inflammation and suppuration
+ensue, followed by the discharge of pus on the free surface. It would
+appear that the most marked changes take place in the submucous tissue,
+causing the covering epithelium in places to die and leave small
+superficial ulcers, for example in gonorrhoeal urethritis, the
+cicatricial contraction of the scar subsequently leading to the
+formation of stricture. When mucous glands are present in the membrane,
+the pus is mixed with mucus--_muco-pus_.
+
+
+DIFFUSE CELLULITIS AND DIFFUSE SUPPURATION
+
+Cellulitis is an acute affection resulting from the introduction of some
+organism--commonly the _streptococcus pyogenes_--into the cellular
+connective tissue of the integument, intermuscular septa, tendon
+sheaths, or other structures. Infection always takes place through a
+breach of the surface, although this may be superficial and
+insignificant, such as a pin-prick, a scratch, or a crack under a nail,
+and the wound may have been healed for some time before the inflammation
+becomes manifest. The cellulitis, also, may develop at some distance
+from the seat of inoculation, the organisms having travelled by the
+lymphatics.
+
+The virulence of the organisms, the loose, open nature of the tissues in
+which they develop, and the free lymphatic circulation by means of which
+they are spread, account for the diffuse nature of the process.
+Sometimes numbers of cocci are carried for a considerable distance from
+the primary area before they are arrested in the lymphatics, and thus
+several patches of inflammation may appear with healthy areas between.
+
+The pus infiltrates the meshes of the cellular tissue, there is
+sloughing of considerable portions of tissue of low vitality, such as
+fat, fascia, or tendon, and if the process continues for some time
+several collections of pus may form.
+
+_Clinical Features._--The reaction in cases of diffuse cellulitis is
+severe, and is usually ushered in by a distinct chill or even a rigor,
+while the temperature rises to 103, 104, or 105 F. The pulse is
+proportionately increased in frequency, and is small, feeble, and often
+irregular. The face is flushed, the tongue dry and brown, and the
+patient may become delirious, especially during the night. Leucocytosis
+is present in cases of moderate severity; but in severe cases the
+virulence of the toxins prevents reaction taking place, and leucocytosis
+is absent.
+
+The local manifestations vary with the relation of the seat of the
+inflammation to the surface. When the superficial cellular tissue is
+involved, the skin assumes a dark bluish-red colour, is swollen,
+oedematous, and the seat of burning pain. To the touch it is firm, hot,
+and tender. When the primary focus is in the deeper tissues, the
+constitutional disturbance is aggravated, while the local signs are
+delayed, and only become prominent when pus forms and approaches the
+surface. It is not uncommon for blebs containing dark serous fluid to
+form on the skin. The infection frequently spreads along the line of the
+main lymph vessels of the part (_septic lymphangitis_) and may reach the
+lymph glands (_septic lymphadenitis_).
+
+With the formation of pus the skin becomes soft and boggy at several
+points, and eventually breaks, giving exit to a quantity of thick
+grumous discharge. Sometimes several small collections under the skin
+fuse, and an abscess is formed in which fluctuation can be detected.
+Occasionally gases are evolved in the tissues, giving rise to emphysema.
+It is common for portions of fascia, ligaments, or tendons to slough,
+and this may often be recognised clinically by a peculiar crunching or
+grating sensation transmitted to the fingers on making firm pressure on
+the part.
+
+If it is not let out by incision, the pus, travelling along the lines of
+least resistance, tends to point at several places on the surface, or to
+open into joints or other cavities.
+
+_Prognosis._--The occurrence of _septicaemia_ is the most serious risk,
+and it is in cases of diffuse suppurative cellulitis that this form of
+blood-poisoning assumes its most aggravated forms. The toxins of the
+streptococci are exceedingly virulent, and induce local death of tissue
+so rapidly that the protective emigration of leucocytes fails to take
+place. In some cases the passage of masses of free cocci in the
+lymphatics, or of infective emboli in the blood vessels, leads to the
+formation of _pyogenic abscesses_ in vital organs, such as the brain,
+lungs, liver, kidneys, or other viscera. _Haemorrhage_ from erosion of
+arterial or venous trunks may take place and endanger life.
+
+_Treatment._--The treatment of diffuse cellulitis depends to a large
+extent on the situation and extent of the affected area, and on the
+stage of the process.
+
+_In the limbs_, for example, where the application of a constricting
+band is practicable, Bier's method of inducing passive hyperaemia yields
+excellent results. If pus is formed, one or more small incisions are
+made and a light moist dressing placed over the wounds to absorb the
+discharge, but no drain is inserted. The whole of the inflamed area
+should be covered with gauze wrung out of a 1 in 10 solution of ichthyol
+in glycerine. The dressing is changed as often as necessary, and in the
+intervals when the band is off, gentle active and passive movements
+should be carried out to prevent the formation of adhesions. After
+incisions have been made, we have found the _immersion_ of the limb, for
+a few hours at a time, in a water-bath containing warm boracic lotion or
+eusol a useful adjuvant to the passive hyperaemia.
+
+_Continuous irrigation_ of the part by a slow, steady stream of lotion,
+at the body temperature, such as eusol, or Dakin's solution, or boracic
+acid, or frequent washing with peroxide of hydrogen, has been found of
+value.
+
+A suitably arranged splint adds to the comfort of the patient; and the
+limb should be placed in the attitude which, in the event of stiffness
+resulting, will least interfere with its usefulness. The elbow, for
+example, should be flexed to a little less than a right angle; at the
+wrist, the hand should be dorsiflexed and the fingers flexed slightly
+towards the palm.
+
+Massage, passive movement, hot and cold douching, and other measures,
+may be necessary to get rid of the chronic oedema, adhesions of tendons,
+and stiffness of joints which sometimes remain.
+
+In situations where a constricting band cannot be applied, for example,
+on the trunk or the neck, Klapp's suction bells may be used, small
+incisions being made to admit of the escape of pus.
+
+If these measures fail or are impracticable, it may be necessary to make
+one or more free incisions, and to insert drainage-tubes, portions of
+rubber dam, or iodoform worsted.
+
+The general treatment of toxaemia must be carried out, and in cases due
+to infection by streptococci, anti-streptococcic serum may be used.
+
+In a few cases, amputation well above the seat of disease, by removing
+the source of toxin production, offers the only means of saving the
+patient.
+
+
+WHITLOW
+
+The clinical term whitlow is applied to an acute infection, usually
+followed by suppuration, commonly met with in the fingers, less
+frequently in the toes. The point of infection is often trivial--a
+pin-prick, a puncture caused by a splinter of wood, a scratch, or even
+an imperceptible lesion of the skin.
+
+Several varieties of whitlow are recognised, but while it is convenient
+to describe them separately, it is to be clearly understood that
+clinically they merge one into another, and it is not always possible to
+determine in which connective-tissue plane a given infection has
+originated.
+
+_Initial Stage._--Attention is usually first attracted to the condition
+by a sensation of tightness in the finger and tenderness when the part
+is squeezed or knocked against anything. In the course of a few hours
+the part becomes red and swollen; there is continuous pain, which soon
+assumes a throbbing character, particularly when the hand is dependent,
+and may be so severe as to prevent sleep, and the patient may feel
+generally out of sorts.
+
+If a constricting band is applied at this stage, the infection can
+usually be checked and the occurrence of suppuration prevented. If this
+fails, or if the condition is allowed to go untreated, the inflammatory
+reaction increases and terminates in suppuration, giving rise to one or
+other of the forms of whitlow to be described.
+
+_The Purulent Blister._--In the most superficial variety, pus forms
+between the rete Malpighii and the stratum corneum of the skin, the
+latter being raised as a blister in which fluctuation can be detected
+(Fig. 9, a). This is commonly met with in the palm of the hand of
+labouring men who have recently resumed work after a spell of idleness.
+When the blister forms near the tip of the finger, the pus burrows under
+the nail--which corresponds to the stratum corneum--raising it from its
+bed.
+
+There is some local heat and discoloration, and considerable pain and
+tenderness, but little or no constitutional disturbance. Superficial
+lymphangitis may extend a short distance up the forearm. By clipping
+away the raised epidermis, and if necessary the nail, the pus is allowed
+to escape, and healing speedily takes place.
+
+_Whitlow at the Nail Fold._--This variety, which is met with among those
+who handle septic material, occurs in the sulcus between the nail and
+the skin, and is due to the introduction of infective matter at the root
+of the nail (Fig. 9, b). A small focus of suppuration forms under the
+nail, with swelling and redness of the nail fold, causing intense pain
+and discomfort, interfering with sleep, and producing a constitutional
+reaction out of all proportion to the local lesion.
+
+To allow the pus to escape, it is necessary, under local anaesthesia, to
+cut away the nail fold as well as the portion of nail in the infected
+area, or, it may be, to remove the nail entirely. If only a small
+opening is made in the nail it is apt to be blocked by granulations.
+
+[Illustration: FIG. 9.--Diagram of various forms of Whitlow.
+  a = Purulent blister.
+  b = Suppuration at nail fold.
+  c = Subcutaneous whitlow.
+  d = Whitlow in sheath of flexor tendon (e). ]
+
+_Subcutaneous Whitlow._--In this variety the infection manifests itself
+as a cellulitis of the pulp of the finger (Fig. 9, c), which sometimes
+spreads towards the palm of the hand. The finger becomes red, swollen,
+and tense; there is severe throbbing pain, which is usually worst at
+night and prevents sleep, and the part is extremely tender on pressure.
+When the palm is invaded there may be marked oedema of the back of the
+hand, the dense integument of the palm preventing the swelling from
+appearing on the front. The pus may be under such tension that
+fluctuation cannot be detected. The patient is usually able to flex the
+finger to a certain extent without increasing the pain--a point which
+indicates that the tendon sheaths have not been invaded. The
+suppurative process may, however, spread to the tendon sheaths, or even
+to the bone. Sometimes the excessive tension and virulent toxins induce
+actual gangrene of the distal part, or even of the whole finger. There
+is considerable constitutional disturbance, the temperature often
+reaching 101 or 102 F.
+
+The treatment consists in applying a constriction band and making an
+incision over the centre of the most tender area, care being taken to
+avoid opening the tendon sheath lest the infection be conveyed to it.
+Moist dressings should be employed while the suppuration lasts. Carbolic
+fomentations, however, are to be avoided on account of the risk of
+inducing gangrene.
+
+_Whitlow of the Tendon Sheaths._--In this form the main incidence of the
+infection is on the sheaths of the flexor tendons, but it is not always
+possible to determine whether it started there or spread thither from
+the subcutaneous cellular tissue (Fig. 9, d). In some cases both
+connective tissue planes are involved. The affected finger becomes red,
+painful, and swollen, the swelling spreading to the dorsum. The
+involvement of the tendon sheath is usually indicated by the patient
+being unable to flex the finger, and by the pain being increased when he
+attempts to do so. On account of the anatomical arrangement of the
+tendon sheaths, the process may spread into the forearm--directly in the
+case of the thumb and little finger, and after invading the palm in the
+case of the other fingers--and there give rise to a diffuse cellulitis
+which may result in sloughing of fasciae and tendons. When the infection
+spreads into the common flexor sheath under the transverse carpal
+(anterior annular) ligament, it is not uncommon for the intercarpal and
+wrist joints to become implicated. Impaired movement of tendons and
+joints is, therefore, a common sequel to this variety of whitlow.
+
+The _treatment_ consists in inducing passive hyperaemia by Bier's method,
+and, if this is done early, suppuration may be avoided. If pus forms,
+small incisions are made, under local anaesthesia, to relieve the tension
+in the sheath and to diminish the risk of the tendons sloughing. No form
+of drain should be inserted. In the fingers the incisions should be made
+in the middle line, and in the palm they should be made over the
+metacarpal bones to avoid the digital vessels and nerves. If pus has
+spread under the transverse carpal ligament, the incision must be made
+above the wrist. Passive movements and massage must be commenced as
+early as possible and be perseveringly employed to diminish the
+formation of adhesions and resulting stiffness.
+
+_Subperiosteal Whitlow._--This form is usually an extension of the
+subcutaneous or of the thecal variety, but in some cases the
+inflammation begins in the periosteum--usually of the terminal phalanx.
+It may lead to necrosis of a portion or even of the entire phalanx. This
+is usually recognised by the persistence of suppuration long after the
+acute symptoms have passed off, and by feeling bare bone with the probe.
+In such cases one or more of the joints are usually implicated also, and
+lateral mobility and grating may be elicited. Recovery does not take
+place until the dead bone is removed, and the usefulness of the finger
+is often seriously impaired by fibrous or bony ankylosis of the
+interphalangeal joints. This may render amputation advisable when a
+stiff finger is likely to interfere with the patient's occupation.
+
+
+SUPPURATIVE CELLULITIS IN DIFFERENT SITUATIONS
+
+_Cellulitis of the forearm_ is usually a sequel to one of the deeper
+varieties of whitlow.
+
+In the _region of the elbow-joint_, cellulitis is common around the
+olecranon. It may originate as an inflammation of the olecranon bursa,
+or may invade the bursa secondarily. In exceptional cases the
+elbow-joint is also involved.
+
+Cellulitis of the _axilla_ may originate in suppuration in the lymph
+glands, following an infected wound of the hand, or it may spread from a
+septic wound on the chest wall or in the neck. In some cases it is
+impossible to discover the primary seat of infection. A firm, brawny
+swelling forms in the armpit and extends on to the chest wall. It is
+attended with great pain, which is increased on moving the arm, and
+there is marked constitutional disturbance. When suppuration occurs, its
+spread is limited by the attachments of the axillary fascia, and the pus
+tends to burrow on to the chest wall beneath the pectoral muscles, and
+upwards towards the shoulder-joint, which may become infected. When the
+pus forms in the axillary space, the treatment consists in making free
+incisions, which should be placed on the thoracic side of the axilla to
+avoid the axillary vessels and nerves. If the pus spreads on to the
+chest wall, the abscess should be opened below the clavicle by Hilton's
+method, and a counter opening may be made in the axilla.
+
+Cellulitis of the _sole of the foot_ may follow whitlow of the toes.
+
+In the _region of the ankle_ cellulitis is not common; but _around the
+knee_ it frequently occurs in relation to the prepatellar bursa and to
+the popliteal lymph glands, and may endanger the knee-joint. It is also
+met with in the _groin_ following on inflammation and suppuration of the
+inguinal glands, and cases are recorded in which the sloughing process
+has implicated the femoral vessels and led to secondary haemorrhage.
+
+Cellulitis of the scalp, orbit, neck, pelvis, and perineum will be
+considered with the diseases of these regions.
+
+
+CHRONIC SUPPURATION
+
+While it is true that a chronic pyogenic abscess is sometimes met
+with--for example, in the breast and in the marrow of long bones--in the
+great majority of instances the formation of a chronic or cold abscess
+is the result of the action of the tubercle bacillus. It is therefore
+more convenient to study this form of suppuration with tuberculosis
+(p. 139).
+
+
+SINUS AND FISTULA
+
+#Sinus.#--A sinus is a track leading from a focus of suppuration to a
+cutaneous or mucous surface. It usually represents the path by which the
+discharge escapes from an abscess cavity that has been prevented from
+closing completely, either from mechanical causes or from the persistent
+formation of discharge which must find an exit. A sinus is lined by
+granulation tissue, and when it is of long standing the opening may be
+dragged below the level of the surrounding skin by contraction of the
+scar tissue around it. As a sinus will persist until the obstacle to
+closure of the original abscess is removed, it is necessary that this
+should be sought for. It may be a foreign body, such as a piece of dead
+bone, an infected ligature, or a bullet, acting mechanically or by
+keeping up discharge, and if the body is removed the sinus usually
+heals. The presence of a foreign body is often suggested by a mass of
+redundant granulations at the mouth of the sinus. If a sinus passes
+through a muscle, the repeated contractions tend to prevent healing
+until the muscle is kept at rest by a splint, or put out of action by
+division of its fibres. The sinuses associated with empyema are
+prevented from healing by the rigidity of the chest wall, and will only
+close after an operation which admits of the cavity being obliterated.
+In any case it is necessary to disinfect the track, and, it may be, to
+remove the unhealthy granulations lining it, by means of the sharp
+spoon, or to excise it bodily. To encourage healing from the bottom the
+cavity should be packed with bismuth or iodoform gauze. The healing of
+long and tortuous sinuses is often hastened by the injection of Beck's
+bismuth paste (p. 145). If disfigurement is likely to follow from
+cicatricial contraction--for example, in a sinus over the lower jaw
+associated with a carious tooth--the sinus should be excised and the raw
+surfaces approximated with stitches.
+
+The _tuberculous sinus_ is described under Tuberculosis.
+
+A #fistula# is an abnormal canal passing from a mucous surface to the
+skin or to another mucous surface. Fistulae resulting from suppuration
+usually occur near the natural openings of mucous canals--for example,
+on the cheek, as a salivary fistula; beside the inner angle of the eye,
+as a lacrymal fistula; near the ear, as a mastoid fistula; or close to
+the anus, as a fistula-in-ano. Intestinal fistulae are sometimes met with
+in the abdominal wall after strangulated hernia, operations for
+appendicitis, tuberculous peritonitis, and other conditions. In the
+perineum, fistulae frequently complicate stricture of the urethra.
+
+Fistulae also occur between the bladder and vagina (_vesico-vaginal
+fistula_), or between the bladder and the rectum (_recto-vesical
+fistula_).
+
+The _treatment_ of these various forms of fistula will be described in
+the sections dealing with the regions in which they occur.
+
+_Congenital fistulae_, such as occur in the neck from imperfect closure
+of branchial clefts, or in the abdomen from unobliterated foetal ducts
+such as the urachus or Meckel's diverticulum, will be described in their
+proper places.
+
+
+CONSTITUTIONAL MANIFESTATIONS OF PYOGENIC INFECTION
+
+We have here to consider under the terms Sapraemia, Septicaemia, and
+Pyaemia certain general effects of pyogenic infection, which, although
+their clinical manifestations may vary, are all associated with the
+action of the same forms of bacteria. They may occur separately or in
+combination, or one may follow on and merge into another.
+
+#Sapraemia#, or septic intoxication, is the name applied to a form of
+poisoning resulting from the absorption into the blood of the toxic
+products of pyogenic bacteria. These products, which are of the nature
+of alkaloids, act immediately on their entrance into the circulation,
+and produce effects in direct proportion to the amount absorbed. As the
+toxins are gradually eliminated from the body the symptoms abate, and if
+no more are introduced they disappear. Sapraemia in these respects,
+therefore, is comparable to poisoning by any other form of alkaloid,
+such as strychnin or morphin.
+
+_Clinical Features._--The symptoms of sapraemia seldom manifest
+themselves within twenty-four hours of an operation or injury, because
+it takes some time for the bacteria to produce a sufficient dose of
+their poisons. The onset of the condition is marked by a feeling of
+chilliness, sometimes amounting to a rigor, and a rise of temperature to
+102, 103, or 104 F., with morning remissions (Fig. 10). The heart's
+action is markedly depressed, and the pulse is soft and compressible.
+The appetite is lost, the tongue dry and covered with a thin
+brownish-red fur, so that it has the appearance of "dried beef." The
+urine is scanty and loaded with urates. In severe cases diarrhoea and
+vomiting of dark coffee-ground material are often prominent features.
+Death is usually impending when the skin becomes cold and clammy, the
+mucous membranes livid, the pulse feeble and fluttering, the discharges
+involuntary, and when a low form of muttering delirium is present.
+
+[Illustration: FIG. 10.--Charts of Acute sapraemia from (a) case of
+crushed foot, and (b) case of incomplete abortion.]
+
+A local form of septic infection is always present--it may be an
+abscess, an infected compound fracture, or an infection of the cavity of
+the uterus, for example, from a retained portion of placenta.
+
+_Treatment._--The first indication is the immediate and complete removal
+of the infected material. The wound must be freely opened, all
+blood-clot, discharge, or necrosed tissue removed, and the area
+disinfected by washing with sterilised salt solution, peroxide of
+hydrogen, or eusol. Stronger lotions are to be avoided as being likely
+to depress the tissues, and so interfere with protective phagocytosis.
+On account of its power of neutralising toxins, iodoform is useful in
+these cases, and is best employed by packing the wound with iodoform
+gauze, and treating it by the open method, if this is possible.
+
+The general treatment is carried out on the same lines as for other
+infective conditions.
+
+#Chronic sapraemia or Hectic Fever.#--Hectic fever differs from acute
+sapraemia merely in degree. It usually occurs in connection with
+tuberculous conditions, such as bone or joint disease, psoas abscess, or
+empyema, which have opened externally, and have thereby become infected
+with pyogenic organisms. It is gradual in its development, and is of a
+mild type throughout.
+
+[Illustration: FIG. 11.--Chart of Hectic Fever.]
+
+The pulse is small, feeble, and compressible, and the temperature rises
+in the afternoon or evening to 102 or 103 F. (Fig. 11), the cheeks
+becoming characteristically flushed. In the early morning the
+temperature falls to normal or below it, and the patient breaks into a
+profuse perspiration, which leaves him pale, weak, and exhausted. He
+becomes rapidly and markedly emaciated, even although in some cases the
+appetite remains good and is even voracious.
+
+The poisons circulating in the blood produce _waxy degeneration_ in
+certain viscera, notably the liver, spleen, kidneys, and intestines. The
+process begins in the arterial walls, and spreads thence to the
+connective-tissue structures, causing marked enlargement of the affected
+organs. Albuminuria, ascites, oedema of the lower limbs, clubbing of the
+fingers, and diarrhoea are among the most prominent symptoms of this
+condition.
+
+The _prognosis_ in hectic fever depends on the completeness with which
+the further absorption of toxins can be prevented. In many cases this
+can only be effected by an operation which provides for free drainage,
+and, if possible, the removal of infected tissues. The resulting wound
+is best treated by the open method. Even advanced waxy degeneration does
+not contra-indicate this line of treatment, as the diseased organs
+usually recover if the focus from which absorption of toxic material is
+taking place is completely eradicated.
+
+[Illustration: FIG. 12.--Chart of case of Septicaemia followed by
+Pyaemia.]
+
+#Septicaemia.#--This form of blood-poisoning is the result of the action
+of pyogenic bacteria, which not only produce their toxins at the primary
+seat of infection, but themselves enter the blood-stream and are carried
+to other parts, where they settle and produce further effects.
+
+_Clinical Features._--There may be an incubation period of some hours
+between the infection and the first manifestation of acute septicaemia.
+In such conditions as acute osteomyelitis or acute peritonitis, we see
+the most typical clinical pictures of this condition. The onset is
+marked by a chill, or a rigor, which may be repeated, while the
+temperature rises to 103 or 104 F., although in very severe cases the
+temperature may remain subnormal throughout, the virulence of the toxins
+preventing reaction. It is in the general appearance of the patient and
+in the condition of the pulse that we have our best guides as to the
+severity of the condition. If the pulse remains firm, full, and regular,
+and does not exceed 110 or even 120, while the temperature is moderately
+raised, the outlook is hopeful; but when the pulse becomes small and
+compressible, and reaches 130 or more, especially if at the same time
+the temperature is low, a grave prognosis is indicated. The tongue is
+often dry and coated with a black crust down the centre, while the sides
+are red. It is a good omen when the tongue becomes moist again. Thirst
+is most distressing, especially in septicaemia of intestinal origin.
+Persistent vomiting of dark-brown material is often present, and
+diarrhoea with blood-stained stools is not uncommon. The urine is small
+in amount, and contains a large proportion of urates. As the poisons
+accumulate, the respiration becomes shallow and laboured, the face of a
+dull ashy grey, the nose pinched, and the skin cold and clammy.
+Capillary haemorrhages sometimes take place in the skin or mucous
+membranes; and in a certain proportion of cases cutaneous eruptions
+simulating those of scarlet fever or measles appear, and are apt to lead
+to errors in diagnosis. In other cases there is slight jaundice. The
+mental state is often one of complete apathy, the patient failing to
+realise the gravity of his condition; sometimes there is delirium.
+
+The _prognosis_ is always grave, and depends on the possibility of
+completely eradicating the focus of infection, and on the reserve force
+the patient has to carry him over the period during which he is
+eliminating the poison already circulating in his blood.
+
+The _treatment_ is carried out on the same lines as in sapraemia, but it
+is less likely to be successful owing to the organisms having entered
+the circulation. When possible, the primary focus of infection should be
+dealt with.
+
+#Pyaemia# is a form of blood-poisoning characterised by the development
+of secondary foci of suppuration in different parts of the body. Toxins
+are thus introduced into the blood, not only at the primary seat of
+infection, but also from each of these metastatic collections. Like
+septicaemia, this condition is due to pyogenic bacteria, the
+_streptococcus pyogenes_ being the commonest organism found. The primary
+infection is usually in a wound--for example, a compound fracture--but
+cases occur in which the point of entrance of the bacteria is not
+discoverable. The dissemination of the organisms takes place through the
+medium of infected emboli which form in a thrombosed vein in the
+vicinity of the original lesion, and, breaking loose, are carried
+thence in the blood-stream. These emboli lodge in the minute vessels of
+the lungs, spleen, liver, kidneys, pleura, brain, synovial membranes, or
+cellular tissue, and the bacteria they contain give rise to secondary
+foci of suppuration. Secondary abscesses are thus formed in those parts,
+and these in turn may be the starting-point of new emboli which give
+rise to fresh areas of pus formation. The organs above named are the
+commonest situations of pyaemic abscesses, but these may also occur in
+the bone marrow, the substance of muscles, the heart and pericardium,
+lymph glands, subcutaneous tissue, or, in fact, in any tissue of the
+body. Organisms circulating in the blood are prone to lodge on the
+valves of the heart and give rise to endocarditis.
+
+[Illustration: FIG. 13.--Chart of Pyaemia following on Acute
+Osteomyelitis.]
+
+_Clinical Features._--Before antiseptic surgery was practised, pyaemia
+was a common complication of wounds. In the present day it is not only
+infinitely less common, but appears also to be of a less severe type.
+Its rarity and its mildness may be related as cause and effect, because
+it was formerly found that pyaemia contracted from a pyaemic patient was
+more virulent than that from other sources.
+
+In contrast with sapraemia and septicaemia, pyaemia is late of developing,
+and it seldom begins within a week of the primary infection. The first
+sign is a feeling of chilliness, or a violent rigor lasting for perhaps
+half an hour, during which time the temperature rises to 103, 104, or
+105 F. In the course of an hour it begins to fall again, and the
+patient breaks into a profuse sweat. The temperature may fall several
+degrees, but seldom reaches the normal. In a few days there is a second
+rigor with rise of temperature, and another remission, and such attacks
+may be repeated at diminishing intervals during the course of the
+illness (Figs. 12 and 13). The pulse is soft, and tends to remain
+abnormally rapid even when the temperature falls nearly to normal.
+
+The face is flushed, and wears a drawn, anxious expression, and the eyes
+are bright. A characteristic sweetish odour, which has been compared to
+that of new-mown hay, can be detected in the breath and may pervade the
+patient. The appetite is lost; there may be sickness and vomiting and
+profuse diarrhoea; and the patient emaciates rapidly. The skin is
+continuously hot, and has often a peculiar pungent feel. Patches of
+erythema sometimes appear scattered over the body. The skin may assume a
+dull sallow or earthy hue, or a bright yellow icteric tint may appear.
+The conjunctivae also may be yellow. In the latter stages of the disease
+the pulse becomes small and fluttering; the tongue becomes dry and
+brown; sordes collect on the teeth; and a low muttering form of delirium
+supervenes.
+
+Secondary infection of the parotid gland frequently occurs, and gives
+rise to a suppurative parotitis. This condition is associated with
+severe pain, gradually extending from behind the angle of the jaw on to
+the face. There is also swelling over the gland, and eventually
+suppuration and sloughing of the gland tissue and overlying skin.
+
+Secondary abscesses in the lymph glands, subcutaneous tissue, or joints
+are often so insidious and painless in their development that they are
+only discovered accidentally. When the abscess is evacuated, healing
+often takes place with remarkable rapidity, and with little impairment
+of function.
+
+The general symptoms may be simulated by an attack of malaria.
+
+_Prognosis._--The prognosis in acute pyaemia is much less hopeless than
+it once was, a considerable proportion of the patients recovering. In
+acute cases the disease proves fatal in ten days or a fortnight, death
+being due to toxaemia. Chronic cases often run a long course, lasting for
+weeks or even months, and prove fatal from exhaustion and waxy disease
+following on prolonged suppuration.
+
+_Treatment._--In such conditions as compound fractures and severe
+lacerated wounds, much can be done to avert the conditions which lead to
+pyaemia, by applying a Bier's constricting bandage as soon as there is
+evidence of infection having taken place, or even if there is reason to
+suspect that the wound is not aseptic.
+
+If sepsis is already established, and evidence of general infection is
+present, the wound should be opened up sufficiently to admit of thorough
+disinfection and drainage, and the constricting bandage applied to aid
+the defensive processes going on in the tissues. If these measures fail,
+amputation of the limb may be the only means of preventing further
+dissemination of infective material from the primary source of
+infection.
+
+Attempts have been made to interrupt the channel along which the
+infective emboli spread, by ligating or resecting the main vein of the
+affected part, but this is seldom feasible except in the case of the
+internal jugular vein for infection of the transverse sinus.
+
+Secondary abscesses must be aspirated or opened and drained whenever
+possible.
+
+The general treatment is conducted on the same lines as on other forms
+of pyogenic infection.
+
+
+
+
+CHAPTER V
+
+ULCERATION AND ULCERS
+
+
+Definitions--Clinical examination of an ulcer--The healing
+    sore.--Classification of ulcers--A. According to cause:
+    _Traumatism_, _Imperfect circulation_, _Imperfect nerve-supply_,
+    _Constitutional causes_--B. According to condition: _Healing_,
+    _Stationary_, _Spreading_.--Treatment.
+
+The process of _ulceration_ may be defined as the molecular or cellular
+death of tissue taking place on a free surface. It is essentially of the
+same nature as the process of suppuration, only that the purulent
+discharge, instead of collecting in a closed cavity and forming an
+abscess, at once escapes on the surface.
+
+An _ulcer_ is an open wound or sore in which there are present certain
+conditions tending to prevent it undergoing the natural process of
+repair. Of these, one of the most important is the presence of
+pathogenic bacteria, which by their action not only prevent healing, but
+so irritate and destroy the tissues as to lead to an actual increase in
+the size of the sore. Interference with the nutrition of a part by oedema
+or chronic venous congestion may impede healing; as may also induration
+of the surrounding area, by preventing the contraction which is such an
+important factor in repair. Defective innervation, such as occurs in
+injuries and diseases of the spinal cord, also plays an important part
+in delaying repair. In certain constitutional conditions, too--for
+example, Bright's disease, diabetes, or syphilis--the vitiated state of
+the tissues is an impediment to repair. Mechanical causes, such as
+unsuitable dressings or ill-fitting appliances, may also act in the same
+direction.
+
+#Clinical Examination of an Ulcer.#--In examining any ulcer, we
+observe--(1) Its _base_ or _floor_, noting the presence or absence of
+granulations, their disposition, size, colour, vascularity, and whether
+they are depressed or elevated in relation to the surrounding parts. (2)
+The _discharge_ as to quantity, consistence, colour, composition, and
+odour. (3) The _edges_, noting particularly whether or not the marginal
+epithelium is attempting to grow over the surface; also their shape,
+regularity, thickness, and whether undermined or overlapping, everted or
+depressed. (4) The _surrounding tissues_, as to whether they are
+congested, oedematous, inflamed, indurated, or otherwise. (5) Whether or
+not there is _pain_ or tenderness in the raw surface or its
+surroundings. (6) The _part of the body_ on which it occurs, because
+certain ulcers have special seats of election--for example, the varicose
+ulcer in the lower third of the leg, the perforating ulcer on the sole
+of the foot, and so on.
+
+#The Healing Sore.#--If a portion of skin be excised aseptically, and no
+attempt made to close the wound, the raw surface left is soon covered
+over with a layer of coagulated blood and lymph. In the course of a few
+days this is replaced by the growth of _granulations_, which are of
+uniform size, of a pinkish-red colour, and moist with a slight serous
+exudate containing a few dead leucocytes. They grow until they reach the
+level of the surrounding skin, and so fill the gap with a fine velvety
+mass of granulation tissue. At the edges, the young epithelium may be
+seen spreading in over the granulations as a fine bluish-white pellicle,
+which gradually covers the sore, becoming paler in colour as it
+thickens, and eventually forming the smooth, non-vascular covering of
+the cicatrix. There is no pain, and the surrounding parts are healthy.
+
+This may be used as a type with which to compare the ulcers seen at the
+bedside, so that we may determine how far, and in what particulars,
+these differ from the type; and that we may in addition recognise the
+conditions that have to be counteracted before the characters of the
+typical healing sore are assumed.
+
+For purposes of contrast we may indicate the characters of an open sore
+in which bacterial infection with pathogenic bacteria has taken place.
+The layer of coagulated blood and lymph becomes liquefied and is thrown
+off, and instead of granulations being formed, the tissues exposed on
+the floor of the ulcer are destroyed by the bacterial toxins, with the
+formation of minute sloughs and a quantity of pus.
+
+The discharge is profuse, thin, acrid, and offensive, and consists of
+pus, broken-down blood-clot, and sloughs. The edges are inflamed,
+irregular, and ragged, showing no sign of growing epithelium--on the
+contrary, the sore may be actually increasing in area by the
+breaking-down of the tissues at its margins. The surrounding parts are
+hot, red, swollen, and oedematous; and there is pain and tenderness both
+in the sore itself and in the parts around.
+
+#Classification of Ulcers.#--The nomenclature of ulcers is much involved
+and gives rise to great confusion, chiefly for the reason that no one
+basis of classification has been adopted. Thus some ulcers are named
+according to the causes at work in producing or maintaining them--for
+example, the traumatic, the septic, and the varicose ulcer; some from
+the constitutional element present, as the gouty and the diabetic ulcer;
+and others according to the condition in which they happen to be when
+seen by the surgeon, such as the weak, the inflamed, and the callous
+ulcer.
+
+So long as we retain these names it will be impossible to find a single
+basis for classification; and yet many of the terms are so descriptive
+and so generally understood that it is undesirable to abolish them. We
+must therefore remain content with a clinical arrangement of ulcers,--it
+cannot be called a classification,--considering any given ulcer from two
+points of view: first its _cause_, and second its _present condition_.
+This method of studying ulcers has the practical advantage that it
+furnishes us with the main indications for treatment as well as for
+diagnosis: the cause must be removed, and the condition so modified as
+to convert the ulcer into an aseptic healing sore.
+
+A. #Arrangement of Ulcers according to their Cause.#--Although any given
+ulcer may be due to a combination of causes, it is convenient to
+describe the following groups:
+
+_Ulcers due to Traumatism._--Traumatism in the form of a _crush_ or
+_bruise_ is a frequent cause of ulcer formation, acting either by
+directly destroying the skin, or by so diminishing its vitality that it
+is rendered a suitable soil for bacteria. If these gain access, in the
+course of a few days the damaged area of skin becomes of a greyish
+colour, blebs form on it, and it undergoes necrosis, leaving an
+unhealthy raw surface when the slough separates.
+
+_Heat_ and _prolonged exposure to the Rontgen rays_ or _to radium
+emanations_ act in a similar way.
+
+The _pressure_ of improperly padded splints or other appliances may so
+far interfere with the circulation of the part pressed upon, that the
+skin sloughs, leaving an open sore. This is most liable to occur in
+patients who suffer from some nerve lesion--such as anterior
+poliomyelitis, or injury of the spinal cord or nerve-trunks.
+Splint-pressure sores are usually situated over bony prominences, such
+as the malleoli, the condyles of the femur or humerus, the head of the
+fibula, the dorsum of the foot, or the base of the fifth metatarsal
+bone. On removing the splint, the skin of the part pressed upon is found
+to be of a red or pink colour, with a pale grey patch in the centre,
+which eventually sloughs and leaves an ulcer. Certain forms of
+_bed-sore_ are also due to prolonged pressure.
+
+Pressure sores are also known to have been produced artificially by
+malingerers and hysterical subjects.
+
+[Illustration: FIG. 14.--Leg Ulcers associated with Varicose Veins and
+Pigmentation of the Skin.]
+
+_Ulcers due to Imperfect Circulation._--Imperfect circulation is an
+important causative factor in ulceration, especially when it is the
+_venous return_ that is defective. This is best illustrated in the
+so-called _leg ulcer_, which occurs most frequently on the front and
+medial aspect of the lower third of the leg. At this point the
+anastomosis between the superficial and deep veins of the leg is less
+free than elsewhere, so that the extra stress thrown upon the surface
+veins interferes with the nutrition of the skin (Hilton). The importance
+of imperfect venous return in the causation of such ulcers is evidenced
+by the fact that as soon as the condition of the circulation is improved
+by confining the patient to bed and elevating the limb, the ulcer begins
+to heal, even although all methods of local treatment have hitherto
+proved ineffectual. In a considerable number of cases, but by no means
+in all, this form of ulcer is associated with the presence of varicose
+veins, and in such cases it is spoken of as the _varicose ulcer_ (Fig. 14).
+The presence of varicose veins is frequently associated with a
+diffuse brownish or bluish pigmentation of the skin of the lower third
+of the leg, or with an obstinate form of dermatitis (_varicose eczema_),
+and the scratching or rubbing of the part is liable to cause a breach of
+the surface and permit of infection which leads to ulceration. Varicose
+ulcers may also originate from the bursting of a small peri-phlebitic
+abscess.
+
+Varicose veins in immediate relation to the base of a large chronic
+ulcer usually become thrombosed, and in time are reduced to fibrous
+cords, and therefore in such cases haemorrhage is not a common
+complication. In smaller and more superficial ulcers, however, the
+destructive process is liable to implicate the wall of the vessel before
+the occurrence of thrombosis, and to lead to profuse and it may be
+dangerous bleeding.
+
+These ulcers are at first small and superficial, but from want of care,
+from continued standing or walking, or from injudicious treatment, they
+gradually become larger and deeper. They are not infrequently multiple,
+and this, together with their depth, may lead to their being mistaken
+for ulcers due to syphilis. The base of the ulcer is covered with
+imperfectly formed, soft, oedematous granulations, which give off a thin
+sero-purulent discharge. The edges are slightly inflamed, and show no
+evidence of healing. The parts around are usually pigmented and slightly
+oedematous, and as a rule there is little pain. This variety of ulcer is
+particularly prone to pass into the condition known as callous.
+
+In _anaemic_ patients, especially young girls, ulcers are occasionally
+met with which have many of the clinical characters of those associated
+with imperfect venous return. They are slow to heal, and tend to pass
+into the condition known as weak.
+
+_Ulcers due to Interference with Nerve-Supply._--Any interference with
+the nerve-supply of the superficial tissues predisposes to ulceration.
+For example, _trophic_ ulcers are liable to occur in injuries or
+diseases of the spinal cord, in cerebral paralysis, in limbs weakened by
+poliomyelitis, in ascending or peripheral neuritis, or after injuries of
+nerve-trunks.
+
+The _acute bed-sore_ is a rapidly progressing form of ulceration, often
+amounting to gangrene, of portions of skin exposed to pressure when
+their trophic nerve-supply has been interfered with.
+
+[Illustration: FIG. 15.--Perforating Ulcers of Sole of Foot.
+
+(From Photograph lent by Sir Montagu Cotterill.)]
+
+The _perforating ulcer of the foot_ is a peculiar type of sore which
+occurs in association with the different forms of peripheral neuritis,
+and with various lesions of the brain and spinal cord, such as general
+paralysis, locomotor ataxia, or syringo-myelia (Fig. 15). It also occurs
+in patients suffering from glycosuria, and is usually associated with
+arterio-sclerosis--local or general. Perforating ulcer is met with most
+frequently under the head of the metatarsal bone of the great toe. A
+callosity forms and suppuration occurs under it, the pus escaping
+through a small hole in the centre. The process slowly and gradually
+spreads deeper and deeper, till eventually the bone or joint is reached,
+and becomes implicated in the destructive process--hence the term
+"perforating ulcer." The flexor tendons are sometimes destroyed, the toe
+being dorsiflexed by the unopposed extensors. The depth of the track
+being so disproportionate to its superficial area, the condition closely
+simulates a tuberculous sinus, for which it is liable to be mistaken.
+The raw surface is absolutely insensitive, so that the probe can be
+freely employed without the patient even being aware of it or suffering
+the least discomfort--a significant fact in diagnosis. The cavity is
+filled with effete and decomposing epidermis, which has a most offensive
+odour. The chronic and intractable character of the ulcer is due to
+interference with the trophic nerve-supply of the parts, and to the fact
+that the epithelium of the skin grows in and lines the track leading
+down to the deepest part of the ulcer and so prevents closure. While
+they are commonest on the sole of the foot and other parts subjected to
+pressure, perforating ulcers are met with on the sides and dorsum of the
+foot and toes, on the hands, and on other parts where no pressure has
+been exerted.
+
+The _tuberculous ulcer_, so often seen in the neck, in the vicinity of
+joints, or over the ribs and sternum, usually results from the bursting
+through the skin of a tuberculous abscess. The base is soft, pale, and
+covered with feeble granulations and grey shreddy sloughs. The edges are
+of a dull blue or purple colour, and gradually thin out towards their
+free margins, and in addition are characteristically undermined, so that
+a probe can be passed for some distance between the floor of the ulcer
+and the thinned-out edges. Thin, devitalised tags of skin often stretch
+from side to side of the ulcer. The outline is irregular; small
+perforations often occur through the skin, and a thin, watery discharge,
+containing grey shreds of tuberculous debris, escapes.
+
+_Bazin's Disease._--This term is applied to an affection of the skin and
+subcutaneous tissue which bears certain resemblances to tuberculosis. It
+is met with almost exclusively between the knee and the ankle, and it
+usually affects both legs. It is commonest in girls of delicate
+constitution, in whose family history there is evidence of a tuberculous
+taint. The patient often presents other lesions of a tuberculous
+character, notably enlarged cervical glands, and phlyctenular
+ophthalmia. The tubercle bacillus has rarely been found, but we have
+always observed characteristic epithelioid cells and giant cells in
+sections made from the edge or floor of the ulcer.
+
+[Illustration: FIG. 16.--Bazin's Disease in a girl aet. 16.]
+
+The condition begins by the formation in the skin and subcutaneous
+tissue of dusky or livid nodules of induration, which soften and
+ulcerate, forming small open sores with ragged and undermined edges, not
+unlike those resulting from the breaking down of superficial syphilitic
+gummata (Fig. 16). Fresh crops of nodules appear in the neighbourhood of
+the ulcers, and in turn break down. While in the nodular stage the
+affection is sometimes painful, but with the formation of the ulcer the
+pain subsides.
+
+The disease runs a chronic course, and may slowly extend over a wide
+area in spite of the usual methods of treatment. After lasting for some
+months, or even years, however, it may eventually undergo spontaneous
+cure. The most satisfactory treatment is to excise the affected tissues
+and fill the gap with skin-grafts.
+
+[Illustration: FIG. 17.--Syphilitic Ulcers in region of Knee, showing
+punched-out appearance and raised indurated edges.]
+
+The _syphilitic ulcer_ is usually formed by the breaking down of a
+cutaneous or subcutaneous gumma in the tertiary stage of syphilis. When
+the gummatous tissue is first exposed by the destruction of the skin or
+mucous membrane covering it, it appears as a tough greyish slough,
+compared to "wash leather," which slowly separates and leaves a more or
+less circular, deep, punched-out gap which shows a few feeble unhealthy
+granulations and small sloughs on its floor. The edges are raised and
+indurated; and the discharge is thick, glairy, and peculiarly offensive.
+The parts around the ulcer are congested and of a dark brown colour.
+There are usually several such ulcers together, and as they tend to heal
+at one part while they spread at another, the affected area assumes a
+sinuous or serpiginous outline. Syphilitic ulcers may be met with in any
+part of the body, but are most frequent in the upper part of the leg
+(Fig. 17), especially around the knee-joint in women, and over the ribs
+and sternum. On healing, they usually leave a depressed and adherent
+cicatrix.
+
+The _scorbutic ulcer_ occurs in patients suffering from scurvy, and is
+characterised by its prominent granulations, which show a marked
+tendency to bleed, with the formation of clots, which dry and form a
+spongy crust on the surface.
+
+In _gouty_ patients small ulcers which are exceedingly irritable and
+painful are liable to occur.
+
+_Ulcers associated with Malignant Disease._--Cancer and sarcoma when
+situated in the subcutaneous tissue may destroy the overlying skin so
+that the substance of the tumour is exposed. The fungating masses thus
+produced are sometimes spoken of as malignant ulcers, but as they are
+essentially different in their nature from all other forms of ulcers,
+and call for totally different treatment, it is best to consider them
+along with the tumours with which they are associated. Rodent ulcer,
+which is one form of cancer of the skin, will be discussed with new
+growths of the skin.
+
+B. #Arrangement of Ulcers according to their Condition.#--Having arrived
+at an opinion as to the cause of a given ulcer, and placed it in one or
+other of the preceding groups, the next question to ask is, In what
+condition do I find this ulcer at the present moment?
+
+Any ulcer is in one of three states--healing, stationary, or spreading;
+although it is not uncommon to find healing going on at one part while
+the destructive process is extending at another.
+
+_The Healing Condition._--The process of healing in an ulcer has already
+been studied, and we have learned that it takes place by the formation
+of granulation tissue, which becomes converted into connective tissue,
+and is covered over by epithelium growing in from the edges.
+
+Those ulcers which are _stationary_--that is, neither healing nor
+spreading--may be in one of several conditions.
+
+_The Weak Condition._--Any ulcer may get into a weak state from
+receiving a blood supply which is defective either in quantity or in
+quality. The granulations are small and smooth, and of a pale yellow or
+grey colour, the discharge is small in amount, and consists of thin
+serum and a few pus cells, and as this dries on the edges it forms scabs
+which interfere with the growth of epithelium.
+
+Should the part become oedematous, either from general causes, such as
+heart or kidney disease, or from local causes, such as varicose veins,
+the granulations share in the oedema, and there is an abundant serous
+discharge.
+
+The excessive use of moist dressings leads to a third variety of weak
+ulcer--namely, one in which the granulations become large, soft, pale,
+and flabby, projecting beyond the level of the skin and overlapping the
+edges, which become pale and sodden. The term "proud flesh" is popularly
+applied to such redundant granulations.
+
+[Illustration: FIG. 18.--Callous Ulcer, showing thickened edges and
+indurated swelling of surrounding parts.]
+
+_The Callous Condition._--This condition is usually met with in ulcers
+on the lower third of the leg, and is often associated with the presence
+of varicose veins. It is chiefly met with in hospital practice. The want
+of healing is mainly due to impeded venous return and to oedema and
+induration of the surrounding skin and cellular tissues (Fig. 18). The
+induration results from coagulation and partial organisation of the
+inflammatory effusion, and prevents the necessary contraction of the
+sore. The base of a callous ulcer lies at some distance below the level
+of the swollen, thickened, and white edges, and presents a glazed
+appearance, such granulations as are present being unhealthy and
+irregular. The discharge is usually watery, and cakes in the dressing.
+When from neglect and want of cleanliness the ulcer becomes inflamed,
+there is considerable pain, and the discharge is purulent and often
+offensive.
+
+The prolonged hyperaemia of the tissues in relation to a callous ulcer of
+the leg often leads to changes in the underlying bones. The periosteum
+is abnormally thick and vascular, the superficial layers of the bone
+become injected and porous, and the bones, as a whole, are thickened. In
+the macerated bone "the surface is covered with irregular,
+stalactite-like processes or foliaceous masses, which, to a certain
+extent, follow the line of attachment of the interosseous membrane and
+of the intermuscular septa" (Cathcart) (Fig. 19). When the whole
+thickness of the soft tissues is destroyed by the ulcerative process,
+the area of bone that comes to form the base of the ulcer projects as a
+flat, porous node, which in its turn may be eroded. These changes as
+seen in the macerated specimen are often mistaken for disease
+originating in the bone.
+
+[Illustration: FIG. 19.--Tibia and Fibula, showing changes due to
+chronic ulcer of leg.]
+
+The _irritable condition_ is met with in ulcers which occur, as a rule,
+just above the external malleolus in women of neurotic temperament. They
+are small in size and have prominent granulations, and by the aid of a
+probe points of excessive tenderness may be discovered. These, Hilton
+believed, correspond to exposed nerve filaments.
+
+_Ulcers which are spreading_ may be met with in one of several
+conditions.
+
+_The Inflamed Condition._--Any ulcer may become acutely inflamed from
+the access of fresh organisms, aided by mechanical irritation from
+trauma, ill-fitting splints or bandages, or want of rest, or from
+chemical irritants, such as strong antiseptics. The best clinical
+example of an inflamed ulcer is the venereal soft sore. The base of the
+ulcer becomes red and angry-looking, the granulations disappear, and a
+copious discharge of thin yellow pus, mixed with blood, escapes. Sloughs
+of granulation tissue or of connective tissue may form. The edges become
+red, ragged, and everted, and the ulcer increases in size by spreading
+into the inflamed and oedematous surrounding tissues. Such ulcers are
+frequently multiple. Pain is a constant symptom, and is often severe,
+and there is usually some constitutional disturbance.
+
+The _phagedaenic condition_ is the result of an ulcer being infected with
+specially virulent bacteria. It occurs in syphilitic ulcers, and rapidly
+leads to a widespread destruction of tissue. It is also met with in the
+throat in some cases of scarlet fever, and may give rise to fatal
+haemorrhage by ulcerating into large blood vessels. All the local and
+constitutional signs of a severe septic infection are present.
+
+#Treatment of Ulcers.#--An ulcer is not only an immediate cause of
+suffering to the patient, crippling and incapacitating him for his work,
+but is a distinct and constant menace to his health: the prolonged
+discharge reduces his strength; the open sore is a possible source of
+infection by the organisms of suppuration, erysipelas, or other specific
+diseases; phlebitis, with formation of septic emboli, leading to pyaemia,
+is liable to occur; and in old persons it is not uncommon for ulcers of
+long standing to become the seat of cancer. In addition, the offensive
+odour of many ulcers renders the patient a source of annoyance and
+discomfort to others. The primary object of treatment in any ulcer is to
+bring it into the condition of a healing sore. When this has been
+effected, nature will do the rest, provided extraneous sources of
+irritation are excluded.
+
+Steps must be taken to facilitate the venous return from the ulcerated
+part, and to ensure that a sufficient supply of fresh, healthy blood
+reaches it. The septic element must be eliminated by disinfecting the
+ulcer and its surroundings, and any other sources of irritation must be
+removed.
+
+If the patient's health is below par, good nourishing food, tonics, and
+general hygienic treatment are indicated.
+
+_Management of a Healing Sore._--Perhaps the best dressing for a healing
+sore is a layer of Lister's perforated oiled-silk protective, which is
+made to cover the raw surface and the skin for about a quarter of an
+inch beyond the margins of the sore. Over this three or four thicknesses
+of sterilised gauze, wrung out of eusol, creolin, or sterilised water,
+are applied, and covered by a pad of absorbent wool. As far as possible
+the part should be kept at rest, and the position should be adjusted so
+as to favour the circulation in the affected area.
+
+The dressing may be renewed at intervals, and care must be taken to
+avoid any rough handling of the sore. Any discharge that lies on the
+surface should be removed by a gentle stream of lotion rather than by
+wiping. The area round the sore should be cleansed before the fresh
+dressing is applied.
+
+In some cases, healing goes on more rapidly under a dressing of weak
+boracic ointment (one-quarter the strength of the pharmacopoeial
+preparation). The growth of epithelium may be stimulated by a 6 to 8 per
+cent. ointment of scarlet-red.
+
+Dusting powders and poultice dressings are best avoided in the treatment
+of healing sores.
+
+In extensive ulcers resulting from recent burns, if the granulations are
+healthy and aseptic, skin-grafts may safely be placed on them directly.
+If, however, their asepticity cannot be relied upon, it is necessary to
+scrape away the superficial layer of the granulations, the young fibrous
+tissue underneath being conserved, as it is sufficiently vascular to
+nourish the grafts placed on it.
+
+#Treatment of Special Varieties of Ulcers.#--Before beginning to treat a
+given ulcer, two questions have to be answered--first, What are the
+causative conditions present? and second, In what condition do I find
+the ulcer?--in other words, In what particulars does it differ from a
+healthy healing sore?
+
+If the cause is a local one, it must be removed; if a constitutional
+one, means must be taken to counteract it. This done, the condition of
+the ulcer must be so modified as to bring it into the state of a healing
+sore, after which it will be managed on the lines already laid down.
+
+#Treatment in relation to the Cause of the Ulcer.#--_Traumatic
+Group._--The _prophylaxis_ of these ulcers consists in excluding
+bacteria, by cleansing crushed or bruised parts, and applying sterilised
+dressings and properly adjusted splints. If there is reason to fear that
+the disinfection has not been complete, a Bier's constricting bandage
+should be applied for some hours each day. These measures will often
+prevent a grossly injured portion of skin dying, and will ensure
+asepticity should it do so. In the event of the skin giving way, the
+same form of dressing should be continued till the slough has separated
+and a healthy granulating surface is formed. The protective dressing
+appropriate to a healing sore is then substituted. _Pressure sores_ are
+treated on the same lines.
+
+The treatment of ulcers caused by _burns and scalds_ will be described
+later.
+
+In _ulcers of the leg due to interference with the venous return_, the
+primary indication is to elevate the limb in order to facilitate the
+flow of the blood in the veins, and so admit of fresh blood reaching the
+part. The limb may be placed on pillows, or the foot of the bed raised
+on blocks, so that the ulcer lies on a higher level than the heart.
+Should varicose veins be present, the question of operative treatment
+must be considered.
+
+When an _imperfect nerve supply_ is the main factor underlying ulcer
+formation, prophylaxis is the chief consideration. In patients suffering
+from spinal injuries or diseases, cerebral paralysis, or affections of
+the peripheral nerves, all sources of irritation, such as ill-fitting
+splints, tight bandages, moist applications, and hot bottles, should be
+avoided. Any part liable to pressure, from the position of the patient
+or otherwise, must be carefully protected by pads of wool, air-cushions,
+or water-bags, and must be kept absolutely dry. The skin should be
+hardened by daily applications of methylated spirit.
+
+Should an ulcer form in spite of these precautions, the mildest
+antiseptics must be employed for bathing and dressing it, and as far as
+possible all dressings should be dry.
+
+The _perforating ulcer_ of the foot calls for special treatment. To
+avoid pressure on the sole of the foot, the patient must be confined to
+bed. As the main local obstacle to healing is the down-growth of
+epithelium along the sides of the ulcer, this must be removed by the
+knife or sharp spoon. The base also should be excised, and any bone
+which may have become involved should be gouged away, so as to leave a
+healthy and vascular surface. The cavity thus formed is stuffed with
+bismuth or iodoform gauze and encouraged to heal from the bottom. As the
+parts are insensitive an anaesthetic is not required. After the ulcer has
+healed, the patient should wear in his boot a thick felt sole with a
+hole cut out opposite the situation of the cicatrix. When a joint has
+been opened into, the difficulty of thoroughly getting rid of all
+unhealthy and infected granulations is so great that amputation may be
+advisable, but it is to be remembered that ulceration may recur in the
+stump if pressure is put upon it. The treatment of any nervous disease
+or glycosuria which may coexist is, of course, indicated.
+
+Exposure of the plantar nerves by an incision behind the medial
+malleolus, and subjecting them to forcible stretching, has been employed
+by Chipault and others in the treatment of perforating ulcers of the
+foot.
+
+The ulcer that forms in relation to callosities on the sole of the foot
+is treated by paring away all the thickened skin, after softening it
+with soda fomentations, removing the unhealthy granulations, and
+applying stimulating dressings.
+
+_Treatment of Ulcers due to Constitutional Causes._--When ulcers are
+associated with such diseases as tuberculosis, syphilis, diabetes,
+Bright's disease, scurvy, or gout, these must receive appropriate
+treatment.
+
+The local treatment of the _tuberculous ulcer_ calls for special
+mention. If the ulcer is of limited extent and situated on an exposed
+part of the body, the most satisfactory method is complete removal, by
+means of the knife, scissors, or sharp spoon, of the ulcerated surface
+and of all the infected area around it, so as to leave a healthy surface
+from which granulations may spring up. Should the raw surface left be
+likely to result in an unsightly scar or in cicatricial contraction,
+skin-grafting should be employed.
+
+For extensive ulcers on the limbs, the chest wall, or on other covered
+parts, or when operative treatment is contra-indicated, the use of
+tuberculin and exposure to the Rontgen rays have proved beneficial. The
+induction of passive hyperaemia, by Bier's or by Klapp's apparatus,
+should also be used, either alone or supplementary to other measures.
+
+No ulcerative process responds so readily to medicinal treatment as the
+_syphilitic ulcer_ does to the intra-venous administration of arsenical
+preparations of the "606" or "914" groups or to full doses of iodide of
+potassium and mercury, and the local application of black wash. When the
+ulceration has lasted for a long time, however, and is widespread and
+deep, the duration of treatment is materially shortened by a thorough
+scraping with the sharp spoon.
+
+#Treatment in relation to the Condition of the Ulcer.#--_Ulcers in a
+weak condition._--If the weak condition of the ulcer is due to anaemia
+or kidney disease, these affections must first be treated. Locally, the
+imperfect granulations should be scraped away, and some stimulating
+agent applied to the raw surface to promote the growth of healthy
+granulations. For this purpose the sore may be covered with gauze
+smeared with a 6 to 8 per cent. ointment of scarlet-red, the surrounding
+parts being protected from the irritant action of the scarlet-red by a
+layer of vaseline. A dressing of gauze moistened with eusol or of
+boracic lint wrung out of red lotion (2 grains of sulphate of zinc, and
+10 minims of compound tincture of lavender, to an ounce of water), and
+covered with a layer of gutta-percha tissue, is also useful.
+
+When the condition has resulted from the prolonged use of moist
+dressings, these must be stopped, the redundant granulations clipped
+away with scissors, the surface rubbed with silver nitrate or sulphate
+of copper (blue-stone), and dry dressings applied.
+
+When the ulcer has assumed the characters of a healing sore, skin-grafts
+may be applied to hasten cicatrisation.
+
+_Ulcers in a callous condition_ call for treatment in three
+directions--(1) The infective element must be eliminated. When the ulcer
+is foul, relays of charcoal poultices (three parts of linseed meal to
+one of charcoal), maintained for thirty-six to forty-eight hours, are
+useful as a preliminary step. The base of the ulcer and the thickened
+edges should then be freely scraped with a sharp spoon, and the
+resulting raw surface sponged over with undiluted carbolic acid or
+iodine, after which an antiseptic dressing is applied, and changed daily
+till healthy granulations appear. (2) The venous return must be
+facilitated by elevation of the limb and massage. (3) The induration of
+the surrounding parts must be got rid of before contraction of the sore
+is possible. For this purpose the free application of blisters, as first
+recommended by Syme, leaves little to be desired. Liquor epispasticus
+painted over the parts, or a large fly-blister (emplastrum cantharidis)
+applied all round the ulcer, speedily disperses the inflammatory
+products which cause the induration. The use of elastic pressure or of
+strapping, of hot-air baths, or the making of multiple incisions in the
+skin around the ulcer, fulfils the same object.
+
+As soon as the ulcer assumes the characters of a healing sore, it should
+be covered with skin-grafts, which furnish a much better cicatrix than
+that which forms when the ulcer is allowed to heal without such aid.
+
+A more radical method of treatment consists in excising the whole
+ulcer, including its edges and about a quarter of an inch of the
+surrounding tissue, as well as the underlying fibrous tissue, and
+grafting the raw surface.
+
+_Ambulatory Treatment._--When the circumstances of the patient forbid
+his lying up in bed, the healing of the ulcer is much delayed. He should
+be instructed to take every possible opportunity of placing the limb in
+an elevated position, and must constantly wear a firm bandage of
+_elastic webbing_. This webbing is porous and admits of evaporation of
+the skin and wound secretions--an advantage it has over Martin's rubber
+bandage. The bandage should extend from the toes to well above the knee,
+and should always be applied while the patient is in the recumbent
+position with the leg elevated, preferably before getting out of bed in
+the morning. Additional support is given to the veins if the bandage is
+applied as a figure of eight.
+
+We have found the following method satisfactory in out-patient
+practice. The patient lying on a couch, the limb is raised about
+eighteen inches and kept in this position for five minutes--till the
+excess of blood has left it. With the limb still raised, the ulcer with
+the surrounding skin is covered with a layer, about half an inch thick,
+of finely powdered boracic acid, and the leg, from foot to knee,
+excluding the sole, is enveloped in a thick layer of wood-wool wadding.
+This is held in position by ordinary cotton bandages, painted over with
+liquid starch; while the starch is drying the limb is kept elevated.
+With this appliance the patient may continue to work, and the dressing
+does not require to be changed oftener than once in three or four weeks
+(W. G. Richardson).
+
+When an ulcer becomes acutely _inflamed_ as a result of superadded
+infection, antiseptic measures are employed to overcome the infection,
+and ichthyol or other soothing applications may be used to allay the
+pain.
+
+The _phagedaenic ulcer_ calls for more energetic means of disinfection;
+the whole of the affected surface is touched with the actual cautery at
+a white heat, or is painted with pure carbolic acid. Relays of charcoal
+poultices are then applied until the spread of the disease is arrested.
+
+For the _irritable ulcer_ the most satisfactory treatment is complete
+excision and subsequent skin-grafting.
+
+
+
+
+CHAPTER VI
+
+GANGRENE
+
+
+Definition--Types: _Dry_, _Moist_--Varieties--Gangrene primarily due to
+    interference with circulation: _Senile gangrene_; _Embolic
+    gangrene_; _Gangrene following ligation of arteries_; _Gangrene
+    from mechanical causes_; _Gangrene from heat, chemical agents, and
+    cold_; _Diabetic gangrene_; _Gangrene associated with spasm of
+    blood vessels_; _Raynaud's disease_; _Angio-sclerotic gangrene_;
+    _Gangrene from ergot_. Bacterial varieties of gangrene.
+    _Pathology_--clinical varieties--_Acute infective gangrene_;
+    _Malignant oedema_; _Acute emphysematous_ or _gas gangrene_;
+    _Cancrum oris_, _etc_. Bed-sores: _Acute_; _chronic_.
+
+Gangrene or mortification is the process by which a portion of tissue
+dies _en masse_, as distinguished from the molecular or cellular death
+which constitutes ulceration. The dead portion is known as a _slough_.
+
+In this chapter we shall confine our attention to the process as it
+affects the limbs and superficial parts, leaving gangrene of the viscera
+to be described in regional surgery.
+
+
+TYPES OF GANGRENE
+
+Two distinct types of gangrene are met with, which, from their most
+obvious point of difference, are known respectively as _dry_ and
+_moist_, and there are several clinical varieties of each type.
+
+Speaking generally, it may be said that dry gangrene is essentially due
+to a simple _interference with the blood supply_ of a part; while the
+main factor in the production of moist gangrene is _bacterial
+infection_.
+
+The cardinal signs of gangrene are: change in the colour of the part,
+coldness, loss of sensation and motor power, and, lastly, loss of
+pulsation in the arteries.
+
+#Dry Gangrene# or #Mummification# is a comparatively slow form of local
+death due, as a rule, to a diminution in the arterial blood supply of
+the affected part, resulting from such causes as the gradual narrowing
+of the lumen of the arteries by disease of their coats, or the blocking
+of the main vessel by an embolus.
+
+As the fluids in the tissues are lost by evaporation the part becomes
+dry and shrivelled, and as the skin is usually intact, infection does
+not take place, or if it does, the want of moisture renders the part an
+unsuitable soil, and the organisms do not readily find a footing. Any
+spread of the process that may take place is chiefly influenced by the
+anatomical distribution of the blocked arteries, and is arrested as soon
+as it reaches an area rich in anastomotic vessels. The dead portion is
+then cast off, the irritation resulting from the contact of the dead
+with the still living tissue inducing the formation of granulations on
+the proximal side of the junction, and these by slowly eating into the
+dead portion produce a furrow--the _line of demarcation_--which
+gradually deepens until complete separation is effected. As the muscles
+and bones have a richer blood supply than the integument, the death of
+skin and subcutaneous tissues extends higher than that of muscles and
+bone, with the result that the stump left after spontaneous separation
+is conical, the end of the bone projecting beyond the soft parts.
+
+_Clinical Features._--The part undergoing mortification becomes colder
+than normal, the temperature falling to that of the surrounding
+atmosphere. In many instances, but not in all, the onset of the process
+is accompanied by severe neuralgic pain in the part, probably due to
+anaemia of the nerves, to neuritis, or to the irritation of the exposed
+axis cylinders by the dead and dying tissues around them. This pain soon
+ceases and gives place to a complete loss of sensation. The dead part
+becomes dry, horny, shrivelled, and semi-transparent--at first of a dark
+brown, but finally of a black colour, from the dissemination of blood
+pigment throughout the tissues. There is no putrefaction, and therefore
+no putrid odour; and the condition being non-infective, there is not
+necessarily any constitutional disturbance. In itself, therefore, dry
+gangrene does not involve immediate risk to life; the danger lies in the
+fact that the breach of surface at the line of demarcation furnishes a
+possible means of entrance for bacteria, which may lead to infective
+complications.
+
+#Moist Gangrene# is an acute process, the dead part retaining its fluids
+and so affording a favourable soil for the development of bacteria. The
+action of the organisms and their toxins on the adjacent tissues leads
+to a rapid and wide spread of the process. The skin becomes moist and
+macerated, and bullae, containing dark-coloured fluid or gases, form
+under the epidermis. The putrefactive gases evolved cause the skin to
+become emphysematous and crepitant and produce an offensive odour. The
+tissues assume a greenish-black colour from the formation in them of a
+sulphide of iron resulting from decomposition of the blood pigment.
+Under certain conditions the dead part may undergo changes resembling
+more closely those of ordinary post-mortem decomposition. Owing to its
+nature the spread of the gangrene is seldom arrested by the natural
+protective processes, and it usually continues until the condition
+proves fatal from the absorption of toxins into the circulation.
+
+The _clinical features_ vary in the different varieties of moist
+gangrene, but the local results of bacterial action and the
+constitutional disturbance associated with toxin absorption are present
+in all; the prognosis therefore is grave in the extreme.
+
+From what has been said, it will be gathered that in dry gangrene there
+is no urgent call for operation to save the patient's life, the primary
+indication being to prevent the access of bacteria to the dead part, and
+especially to the surface exposed at the line of demarcation. In moist
+gangrene, on the contrary, organisms having already obtained a footing,
+immediate removal of the dead and dying tissues, as a rule, offers the
+only hope of saving life.
+
+
+VARIETIES OF GANGRENE
+
+#Varieties of Gangrene essentially due to Interference with the
+Circulation#
+
+While the varieties of gangrene included in this group depend primarily
+on interference with the circulation, it is to be borne in mind that the
+clinical course of the affection may be profoundly influenced by
+superadded infection with micro-organisms. Although the bacteria do not
+play the most important part in producing tissue necrosis, their
+subsequent introduction is an accident of such importance that it may
+change the whole aspect of affairs and convert a dry form of gangrene
+into one of the moist type. Moreover, the low state of vitality of the
+tissues, and the extreme difficulty of securing and maintaining asepsis,
+make it a sequel of great frequency.
+
+#Senile Gangrene.#--Senile gangrene is the commonest example of local
+death produced by a _gradual_ diminution in the quantity of blood
+passing through the parts, as a result of arterio-sclerosis or other
+chronic disease of the arteries leading to diminution of their calibre.
+It is the most characteristic example of the dry type of gangrene. As
+the term indicates, it occurs in old persons, but the patient's age is
+to be reckoned by the condition of his arteries rather than by the
+number of his years. Thus the vessels of a comparatively young man who
+has suffered from syphilis and been addicted to alcohol are more liable
+to atheromatous degeneration leading to this form of gangrene than are
+those of a much older man who has lived a regular and abstemious life.
+This form of gangrene is much more common in men than in women. While it
+usually attacks only one foot, it is not uncommon for the other foot to
+be affected after an interval, and in some cases it is bilateral from
+the outset. It must clearly be understood that any form of gangrene may
+occur in old persons, the term senile being here restricted to that
+variety which results from arterio-sclerosis.
+
+[Illustration: FIG. 20.--Senile Gangrene of the Foot, showing line of
+demarcation.]
+
+_Clinical Features._--The commonest seat of the disease is in the toes,
+especially the great toe, whence it spreads up the foot to the heel, or
+even to the leg (Fig. 20). There is often a history of some slight
+injury preceding its onset. The vitality of the tissues is so low that
+the balance between life and death may be turned by the most trivial
+injury, such as a cut while paring a toe-nail or a corn, a blister
+caused by an ill-fitting shoe or the contact of a hot-bottle. In some
+cases the actual gangrene is determined by thrombosis of the popliteal
+or tibial arteries, which are already narrowed by obliterating
+endarteritis.
+
+It is common to find that the patient has been troubled for a long time
+before the onset of definite signs of gangrene, with cold feet, with
+tingling and loss of feeling, or a peculiar sensation as if walking on
+cotton wool.
+
+The first evidence of the death of the part varies in different cases.
+Sometimes a dark-blue spot appears on the medial side of the great toe
+and gradually increases in size; or a blister containing blood-stained
+fluid may form. Streaks or patches of dark-blue mottling appear higher
+up on the foot or leg. In other cases a small sore surrounded by a
+congested areola forms in relation to the nail and refuses to heal. Such
+sores on the toes of old persons are always to be looked upon with
+suspicion and treated with the greatest care; and the urine should be
+examined for sugar. There is often severe, deep-seated pain of a
+neuralgic character, with cramps in the limb, and these may persist long
+after a line of demarcation has formed. The dying part loses sensibility
+to touch and becomes cold and shrivelled.
+
+All the physical appearances and clinical symptoms associated with dry
+gangrene supervene, and the dead portion is delimited by a line of
+demarcation. If this forms slowly and irregularly it indicates a very
+unsatisfactory condition of the circulation; while, if it forms quickly
+and decidedly, the presumption is that the circulation in the parts
+above is fairly good. The separation of the dead part is always attended
+with the risk of infection taking place, and should this occur, the
+temperature rises and other evidences of toxaemia appear.
+
+_Prophylaxis._--The toes and feet of old people, the condition of whose
+circulation predisposes them to gangrene, should be protected from
+slight injuries such as may be received while paring nails, cutting
+corns, or wearing ill-fitting boots. The patient should also be warned
+of the risk of exposure to cold, the use of hot-bottles, and of placing
+the feet near a fire. Attempts have been made to improve the peripheral
+circulation by establishing an anastomosis between the main artery of a
+limb and its companion vein, so that arterial blood may reach the
+peripheral capillaries--reversal of the circulation--but the clinical
+results have proved disappointing. (See _Op. Surg._, p. 29.)
+
+_Treatment._--When there is evidence that gangrene has occurred, the
+first indication is to prevent infection by purifying the part, and
+after careful drying to wrap it in a thick layer of absorbent and
+antiseptic wool, retained in place by a loosely applied bandage. A
+slight degree of elevation of the limb is an advantage, but it must not
+be sufficient to diminish the amount of blood entering the part.
+Hot-bottles are to be used with the utmost caution. As absolute dryness
+is essential, ointments or other greasy dressings are to be avoided, as
+they tend to prevent evaporation from the skin. Opium should be given
+freely to alleviate pain. Stimulation is to be avoided, and the patient
+should be carefully dieted.
+
+When the gangrene is limited to the toes in old and feeble patients,
+some surgeons advocate the expectant method of treatment, waiting for a
+line of demarcation to form and allowing the dead part to be separated.
+This takes place so slowly, however, that it necessitates the patient
+being laid up for many weeks, or even months; and we agree with the
+majority in advising early amputation.
+
+In this connection it is worthy of note that there are certain points at
+which gangrene naturally tends to become arrested--namely, at the highly
+vascular areas in the neighbourhood of joints. Thus gangrene of the
+great toe often stops when it reaches the metatarso-phalangeal joint; or
+if it trespasses this limit it may be arrested either at the
+tarso-metatarsal or at the ankle joint. If these be passed, it usually
+spreads up the leg to just below the knee before signs of arrestment
+appear. Further, it is seen from pathological specimens that the spread
+is greater on the dorsal than on the plantar aspect, and that the death
+of skin and subcutaneous tissues extends higher than that of bone and
+muscle.
+
+These facts furnish us with indications as to the seat and method of
+amputation. Experience has proved that in senile gangrene of the lower
+extremity the most reliable and satisfactory results are obtained by
+amputating in the region of the knee, care being taken to perform the
+operation so as to leave the prepatellar anastomosis intact by retaining
+the patella in the anterior flap. The most satisfactory operation in
+these cases is Gritti's supra-condylar amputation. Haemorrhage is easily
+controlled by digital pressure, and the use of a tourniquet should be
+dispensed with, as the constriction of the limb is liable to interfere
+with the vitality of the flaps.
+
+When the tibial vessels can be felt pulsating at the ankle it may be
+justifiable, if the patient urgently desires it, to amputate lower than
+the knee; but there is considerable risk of gangrene recurring in the
+stump and necessitating a second operation.
+
+That amputation for senile gangrene performed between the ankle and the
+knee seldom succeeds, is explained by the fact that the vascular
+obstruction is usually in the upper part of the posterior tibial artery,
+and the operation is therefore performed through tissues with an
+inadequate blood supply. It is not uncommon, indeed, on amputating above
+the knee, to find even the popliteal artery plugged by a clot. This
+should be removed at the amputation by squeezing the vessel from above
+downward by a "milking" movement, or by "catheterising the artery" with
+the aid of a cannula with a terminal aperture.
+
+It is to be borne in mind that the object of amputation in these cases
+is merely to remove the gangrenous part, and so relieve the patient of
+the discomfort and the risks from infection which its presence involves.
+While it is true that in many of these patients the operation is borne
+remarkably well, it must be borne in mind that those who suffer from
+senile gangrene are of necessity bad lives, and a guarded opinion should
+be expressed as to the prospects of survival. The possibility of the
+disease developing in the other limb has already been referred to.
+
+[Illustration: FIG. 21.--Embolic Gangrene of Hand and Arm.]
+
+#Embolic Gangrene# (Fig. 21).--This is the most typical form of gangrene
+resulting from the _sudden_ occlusion of the main artery of a part,
+whether by the impaction of an embolus or the formation of a thrombus in
+its lumen, when the collateral circulation is not sufficiently free to
+maintain the vitality of the tissues.
+
+There is sudden pain at the site of impaction of the embolus, and the
+pulses beyond are lost. The limb becomes cold, numb, insensitive, and
+powerless. It is often pale at first--hence the term "white gangrene"
+sometimes applicable to the early appearances, which closely resemble
+those presented by the limb of a corpse.
+
+If the part is aseptic it shrivels, and presents the ordinary features
+of dry gangrene. It is liable, however, especially in the lower
+extremity and when the veins also are obstructed, to become infected and
+to assume the characters of the moist type.
+
+The extent of the gangrene depends upon the site of impaction of the
+embolus, thus if the _abdominal aorta_ becomes suddenly occluded by an
+embolus at its bifurcation, the obstruction of the iliacs and femorals
+induces symmetrical gangrene of both extremities as high as the inguinal
+ligaments. When gangrene follows occlusion of the _external iliac_ or of
+the _femoral artery_ above the origin of its deep branch, the death of
+the limb extends as high as the middle or upper third of the thigh. When
+the _femoral_ below the origin of its deep branch or the _popliteal
+artery_ is obstructed, the veins remaining pervious, the anastomosis
+through the profunda is sufficient to maintain the vascular supply, and
+gangrene does not necessarily follow. The rupture of a popliteal
+aneurysm, however, by compressing the vein and the articular branches,
+usually determines gangrene. When an embolus becomes impacted at the
+_bifurcation of the popliteal_, if gangrene ensues it usually spreads
+well up the leg.
+
+When the _axillary artery_ is the seat of embolic impaction, and
+gangrene ensues, the process usually reaches the middle of the upper
+arm. Gangrene following the blocking of the _brachial_ at its
+bifurcation usually extends as far as the junction of the lower and
+middle thirds of the forearm.
+
+Gangrene due to thrombosis or embolism is sometimes met with in patients
+recovering from typhus, typhoid, or other fevers, such as that
+associated with child-bed. It occurs in peripheral parts, such as the
+toes, fingers, nose, or ears.
+
+_Treatment._--The general treatment of embolic gangrene is the same as
+that for the senile form. Success has followed opening the artery and
+removing the embolus. The artery is exposed at the seat of impaction
+and, having been clamped above and below, a longitudinal opening is made
+and the clot carefully extracted with the aid of forceps; it is
+sometimes unexpectedly long (one recorded from the femoral artery
+measured nearly 34 inches); the wound in the artery is then sewn up with
+fine silk soaked in paraffin. When amputation is indicated, it must be
+performed sufficiently high to ensure a free vascular supply to the
+flaps.
+
+#Gangrene following Ligation of Arteries.#--After the ligation of an
+artery in its continuity--for example, in the treatment of aneurysm--the
+limb may for some days remain in a condition verging on gangrene, the
+distal parts being cold, devoid of sensation, and powerless. As the
+collateral circulation is established, the vitality of the tissues is
+gradually restored and these symptoms pass off. In some cases,
+however,--and especially in the lower extremity--gangrene ensues and
+presents the same characters as those resulting from embolism. It tends
+to be of the dry type. The occlusion of the vein as well as the artery
+is not found to increase the risk of gangrene.
+
+#Gangrene from Mechanical Constriction of the Vessels of the part.#--The
+application of a bandage or plaster-of-Paris case too tightly, or of a
+tourniquet for too long a time, has been known to lead to death of the
+part beyond; but such cases are rare, as are also those due to the
+pressure of a fractured bone or of a tumour on a large artery or vein.
+When gangrene occurs from such causes, it tends to be of the moist type.
+
+Much commoner is it to meet with localised areas of necrosis due to the
+excessive _pressure of splints_ over bony prominences, such as the
+lateral malleolus, the medial condyle of the humerus, or femur, or over
+the dorsum of the foot. This is especially liable to occur when the
+nutrition of the skin is depressed by any interference with its
+nerve-supply, such as follows injuries to the spine or peripheral
+nerves, disease of the brain, or acute anterior poliomyelitis. When the
+splint is removed the skin pressed upon is found to be of a pale yellow
+or grey colour, and is surrounded by a ring of hyperaemia. If protected
+from infection, the clinical course is that of dry gangrene.
+
+Bed-sores, which are closely allied to pressure sores, will be described
+at the end of this chapter.
+
+When a localised portion of tissue, for example, a piece of skin, is so
+severely _crushed_ or _bruised_ that its blood vessels are occluded and
+its structure destroyed, it dies, and, if not infected with bacteria,
+dries up, and the shrivelled brown skin is slowly separated by the
+growth of granulation tissue beneath and around it.
+
+Fingers, toes, or even considerable portions of limbs may in the same
+way be suddenly destroyed by severe trauma, and undergo mummification.
+If organisms gain access, typical moist gangrene may ensue, or changes
+similar to those of ordinary post-mortem decomposition may take place.
+
+_Treatment._--The first indication is to exclude bacteria by purifying
+the damaged part and its surroundings, and applying dry, non-irritating
+dressings.
+
+When these measures are successful, dry gangrene ensues. The raw surface
+left after the separation of the dead skin may be allowed to heal by
+granulation, or may be covered by skin-grafts. In the case of a finger
+or a limb it is not necessary to wait until spontaneous separation takes
+place, as this is often a slow process. When a well-marked line of
+demarcation has formed, amputation may be performed just sufficiently
+far above it to enable suitable flaps to be made.
+
+The end of a stump, after spontaneous separation of the gangrenous
+portion, requires to be trimmed, sufficient bone being removed to permit
+of the soft parts coming together.
+
+If moist gangrene supervenes, amputation must be performed without
+delay, and at a higher level.
+
+#Gangrene from Heat, Chemical Agents, and Cold.#--Severe #burns# and
+#scalds# may be followed by necrosis of tissue. So long as the parts are
+kept absolutely dry--as, for example, by the picric acid method of
+treatment--the grossly damaged portions of tissue undergo dry gangrene;
+but when wet or oily dressings are applied and organisms gain access,
+moist gangrene follows.
+
+Strong #chemical agents#, such as caustic potash, nitric or sulphuric
+acid, may also induce local tissue necrosis, the general appearances of
+the lesions produced being like those of severe burns. The resulting
+sloughs are slow to separate, and leave deep punched-out cavities which
+are long of healing.
+
+#Carbolic Gangrene.#--Carbolic acid, even in comparatively weak
+solution, is liable to induce dry gangrene when applied as a fomentation
+to a finger, especially in women and children. Thrombosis occurs in the
+blood vessels of the part, which at first is pale and soft, but later
+becomes dark and leathery. On account of the anaesthetic action of
+carbolic acid, the onset of the process is painless, and the patient
+does not realise his danger. A line of demarcation soon forms, but the
+dead part separates very slowly.
+
+#Gangrene from Frost-bite.#--It is difficult to draw the line between
+the third degree of chilblain and the milder forms of true frost-bite;
+the difference is merely one of degree. Frost-bite affects chiefly the
+toes and fingers--especially the great toe and the little finger--the
+ears, and the nose. In this country it is seldom seen except in members
+of the tramp class, who, in addition to being exposed to cold by
+sleeping in the open air, are ill-fed and generally debilitated. The
+condition usually manifests itself after the parts, having been
+subjected to extreme cold, are brought into warm surroundings. The first
+symptom is numbness in the part, followed by a sense of weight,
+tingling, and finally by complete loss of sensation. The part attacked
+becomes white and bleached-looking, feels icy cold, and is insensitive
+to touch. Either immediately, or, it may be, not for several days, it
+becomes discoloured and swollen, and finally contracts and shrivels.
+Above the dead area the limb may be the seat of excruciating pain. The
+dead portion is cast off, as in other forms of dry gangrene, by the
+formation of a line of demarcation.
+
+To prevent the occurrence of gangrene from frost-bite it is necessary to
+avoid the sudden application of heat. The patient should be placed in a
+cold room, and the part rubbed with snow, or put in a cold bath, and
+have light friction applied to it. As the circulation is restored the
+general surroundings and the local applications are gradually made
+warmer. Elevation of the part, wrapping it in cotton wool, and removal
+to a warmer room, are then permissible, and stimulants and warm drinks
+may be given with caution. When by these means the occurrence of
+gangrene is averted, recovery ensues, its onset being indicated by the
+white parts assuming a livid red hue and becoming the seat of an acute
+burning sensation.
+
+A condition known as _Trench feet_ was widely prevalent amongst the
+troops in France during the European War. Although allied to frost-bite,
+cold appears to play a less important part in its causation than
+humidity and constriction of the limbs producing ischaemia of the feet.
+Changes were found in the endothelium of the blood vessels, the axis
+cylinders of nerves, and the muscles. The condition does not occur in
+civil life.
+
+#Diabetic Gangrene.#--This form of gangrene is prone to occur in persons
+over fifty years of age who suffer from glycosuria. The arteries are
+often markedly diseased. In some cases the existence of the glycosuria
+is unsuspected before the onset of the gangrene, and it is only on
+examining the urine that the cause of the condition is discovered. The
+gangrenous process seldom begins as suddenly as that associated with
+embolism, and, like senile gangrene, which it may closely simulate in
+its early stages, it not infrequently begins after a slight injury to
+one of the toes. It but rarely, however, assumes the dry, shrivelling
+type, as a rule being attended with swelling, oedema, and dusky redness
+of the foot, and severe pain. According to Paget, the dead part remains
+warm longer than in other forms of senile gangrene; there is a greater
+tendency for patches of skin at some distance from the primary seat of
+disease to become gangrenous, and for the death of tissue to extend
+upwards in the subcutaneous planes, leaving the overlying skin
+unaffected. The low vitality of the tissues favours the growth of
+bacteria, and if these gain access, the gangrene assumes the characters
+of the moist type and spreads rapidly.
+
+The rules for amputation are the same as those governing the treatment
+of senile gangrene, the level at which the limb is removed depending
+upon whether the gangrene is of the dry or moist type. The general
+treatment for diabetes must, of course, be employed whether amputation
+is performed or not. Paget recommended that the dietetic treatment
+should not be so rigid as in uncomplicated diabetes, and that opium
+should be given freely.
+
+The _prognosis_ even after amputation is unfavourable. In many cases the
+patient dies with symptoms of diabetic coma within a few days of the
+operation; or, if he survives this, he may eventually succumb to
+diabetes. In others there is sloughing of the flaps and death results
+from toxaemia. Occasionally the other limb becomes gangrenous. On the
+other hand, the glycosuria may diminish or may even disappear after
+amputation.
+
+#Gangrene associated with Spasm of Blood Vessels.#--#Raynaud's Disease#,
+or symmetrical gangrene, is supposed to be due to spasm of the
+arterioles, resulting from peripheral neuritis. It occurs oftenest in
+women, between the ages of eighteen and thirty, who are the subjects of
+uterine disorders, anaemia, or chlorosis. Cold is an aggravating factor,
+as the disease is commonest during the winter months. The digits of both
+hands or the toes of both feet are simultaneously attacked, and the
+disease seldom spreads beyond the phalanges or deeper than the skin.
+
+The first evidence is that the fingers become cold, white, and
+insensitive to touch and pain. These attacks of _local syncope_ recur at
+varying intervals for months or even years. They last for a few minutes
+or even for some hours, and as they pass off the parts become hyperaemic
+and painful.
+
+A more advanced stage of the disease is known as _local asphyxia_. The
+circulation through the fingers becomes exceedingly sluggish, and the
+parts assume a dull, livid hue. There is swelling and burning or
+shooting pain. This may pass off in a few days, or may increase in
+severity, with the formation of bullae, and end in dry gangrene. As a
+rule, the slough which forms is comparatively small and superficial,
+but it may take some months to separate. The condition tends to recur in
+successive winters.
+
+The _treatment_ consists in remedying any nervous or uterine disorder
+that may be present, keeping the parts warm by wrapping them in cotton
+wool, and in the use of hot-air or electric baths, the parts being
+immersed in water through which a constant current is passed. When
+gangrene occurs, it is treated on the same lines as other forms of dry
+gangrene, but if amputation is called for it is only with a view to
+removing the dead part.
+
+#Angio-sclerotic Gangrene.#--A form of gangrene due to _angio-sclerosis_
+is occasionally met with in young persons, even in children. It bears
+certain analogies to Raynaud's disease in that spasm of the vessels
+plays a part in determining the local death.
+
+The main arteries are narrowed by hyperplastic endarteritis followed by
+thrombosis, and similar changes are found in the veins. The condition is
+usually met with in the feet, but the upper extremity may be affected,
+and is attended with very severe pain, rendering sleep impossible.
+
+The patient is liable to sudden attacks of numbness, tingling and
+weakness of the limbs which pass off with rest--_intermittent
+claudication_. During these attacks the large arteries--femoral,
+brachial, and subclavian--can be felt as firm cords, while pulsation is
+lost in the peripheral vessels. Gangrene eventually ensues, is attended
+with great pain and runs a slow course. It is treated on the same lines
+as Raynaud's disease.
+
+#Gangrene from Ergot.#--Gangrene may occur from interference with blood
+supply, the result of tetanic contraction of the minute vessels, such as
+results in ill-nourished persons who eat large quantities of coarse rye
+bread contaminated with the _claviceps purpurea_ and containing the
+ergot of rye. It has also occurred in the fingers of patients who have
+taken ergot medicinally over long periods. The gangrene, which attacks
+the toes, fingers, ears, or nose, is preceded by formication, numbness,
+and pains in the parts to be affected, and is of the dry variety.
+
+In this country it is usually met with in sailors off foreign ships,
+whose dietary largely consists of rye bread. Trivial injuries may be the
+starting-point, the anaesthesia produced by the ergotin preventing the
+patient taking notice of them. Alcoholism is a potent predisposing
+cause.
+
+As it is impossible to predict how far the process will spread, it is
+advisable to wait for the formation of a line of demarcation before
+operating, and then to amputate immediately above the dead part.
+
+
+BACTERIAL VARIETIES OF GANGRENE
+
+The acute bacillary forms of gangrene all assume the moist type from the
+first, and, spreading rapidly, result in extensive necrosis of tissue,
+and often end fatally.
+
+The infection is usually a mixed one in which anaerobic bacteria
+predominate. The anaerobe most constantly present is the _bacillus
+aerogenes capsulatus_, usually in association with other anaerobes, and
+sometimes with pyogenic diplo- and streptococci. According to the mode of
+action of the associated organisms and the combined effects of their
+toxins on the tissues, the gangrenous process presents different
+pathological and clinical features. Some combinations, for example,
+result in a rapidly spreading cellulitis with early necrosis of
+connective tissue accompanied by thrombosis throughout the capillary and
+venous circulation of the parts implicated; other combinations cause
+great oedema of the part, and others again lead to the formation of gases
+in the tissues, particularly in the muscles.
+
+These different effects do not appear to be due to a specific action of
+any one of the organisms present, but to the combined effect of a
+particular group living in symbiosis.
+
+According as the cellulitic, the oedematous, or the gaseous
+characteristics predominate, the clinical varieties of bacillary
+gangrene may be separately described, but it must be clearly understood
+that they frequently overlap and cannot always be distinguished from one
+another.
+
+#Clinical Varieties of Bacillary Gangrene.#--#Acute infective gangrene#
+is the form most commonly met with in civil practice. It may follow such
+trivial injuries as a pin-prick or a scratch, the signs of acute
+cellulitis rapidly giving place to those of a spreading gangrene. Or it
+may ensue on a severe railway, machinery, or street accident, when
+lacerated and bruised tissues are contaminated with gross dirt. Often
+within a few hours of the injury the whole part rapidly becomes painful,
+swollen, oedematous, and tense. The skin is at first glazed, and perhaps
+paler than normal, but soon assumes a dull red or purplish hue, and
+bullae form on the surface. Putrefactive gases may be evolved in the
+tissues, and their presence is indicated by emphysematous crackling when
+the part is handled. The spread of the disease is so rapid that its
+progress is quite visible from hour to hour, and may be traced by the
+occurrence of red lines along the course of the lymphatics of the limb.
+In the most acute cases the death of the affected part takes place so
+rapidly that the local changes indicative of gangrene have not time to
+occur, and the fact that the part is dead may be overlooked.
+
+[Illustration: FIG. 22.--Gangrene of Terminal Phalanx of Index-Finger,
+following cellulitis of hand resulting from a scratch on the palm of the
+hand.]
+
+Rigors may occur, but the temperature is not necessarily raised--indeed,
+it is sometimes subnormal. The pulse is small, feeble, rapid, and
+irregular. Unless amputation is promptly performed, death usually
+follows within thirty-six or forty-eight hours. Even early operation
+does not always avert the fatal issue, because the quantity of toxin
+absorbed and its extreme virulence are often more than even a robust
+subject can outlive.
+
+_Treatment._--Every effort must be made to purify all such wounds as are
+contaminated by earth, street dust, stable refuse, or other forms of
+gross dirt. Devitalised and contaminated tissue is removed with the
+knife or scissors and the wound purified with antiseptics of the
+chlorine group or with hydrogen peroxide. If there is a reasonable
+prospect that infection has been overcome, the wound may be at once
+sutured, but if this is doubtful it is left open and packed or
+irrigated.
+
+When acute gangrene has set in no treatment short of amputation is of
+any avail, and the sooner this is done, the greater is the hope of
+saving the patient. The limb must be amputated well beyond the apparent
+limits of the infected area, and stringent precautions must be taken to
+avoid discharge from the already gangrenous area reaching the operation
+wound. An assistant or nurse, who is to take no other part in the
+operation, is told off to carry out the preliminary purification, and to
+hold the limb during the operation.
+
+#Malignant Oedema.#--This form of acute gangrene has been defined as
+"a spreading inflammatory oedema attended with emphysema, and ultimately
+followed by gangrene of the skin and adjacent parts." The predominant
+organism is the _bacillus of malignant oedema_ or _vibrion septique_ of
+Pasteur, which is found in garden soil, dung, and various putrefying
+substances. It is anaerobic, and occurs as long, thick rods with
+somewhat rounded ends and several laterally placed flagella. Spores,
+which have a high power of resistance, form in the centre of the rods,
+and bulge out the sides so as to give the organisms a spindle-shaped
+outline. Other pathogenic organisms are also present and aid the
+specific bacillus in its action.
+
+At the bedside it is difficult, if not impossible, to distinguish it
+from acute infective gangrene. Both follow on the same kinds of injury
+and run an exceedingly rapid course. In malignant oedema, however, the
+incidence of the disease is mainly on the superficial parts, which
+become oedematous and emphysematous, and acquire a marbled appearance
+with the veins clearly outlined. Early disappearance of sensation is a
+particularly grave symptom. Bullae form on the skin, and the tissues
+have "a peculiar heavy but not putrid odour." The constitutional effects
+are extremely severe, and death may ensue within a few hours.
+
+#Acute Emphysematous# or #Gas Gangrene# was prevalent in certain areas
+at various periods during the European War. It follows infection of
+lacerated wounds with the _bacillus aerogenes capsulatus_, usually in
+combination with other anaerobes, and its main incidence is on the
+muscles, which rapidly become infiltrated with gas that spreads
+throughout the whole extent of the muscle, disintegrating its fibres and
+leading to necrosis. The gangrenous process spreads with appalling
+rapidity, the limb becoming enormously swollen, painful, and crepitant
+or even tympanitic. Patches of coppery or purple colour appear on the
+skin, and bullae containing blood-stained serum form on the surface. The
+toxaemia is profound, and the face and lips assume a characteristic
+cyanosis. The condition is attended with a high mortality. Only in the
+early stages and when the infection is limited are local measures
+successful in arresting the spread; in more severe cases amputation is
+the only means of saving life.
+
+#Cancrum Oris# or #Noma#.--This disease is believed to be due to a
+specific bacillus, which occurs in long delicate rods, and is chiefly
+found at the margin of the gangrenous area. It is prone to attack
+unhealthy children from two to five years of age, especially during
+their convalescence from such diseases as measles, scarlet fever, or
+typhoid, but may attack adults when they are debilitated. It is most
+common in the mouth, but sometimes occurs on the vulva. In the mouth it
+begins as an ulcerative stomatitis, more especially affecting the gums
+or inner aspect of the cheek. The child lies prostrated, and from the
+open mouth foul-smelling saliva, streaked with blood, escapes; the face
+is of an ashy-grey colour, the lips dark and swollen. On the inner
+aspect of the cheek is a deeply ulcerated surface, with sloughy shreds
+of dark-brown or black tissue covering its base; the edges are
+irregular, firm, and swollen, and the surrounding mucous membrane is
+infiltrated and oedematous. In the course of a few hours a dark spot
+appears on the outer aspect of the cheek, and rapidly increases in size;
+towards the centre it is black, shading off through blue and grey into a
+dark-red area which extends over the cheek (Fig. 23). The tissue
+implicated is at first firm and indurated, but as it loses its vitality
+it becomes doughy and sodden. Finally a slough forms, and, when it
+separates, the cheek is perforated.
+
+Meanwhile the process spreads inside the mouth, and the gums, the floor
+of the mouth, or even the jaws, may become gangrenous and the teeth fall
+out. The constitutional disturbance is severe, the temperature raised,
+and the pulse feeble and rapid.
+
+The extremely foetid odour which pervades the room or even the house the
+patient occupies, is usually sufficient to suggest the diagnosis of
+cancrum oris. The odour must not be mistaken for that due to
+decomposition of sordes on the teeth and gums of a debilitated patient.
+
+The _prognosis_ is always grave in the extreme, the main risks being
+general toxaemia and septic pneumonia. When recovery takes place there is
+serious deformity, and considerable portions of the jaws may be lost by
+necrosis.
+
+[Illustration: FIG. 23.--Cancrum oris.
+
+(From a photograph lent by Sir George T. Beatson.)]
+
+_Treatment._--The only satisfactory treatment is thorough removal under
+an anaesthetic of all the sloughy tissue, with the surrounding zone in
+which the organisms are active. This is most efficiently accomplished by
+the knife or scissors, cutting until the tissue bleeds freely, after
+which the raw surface is painted with undiluted carbolic acid and
+dressed with iodoform gauze. It may be necessary to remove large pieces
+of bone when the necrotic process has implicated the jaws. The mouth
+must be constantly sprayed with peroxide of hydrogen, and washed out
+with a disinfectant and deodorant lotion, such as Condy's fluid. The
+patient's general condition calls for free stimulation.
+
+The deformity resulting from these necessarily heroic measures is not so
+great as might be expected, and can be further diminished by plastic
+operations, which should be undertaken before cicatricial contraction
+has occurred.
+
+
+BED-SORES
+
+Bed-sores are most frequently met with in old and debilitated patients,
+or in those whose tissues are devitalised by acute or chronic diseases
+associated with stagnation of blood in the peripheral veins. Any
+interference with the nerve-supply of the skin, whether from injury or
+disease of the central nervous system or of the peripheral nerves,
+strongly predisposes to the formation of bed-sores. Prolonged and
+excessive pressure over a bony prominence, especially if the parts be
+moist with skin secretions, urine, or wound discharges, determines the
+formation of a sore. Excoriations, which may develop into true
+bed-sores, sometimes form where two skin surfaces remain constantly
+apposed, as in the region of the scrotum or labium, under pendulous
+mammae, or between fingers or toes confined in a splint.
+
+[Illustration: FIG. 24.--Acute Bed-Sores over Right Buttock.]
+
+_Clinical Features._--Two clinical varieties are met with--the acute
+and the chronic bed-sore.
+
+The _acute_ bed-sore usually occurs over the sacrum or buttock. It
+develops rapidly after spinal injuries and in the course of certain
+brain diseases. The part affected becomes red and congested, while the
+surrounding parts are oedematous and swollen, blisters form, and the skin
+loses its vitality (Fig. 24).
+
+In advanced cases of general paralysis of the insane, a peculiar form of
+acute bed-sore beginning as a blister, and passing on to the formation
+of a black, dry eschar, which slowly separates, occurs on such parts as
+the medial side of the knee, the angle of the scapula, and the heel.
+
+The _chronic_ bed-sore begins as a dusky reddish purple patch, which
+gradually becomes darker till it is almost black. The parts around are
+oedematous, and a blister may form. This bursts and exposes the papillae
+of the skin, which are of a greenish hue. A tough greyish-black slough
+forms, and is slowly separated. It is not uncommon for the gangrenous
+area to continue to spread both in width and in depth till it reaches
+the periosteum or bone. Bed-sores over the sacrum sometimes implicate
+the vertebral canal and lead to spinal meningitis, which usually proves
+fatal.
+
+In old and debilitated patients the septic absorption taking place from
+a bed-sore often proves a serious complication of other surgical
+conditions. From this cause, for example, old people may succumb during
+the treatment of a fractured thigh.
+
+The granulating surface left on the separation of the slough tends to
+heal comparatively rapidly.
+
+_Prevention of Bed-sores._--The first essential in the prevention of
+bed-sores is the regular changing of the patient's position, so that no
+one part of the body is continuously pressed upon for any length of
+time. Ring-pads of wool, air-cushions, or water-beds are necessary to
+remove pressure from prominent parts. Absolute dryness of the skin is
+all-important. At least once a day, the sacrum, buttocks,
+shoulder-blades, heels, elbows, malleoli, or other parts exposed to
+pressure, must be sponged with soap and water, thoroughly dried, and
+then rubbed with methylated spirit, which is allowed to dry on the skin.
+Dusting the part with boracic acid powder not only keeps it dry, but
+prevents the development of bacteria in the skin secretions.
+
+In operation cases, care must be taken that irritating chemicals used to
+purify the skin do not collect under the patient and remain in contact
+with the skin of the sacrum and buttocks during the time he is on the
+operating-table. There is reason to believe that the so-called
+"post-operation bed-sore" may be due to such causes. A similar result
+has been known to follow soiling of the sheets by the escape of a
+turpentine enema.
+
+_Treatment._--Once a bed-sore has formed, every effort must be made to
+prevent its spread. Alcohol is used to cleanse the broken surface, and
+dry absorbent dressings are applied and frequently changed. It is
+sometimes found necessary to employ moist or oily substances, such as
+boracic poultices, eucalyptus ointment, or balsam of Peru, to facilitate
+the separation of sloughs, or to promote the growth of granulations. In
+patients who are not extremely debilitated the slough may be excised,
+the raw surface scraped, and then painted with iodine.
+
+Skin-grafting is sometimes useful in covering in the large raw surface
+left after separation or removal of sloughs.
+
+
+
+
+CHAPTER VII
+
+BACTERIAL AND OTHER WOUND INFECTIONS
+
+
+_Erysipelas_--_Diphtheria_--_Tetanus_--_Hydrophobia_--_Anthrax_--
+    _Glanders_--_Actinomycosis_--_Mycetoma_--_Delhi
+    boil_--_Chigoe_--_Poisoning by insects_--_Snake-bites_.
+
+
+ERYSIPELAS
+
+Erysipelas, popularly known as "rose," is an acute spreading infective
+disease of the skin or of a mucous membrane due to the action of a
+streptococcus. Infection invariably takes place through an abrasion of
+the surface, although this may be so slight that it escapes observation
+even when sought for. The streptococci are found most abundantly in the
+lymph spaces just beyond the swollen margin of the inflammatory area,
+and in the serous blebs which sometimes form on the surface.
+
+#Clinical Features.#--_Facial erysipelas_ is the commonest clinical
+variety, infection usually occurring through some slight abrasion in the
+region of the mouth or nose, or from an operation wound in this area.
+From this point of origin the inflammation may spread all over the face
+and scalp as far back as the nape of the neck. It stops, however, at the
+chin, and never extends on to the front of the neck. There is great
+oedema of the face, the eyes becoming closed up, and the features
+unrecognisable. The inflammation may spread to the meninges, the
+intracranial venous sinuses, the eye, or the ear. In some cases the
+erysipelas invades the mucous membrane of the mouth, and spreads to the
+fauces and larynx, setting up an oedema of the glottis which may prove
+dangerous to life.
+
+Erysipelas occasionally attacks an operation wound that has become
+septic; and it may accompany septic infection of the genital tract in
+puerperal women, or the separation of the umbilical cord in infants
+(_erysipelas neonatorum_). After an incubation period, which varies from
+fifteen to sixty hours, the patient complains of headache, pains in the
+back and limbs, loss of appetite, nausea, and frequently there is
+vomiting. He has a chill or slight rigor, initiating a rise of
+temperature to 103, 104, or 105 F.; and a full bounding pulse of
+about 100 (Fig. 25). The tongue is foul, the breath heavy, and, as a
+rule, the bowels are constipated. There is frequently albuminuria, and
+occasionally nocturnal delirium. A moderate degree of leucocytosis
+(15,000 to 20,000) is usually present.
+
+Around the seat of inoculation a diffuse red patch forms, varying in hue
+from a bright scarlet to a dull brick-red. The edges are slightly raised
+above the level of the surrounding skin, as may readily be recognised by
+gently stroking the part from the healthy towards the affected area. The
+skin is smooth, tense, and glossy, and presents here and there blisters
+filled with serous fluid. The local temperature is raised, and the part
+is the seat of a burning sensation and is tender to the touch, the most
+tender area being the actively spreading zone which lies about half an
+inch beyond the red margin.
+
+[Illustration: FIG. 25.--Chart of Erysipelas occurring in a wound.]
+
+The disease tends to spread spasmodically and irregularly, and the
+direction and extent of its progress may be recognised by mapping out
+the peripheral zone of tenderness. Red streaks appear along the lines of
+the superficial lymph vessels, and the deep lymphatics may sometimes be
+palpated as firm, tender cords. The neighbouring glands, also, are
+generally enlarged and tender.
+
+The disease lasts for from two or three days to as many weeks, and
+relapses are frequent. Spontaneous resolution usually takes place, but
+the disease may prove fatal from absorption of toxins, involvement of
+the brain or meninges, or from general streptococcal infection.
+
+#Complications.#--_Diffuse suppurative cellulitis_ is the most serious
+local complication, and results from a mixed infection with other
+pyogenic bacteria. Small _localised superficial abscesses_ may form
+during the convalescent stage. They are doubtless due to the action of
+skin bacteria, which attack the tissues devitalised by the erysipelas. A
+persistent form of _oedema_ sometimes remains after recurrent attacks of
+erysipelas, especially when they affect the face or the lower extremity,
+a condition which is referred to with elephantiasis.
+
+#Treatment.#--The first indication is to endeavour to arrest the spread
+of the process. We have found that by painting with linimentum iodi, a
+ring half an inch broad, about an inch in front of the peripheral tender
+zone--not the red margin--an artificial leucocytosis is produced, and
+the advancing streptococci are thereby arrested. Several coats of the
+iodine are applied, one after the other, and this is repeated daily for
+several days, even although the erysipelas has not overstepped the ring.
+Success depends upon using the liniment of iodine (the tincture is not
+strong enough), and in applying it well in front of the disease. To
+allay pain the most useful local applications are ichthyol ointment (1
+in 6), or lead and opium fomentations.
+
+The general treatment consists in attending to the emunctories, in
+administrating quinine in small--two-grain--doses every four hours, or
+salicylate of iron (2-5 gr. every three hours), and in giving plenty of
+fluid nourishment. It is worthy of note that the anti-streptococcic
+serum has proved of less value in the treatment of erysipelas than might
+have been expected, probably because the serum is not made from the
+proper strain of streptococcus.
+
+It is not necessary to isolate cases of erysipelas, provided the usual
+precautions against carrying infection from one patient to another are
+rigidly carried out.
+
+
+DIPHTHERIA
+
+Diphtheria is an acute infective disease due to the action of a specific
+bacterium, the _bacillus diphtheriae_ or _Klebs-Loffler bacillus_. The
+disease is usually transmitted from one patient to another, but it may
+be contracted from cats, fowls, or through the milk of infected cows.
+Cases have occurred in which the surgeon has carried the infection from
+one patient to another through neglect of antiseptic precautions. The
+incubation period varies from two to seven days.
+
+#Clinical Features.#--In _pharyngeal diphtheria_, on the first or
+second day of the disease, redness and swelling of the mucous membrane
+of the pharynx, tonsils, and palate are well marked, and small, circular
+greenish or grey patches of false membrane, composed of necrosed
+epithelium, fibrin, leucocytes, and red blood corpuscles, begin to
+appear. These rapidly increase in area and thickness, till they coalesce
+and form a complete covering to the parts. In the pharynx the false
+membrane is less adherent to the surface than it is when the disease
+affects the air-passages. The diphtheritic process may spread from the
+pharynx to the nasal cavities, causing blocking of the nares, with a
+profuse ichorous discharge from the nostrils, and sometimes severe
+epistaxis. The infection may spread along the nasal duct to the
+conjunctiva. The middle ear also may become involved by spread along the
+auditory (Eustachian) tube.
+
+The lymph glands behind the angle of the jaw enlarge and become tender,
+and may suppurate from superadded infection. There is pain on
+swallowing, and often earache; and the patient speaks with a nasal
+accent. He becomes weak and anaemic, and loses his appetite. There is
+often albuminuria. Leucocytosis is usually well marked before the
+injection of antitoxin; after the injection there is usually a
+diminution in the number of leucocytes. The false membrane may separate
+and be cast off, after which the patient gradually recovers. Death may
+take place from gradual failure of the heart's action or from syncope
+during some slight exertion.
+
+_Laryngeal Diphtheria._--The disease may arise in the larynx, although,
+as a rule, it spreads thence from the pharynx. It first manifests itself
+by a short, dry, croupy cough, and hoarseness of the voice. The first
+difficulty in breathing usually takes place during the night, and once
+it begins, it rapidly gets worse. Inspiration becomes noisy, sometimes
+stridulous or metallic or sibilant, and there is marked indrawing of the
+epigastrium and lower intercostal spaces. The hoarseness becomes more
+marked, the cough more severe, and the patient restless. The difficulty
+of breathing occurs in paroxysms, which gradually increase in frequency
+and severity, until at length the patient becomes asphyxiated. The
+duration of the disease varies from a few hours to four or five days.
+
+After the acute symptoms have passed off, various localised
+paralyses may develop, affecting particularly the nerves of the palatal
+and orbital muscles, less frequently the lower limbs.
+
+#Diagnosis.#--The finding of the Klebs-Loffler bacillus is the only
+conclusive evidence of the disease. The bacillus may be obtained by
+swabbing the throat with a piece of aseptic--not antiseptic--cotton wool
+or clean linen rag held in a pair of forceps, and rotated so as to
+entangle portions of the false membrane or exudate. The swab thus
+obtained is placed in a test-tube, previously sterilised by having had
+some water boiled in it, and sent to a laboratory for investigation. To
+identify the bacillus a piece of the membrane from the swab is rubbed on
+a cover glass, dried, and stained with methylene blue or other basic
+stain; or cultures may be made on agar or other suitable medium. When a
+bacteriological examination is impossible, or when the clinical features
+do not coincide with the results obtained, the patient should always be
+treated on the assumption that he suffers from diphtheria. So much doubt
+exists as to the real nature of membranous croup and its relationship to
+true diphtheria, that when the diagnosis between the two is uncertain
+the safest plan is to treat the case as one of diphtheria.
+
+In children, diphtheria may occur on the vulva, vagina, prepuce, or
+glans penis, and give rise to difficulty in diagnosis, which is only
+cleared up by demonstration of the bacillus.
+
+#Treatment.#--An attempt may be made to destroy or to counteract the
+organisms by swabbing the throat with strong antiseptic solutions, such
+as 1 in 1000 corrosive sublimate or 1 in 30 carbolic acid, or by
+spraying with peroxide of hydrogen.
+
+The antitoxic serum is our sheet-anchor in the treatment of diphtheria,
+and recourse should be had to its use as early as possible.
+
+Difficulty of swallowing may be met by the use of a stomach tube passed
+either through the mouth or nose. When this is impracticable, nutrient
+enemata are called for.
+
+In laryngeal diphtheria, the interference with respiration may call for
+intubation of the larynx, or tracheotomy, but the antitoxin treatment
+has greatly diminished the number of cases in which it becomes necessary
+to have recourse to these measures.
+
+Intubation consists in introducing through the mouth into the larynx a
+tube which allows the patient to breathe freely during the period while
+the membrane is becoming separated and thrown off. This is best done
+with the apparatus of O'Dwyer; but when this instrument is not
+available, a simple gum-elastic catheter with a terminal opening (as
+suggested by Macewen and Annandale) may be employed.
+
+When intubation is impracticable, the operation of tracheotomy is
+called for if the patient's life is endangered by embarrassment of
+respiration. Unless the patient is in hospital with skilled assistance
+available, tracheotomy is the safer of the two procedures.
+
+
+TETANUS
+
+Tetanus is a disease resulting from infection of a wound by a specific
+micro-organism, the _bacillus tetani_, and characterised by increased
+reflex excitability, hypertonus, and spasm of one or more groups of
+voluntary muscles.
+
+_Etiology and Morbid Anatomy._--The tetanus bacillus, which is a perfect
+anaerobe, is widely distributed in nature and can be isolated from
+garden earth, dung-heaps, and stable refuse. It is a slender rod-shaped
+bacillus, with a single large spore at one end giving it the shape of a
+drum-stick (Fig. 26). The spores, which are the active agents in
+producing tetanus, are highly resistant to chemical agents, retain their
+vitality in a dry condition, and even survive boiling for five minutes.
+
+The organism does not readily establish itself in the human body, and
+seems to flourish best when it finds a nidus in necrotic tissue and is
+accompanied by aerobic organisms, which, by using up the oxygen in the
+tissues, provide for it a suitable environment. The presence of a
+foreign body in the wound seems to favour its action. The infection is
+for all practical purposes a local one, the symptoms of the disease
+being due to the toxins produced in the wound of infection acting upon
+the central nervous system.
+
+The toxin acts principally on the nerve centres in the spinal medulla,
+to which it travels from the focus of infection by way of the nerve
+fibres supplying the voluntary muscles. Its first effect on the motor
+ganglia of the cord is to render them hypersensitive, so that they are
+excited by mild stimuli, which under ordinary conditions would produce
+no reaction. As the toxin accumulates the reflex arc is affected, with
+the result that when a stimulus reaches the ganglia a motor discharge
+takes place, which spreads by ascending and descending collaterals to
+the reflex apparatus of the whole cord. As the toxin spreads it causes
+both motor hyper-tonus and hyper-excitability, which accounts for the
+tonic contraction and the clonic spasms characteristic of tetanus.
+
+[Illustration: FIG. 26.--Bacillus of Tetanus from scraping of a wound of
+finger, x 1000 diam. Basic fuchsin stain.]
+
+#Clinical Varieties of Tetanus.#--_Acute_ or _Fulminating
+Tetanus_.--This variety is characterised by the shortness of the
+incubation period, the rapidity of its progress, the severity of its
+symptoms, and its all but universally fatal issue in spite of
+treatment, death taking place in from one to four days. The
+characteristic symptoms may appear within three or four days of the
+infliction of the wound, but the incubation period may extend to three
+weeks, and the wound may be quite healed before the disease declares
+itself--_delayed tetanus_. Usually, however, the wound is inflamed and
+suppurating, with ragged and sloughy edges. A slight feverish attack may
+mark the onset of the tetanic condition, or the patient may feel
+perfectly well until the spasms begin. If careful observations be made,
+it may be found that the muscles in the immediate neighbourhood of the
+wound are the first to become contracted; but in the majority of
+instances the patient's first complaint is of pain and stiffness in the
+muscles of mastication, notably the masseter, so that he has difficulty
+in opening the mouth--hence the popular name "lock-jaw." The muscles of
+expression soon share in the rigidity, and the face assumes a taut,
+mask-like aspect. The angles of the mouth may be retracted, producing a
+grinning expression known as the _risus sardonicus_.
+
+The next muscles to become stiff and painful are those of the neck,
+especially the sterno-mastoid and trapezius. The patient is inclined to
+attribute the pain and stiffness to exposure to cold or rheumatism. At
+an early stage the diaphragm and the muscles of the anterior abdominal
+wall become contracted; later the muscles of the back and thorax are
+involved; and lastly those of the limbs. Although this is the typical
+order of involvement of the different groups of muscles, it is not
+always adhered to.
+
+To this permanent tonic contraction of the muscles there are soon added
+clonic spasms. These spasms are at first slight and transient, with
+prolonged intervals between the attacks, but rapidly tend to become more
+frequent, more severe, and of longer duration, until eventually the
+patient simply passes out of one seizure into another.
+
+The distribution of the spasms varies in different cases: in some it is
+confined to particular groups of muscles, such as those of the neck,
+back, abdominal walls, or limbs; in others all these groups are
+simultaneously involved.
+
+When the muscles of the back become spasmodically contracted, the body
+is raised from the bed, sometimes to such an extent that the patient
+rests only on his heels and occiput--the position of _opisthotonos_.
+Lateral arching of the body from excessive action of the muscles on one
+side--_pleurosthotonos_--is not uncommon, the arching usually taking
+place towards the side on which the wound of infection exists. Less
+frequently the body is bent forward so that the knees and chin almost
+meet (_emprosthotonos_). Sometimes all the muscles simultaneously become
+rigid, so that the body assumes a statuesque attitude (_orthotonos_).
+When the thoracic muscles, including the diaphragm, are thrown into
+spasm, the patient experiences a distressing sensation as if he were
+gripped in a vice, and has extreme difficulty in getting breath. Between
+the attacks the limbs are kept rigidly extended. The clonic spasms may
+be so severe as to rupture muscles or even to fracture one of the long
+bones.
+
+As time goes on, the clonic exacerbations become more and more frequent,
+and the slightest external stimulus, such as the feeling of the pulse, a
+whisper in the room, a noise in the street, a draught of cold air, the
+effort to swallow, a question addressed to the patient or his attempt to
+answer, is sufficient to determine an attack. The movements are so
+forcible and so continuous that the nurse has great difficulty in
+keeping the bedclothes on the patient, or even in keeping him in bed.
+
+The general condition of the patient is pitiful in the extreme. He is
+fully conscious of the gravity of the disease, and his mind remains
+clear to the end. The suffering induced by the cramp-like spasms of the
+muscles keeps him in a constant state of fearful apprehension of the
+next seizure, and he is unable to sleep until he becomes utterly
+exhausted.
+
+The temperature is moderately raised (100 to 102 F.), or may remain
+normal throughout. Shortly before death very high temperatures (110 F.)
+have been recorded, and it has been observed that the thermometer
+sometimes continues to rise after death, and may reach as high as
+112 F. or more.
+
+The pulse corresponds with the febrile condition. It is accelerated
+during the spasms, and may become exceedingly rapid and feeble before
+death, probably from paralysis of the vagus. Sudden death from cardiac
+paralysis or from cardiac spasm is not uncommon.
+
+The respiration is affected in so far as the spasms of the respiratory
+muscles produce dyspnoea, and a feeling of impending suffocation which
+adds to the horrors of the disease.
+
+One of the most constant symptoms is a copious perspiration, the patient
+being literally bathed in sweat. The urine is diminished in quantity,
+but as a rule is normal in composition; as in other acute infective
+conditions, albumen and blood may be present. Retention of urine may
+result from spasm of the urethral muscles, and necessitate the use of
+the catheter.
+
+The fits may cease some time before death, or, on the other hand, death
+may occur during a paroxysm from fixation of the diaphragm and arrest of
+respiration.
+
+_Differential Diagnosis._--There is little difficulty, as a rule, in
+diagnosing a case of fulminating tetanus, but there are several
+conditions with which it may occasionally be confused. In _strychnin
+poisoning_, for example, the spasms come on immediately after the
+patient has taken a toxic dose of the drug; they are clonic in
+character, but the muscles are relaxed between the fits. If the dose is
+not lethal, the spasms soon cease. In _hydrophobia_ a history of having
+been bitten by a rabid animal is usually forthcoming; the spasms, which
+are clonic in character, affect chiefly the muscles of respiration and
+deglutition, and pass off entirely in the intervals between attacks.
+Certain cases of _haemorrhage into the lateral ventricles_ of the brain
+also simulate tetanus, but an analysis of the symptoms will prevent
+errors in diagnosis. _Cerebro-spinal meningitis_ and _basal meningitis_
+present certain superficial resemblances to tetanus, but there is no
+trismus, and the spasms chiefly affect the muscles of the neck and
+back. _Hysteria and catalepsy_ may assume characters resembling those
+of tetanus, but there is little difficulty in distinguishing between
+these diseases. Lastly, in the _tetany_ of children, or that following
+operations on the thyreoid gland, the spasms are of a jerking character,
+affect chiefly the hands and fingers, and yield to medicinal treatment.
+
+#Chronic Tetanus.#--The difference between this and acute tetanus is
+mainly one of degree. Its incubation period is longer, it is more slow
+and insidious in its progress, and it never reaches the same degree of
+severity. Trismus is the most marked and constant form of spasm; and
+while the trunk muscles may be involved, those of respiration as a rule
+escape. Every additional day the patient lives adds to the probability
+of his ultimate recovery. When the disease does prove fatal, it is from
+exhaustion, and not from respiratory or cardiac spasm. The usual
+duration is from six to ten weeks.
+
+#Delayed Tetanus.#--During the European War acute tetanus occasionally
+developed many weeks or even months after a patient had been injured,
+and when the original wound had completely healed. It usually followed
+some secondary operation, _e.g._, for the removal of a foreign body, or
+the breaking down of adhesions, which aroused latent organisms.
+
+#Local Tetanus.#--This term is applied to a form of the disease in which
+the hypertonus and spasms are localised to the muscles in the vicinity
+of the wound. It usually occurs in patients who have had prophylactic
+injections of anti-tetanic serum, the toxins entering the blood being
+probably neutralised by the antibodies in circulation, while those
+passing along the motor nerves are unaffected.
+
+When it occurs in the _limbs_, attention is usually directed to the fact
+by pain accompanying the spasms; the muscles are found to be hard and
+there are frequent twitchings of the limb. A characteristic reflex is
+present in the lower extremity, namely, extension of the foot and leg
+when the sole is tickled.
+
+_Cephalic Tetanus_ is another localised variety which follows injury in
+the distribution of the facial nerve. It is characterised by the
+occurrence on the same side as the injury, of facial spasm, rapidly
+followed by more or less complete paralysis of the muscles of
+expression, with unilateral trismus and difficulty in swallowing. Other
+cranial nerves, particularly the oculomotor and the hypoglossal, may
+also be implicated. A remarkable feature of this condition is that
+although the muscles are irresponsive to ordinary physiological stimuli,
+they are thrown into spasm by the abnormal impulses of tetanus.
+
+_Trismus._--This term is used to denote a form of tetanic spasm limited
+to the muscles of mastication. It is really a mild form of chronic
+tetanus, and the prognosis is favourable. It must not be confused with
+the fixation of the jaw sometimes associated with a wisdom-tooth
+gumboil, with tonsillitis, or with affections of the temporo-mandibular
+articulation.
+
+_Tetanus neonatorum_ is a form of tetanus occurring in infants of about
+a week old. Infection takes place through the umbilicus, and manifests
+itself clinically by spasms of the muscles of mastication. It is almost
+invariably fatal within a few days.
+
+_Prophylaxis._--Experience in the European War has established the
+fact that the routine injection of anti-tetanic serum to all patients
+with lacerated and contaminated wounds greatly reduces the frequency of
+tetanus. The sooner the serum is given after the injury, the more
+certain is its effect; within twenty-four hours 1500 units injected
+subcutaneously is sufficient for the initial dose; if a longer period
+has elapsed, 2000 to 3000 units should be given intra-muscularly, as
+this ensures more rapid absorption. A second injection is given a week
+after the first.
+
+The wound must be purified in the usual way, and all instruments and
+appliances used for operations on tetanic patients must be immediately
+sterilised by prolonged boiling.
+
+_Treatment._--When tetanus has developed the main indications are to
+prevent the further production of toxins in the wound, and to neutralise
+those that have been absorbed into the nervous system. Thorough
+purification with antiseptics, excision of devitalised tissues, and
+drainage of the wound are first carried out. To arrest the absorption of
+toxins intra-muscular injections of 10,000 units of serum are given
+daily into the muscles of the affected limb, or directly into the nerve
+trunks leading from the focus of infection, in the hope of "blocking"
+the nerves with antitoxin and so preventing the passage of toxins
+towards the spinal cord.
+
+To neutralise the toxins that have already reached the spinal cord, 5000
+units should be injected intra-thecally daily for four or five days, the
+foot of the bed being raised to enable the serum to reach the upper
+parts of the cord.
+
+The quantity of toxin circulating in the blood is so small as to be
+practically negligible, and the risk of anaphylactic shock attending
+intra-venous injection outweighs any benefit likely to follow this
+procedure.
+
+Baccelli recommends the injection of 20 c.c. of a 1 in 100 solution of
+carbolic acid into the subcutaneous tissues every four hours during the
+period that the contractions persist. Opinions vary as to the
+efficiency of this treatment. The intra-thecal injection of 10 c.c. of a
+15 per cent. solution of magnesium sulphate has proved beneficial in
+alleviating the severity of the spasms, but does not appear to have a
+curative effect.
+
+To conserve the patient's strength by preventing or diminishing the
+severity of the spasms, he should be placed in a quiet room, and every
+form of disturbance avoided. Sedatives, such as bromides, paraldehyde,
+or opium, must be given in large doses. Chloral is perhaps the best, and
+the patient should rarely have less than 150 grains in twenty-four
+hours. When he is unable to swallow, it should be given by the rectum.
+The administration of chloroform is of value in conserving the strength
+of the patient, by abolishing the spasms, and enabling the attendants to
+administer nourishment or drugs either through a stomach tube or by the
+rectum. Extreme elevation of temperature is met by tepid sponging. It is
+necessary to use the catheter if retention of urine occurs.
+
+
+HYDROPHOBIA
+
+Hydrophobia is an acute infective disease following on the bite of a
+rabid animal. It most commonly follows the bite or lick of a rabid dog
+or cat. The virus appears to be communicated through the saliva of the
+animal, and to show a marked affinity for nerve tissues; and the disease
+is most likely to develop when the patient is infected on the face or
+other uncovered part, or in a part richly endowed with nerves.
+
+A dog which has bitten a person should on no account be killed until its
+condition has been proved one way or the other. Should rabies develop
+and its destruction become necessary, the head and spinal cord should be
+retained and forwarded, packed in ice, to a competent observer. Much
+anxiety to the person bitten and to his friends would be avoided if
+these rules were observed, because in many cases it will be shown that
+the animal did not after all suffer from rabies, and that the patient
+consequently runs no risk. If, on the other hand, rabies is proved to be
+present, the patient should be submitted to the Pasteur treatment.
+
+_Clinical Features._--There is almost always a history of the patient
+having been bitten or licked by an animal supposed to suffer from
+rabies. The incubation period averages about forty days, but varies from
+a fortnight to seven or eight months, and is shorter in young than in
+old persons. The original wound has long since healed, and beyond a
+slight itchiness or pain shooting along the nerves of the part, shows no
+sign of disturbance. A few days of general malaise, with chills and
+giddiness precede the onset of the acute manifestations, which affect
+chiefly the muscles of deglutition and respiration. One of the earliest
+signs is that the patient has periodically a sudden catch in his
+breathing "resembling what often occurs when a person goes into a cold
+bath." This is due to spasm of the diaphragm, and is frequently
+accompanied by a loud-sounding hiccough, likened by the laity to the
+barking of a dog. Difficulty in swallowing fluids may be the first
+symptom.
+
+The spasms rapidly spread to all the muscles of deglutition and
+respiration, so that the patient not only has the greatest difficulty in
+swallowing, but has a constant sense of impending suffocation. To add to
+his distress, a copious secretion of viscid saliva fills his mouth. Any
+voluntary effort, as well as all forms of external stimuli, only serve
+to aggravate the spasms which are always induced by the attempt to
+swallow fluid, or even by the sound of running water.
+
+The temperature is raised; the pulse is small, rapid, and intermittent;
+and the urine may contain sugar and albumen.
+
+The mind may remain clear to the end, or the patient may have delusions,
+supposing himself to be surrounded by terrifying forms. There is always
+extreme mental agitation and despair, and the sufferer is in constant
+fear of his impending fate. Happily the inevitable issue is not long
+delayed, death usually occurring in from two to four days from the
+onset. The symptoms of the disease are so characteristic that there is
+no difficulty in diagnosis. The only condition with which it is liable
+to be confused is the variety of cephalic tetanus in which the muscles
+of deglutition are specially involved--the so-called tetanus
+hydrophobicus.
+
+_Prophylaxis._--The bite of an animal suspected of being rabid should be
+cauterised at once by means of the actual or Paquelin cautery, or by a
+strong chemical escharotic such as pure carbolic acid, after which
+antiseptic dressings are applied.
+
+It is, however, to Pasteur's _preventive inoculation_ that we must look
+for our best hope of averting the onset of symptoms. "It may now be
+taken as established that a grave responsibility rests on those
+concerned if a person bitten by a mad animal is not subjected to the
+Pasteur treatment" (Muir and Ritchie).
+
+This method is based on the fact that the long incubation period of the
+disease admits of the patient being inoculated with a modified virus
+producing a mild attack, which protects him from the natural disease.
+
+_Treatment._--When the symptoms have once developed they can only be
+palliated. The patient must be kept absolutely quiet and free from all
+sources of irritation. The spasms may be diminished by means of chloral
+and bromides, or by chloroform inhalation.
+
+
+ANTHRAX
+
+Anthrax is a comparatively rare disease, communicable to man from
+certain of the lower animals, such as sheep, oxen, horses, deer, and
+other herbivora. In animals it is characterised by symptoms of acute
+general poisoning, and, from the fact that it produces a marked
+enlargement of the spleen, is known in veterinary surgery as "splenic
+fever."
+
+The _bacillus anthracis_ (Fig. 27), the largest of the known pathogenic
+bacteria, occurs in groups or in chains made up of numerous bacilli,
+each bacillus measuring from 6 to 8 [micron] in length. The organisms
+are found in enormous numbers throughout the bodies of animals that have
+died of anthrax, and are readily recognised and cultivated. Sporulation
+only takes place outside the body, probably because free oxygen is
+necessary to the process. In the spore-free condition, the organisms
+are readily destroyed by ordinary germicides, and by the gastric juice.
+The spores, on the other hand, have a high degree of resistance. Not
+only do they remain viable in the dry state for long periods, even up to
+a year, but they survive boiling for five minutes, and must be subjected
+to dry heat at 140 C. for several hours before they are destroyed.
+
+[Illustration: FIG. 27.--Bacillus of Anthrax in section of skin, from a
+case of malignant pustule; shows vesicle containing bacilli. x 400 diam.
+Gram's stain.]
+
+_Clinical Varieties of Anthrax._--In man, anthrax may manifest itself in
+one of three clinical forms.
+
+It may be transmitted by means of spores or bacilli directly from a
+diseased animal to those who, by their occupation or otherwise, are
+brought into contact with it--for example, shepherds, butchers,
+veterinary surgeons, or hide-porters. Infection may occur on the face by
+the use of a shaving-brush contaminated by spores. The path of infection
+is usually through an abrasion of the skin, and the primary
+manifestations are local, constituting what is known as _the malignant
+pustule_.
+
+In other cases the disease is contracted through the inhalation of the
+dried spores into the respiratory passages. This occurs oftenest in
+those who work amongst wool, fur, and rags, and a form of acute
+pneumonia of great virulence ensues. This affection is known as
+_wool-sorter's disease_, and is almost universally fatal.
+
+There is reason to believe that infection may also take place by means
+of spores ingested into the alimentary canal in meat or milk derived
+from diseased animals, or in infected water.
+
+#Clinical Features of Malignant Pustule.#--We shall here confine
+ourselves to the consideration of the local lesion as it occurs in the
+skin--_the malignant pustule_.
+
+The point of infection is usually on an uncovered part of the body, such
+as the face, hands, arms, or back of the neck, and the wound may be
+exceedingly minute. After an incubation period varying from a few hours
+to several days, a reddish nodule resembling a small boil appears at the
+seat of inoculation, the immediately surrounding skin becomes swollen
+and indurated, and over the indurated area there appear a number of
+small vesicles containing serum, which at first is clear but soon
+becomes blood-stained (Fig. 28). Coincidently the subcutaneous tissue
+for a considerable distance around becomes markedly oedematous, and the
+skin red and tense. Within a few hours, blood is extravasated in the
+centre of the indurated area, the blisters burst, and a dark brown or
+black eschar, composed of necrosed skin and subcutaneous tissue and
+altered blood, forms (Fig. 29). Meanwhile the induration extends, fresh
+vesicles form and in turn burst, and the eschar increases in size. The
+neighbouring lymph glands soon become swollen and tender. The affected
+part is hot and itchy, but the patient does not complain of great pain.
+There is a moderate degree of constitutional disturbance, with headache,
+nausea, and sometimes shivering.
+
+If the infection becomes generalised--_anthracaemia_--the temperature
+rises to 103 or 104 F., the pulse becomes feeble and rapid, and other
+signs of severe blood-poisoning appear: vomiting, diarrhoea, pains in the
+limbs, headache and delirium, and the condition proves fatal in from
+five to eight days.
+
+_Differential Diagnosis._--When the malignant pustule is fully
+developed, the central slough with the surrounding vesicles and the
+widespread oedema are characteristic. The bacillus can be obtained from
+the peripheral portion of the slough, from the blisters, and from the
+adjacent lymph vessels and glands. The occupation of the patient may
+suggest the possibility of anthrax infection.
+
+[Illustration: FIG. 28.--Malignant Pustule, third day after infection
+with Anthrax, showing great oedema of upper extremity and pectoral region
+(cf. Fig. 29).]
+
+[Illustration: FIG. 29.--Malignant Pustule, fourteen days after
+infection, showing black eschar in process of separation. The oedema has
+largely disappeared. Treated by Sclavo's serum (cf. Fig. 28).]
+
+_Prophylaxis._--Any wound suspected of being infected with anthrax
+should at once be cauterised with caustic potash, the actual cautery, or
+pure carbolic acid.
+
+_Treatment._--The best results hitherto obtained have followed the use
+of the anti-anthrax serum introduced by Sclavo. The initial dose is 40
+c.c., and if the serum is given early in the disease, the beneficial
+effects are manifest in a few hours. Favourable results have also
+followed the use of pyocyanase, a vaccine prepared from the bacillus
+pyocyaneus.
+
+By some it is recommended that the local lesion should be freely
+excised; others advocate cauterisation of the affected part with solid
+caustic potash till all the indurated area is softened. Graf has had
+excellent results by the latter method in a large series of cases, the
+oedema subsiding in about twenty-four hours and the constitutional
+symptoms rapidly improving. Wolff and Wiewiorowski, on the other hand,
+have had equally good results by simply protecting the local lesion with
+a mild antiseptic dressing, and relying upon general treatment.
+
+The general treatment consists in feeding and stimulating the patient as
+freely as possible. Quinine, in 5 to 10 grain doses every four hours,
+and powdered ipecacuanha, in 40 to 60 grain doses every four hours, have
+also been employed with apparent benefit.
+
+
+GLANDERS
+
+Glanders is due to the action of a specific bacterium, the _bacillus
+mallei_, which resembles the tubercle bacillus, save that it is somewhat
+shorter and broader, and does not stain by Gram's method. It requires
+higher temperatures for its cultivation than the tubercle bacillus, and
+its growth on potato is of a characteristic chocolate-brown colour, with
+a greenish-yellow ring at the margin of the growth. The bacillus mallei
+retains its vitality for long periods under ordinary conditions, but is
+readily killed by heat and chemical agents. It does not form spores.
+
+_Clinical Features._--Both in the lower animals and in man the bacillus
+gives rise to two distinct types of disease--_acute glanders_, and
+_chronic glanders_ or _farcy_.
+
+Acute Glanders is most commonly met with in the horse and in other
+equine animals, horned cattle being immune. It affects the septum of the
+nose and adjacent parts, firm, translucent, greyish nodules containing
+lymphoid and epithelioid cells appearing in the mucous membrane. These
+nodules subsequently break down in the centre, forming irregular
+ulcers, which are attended with profuse discharge, and marked
+inflammatory swelling. The cervical lymph glands, as well as the lungs,
+spleen, and liver, may be the seat of secondary nodules.
+
+_In man_, acute glanders is commoner than the chronic variety. Infection
+always takes place through an abraded surface, and usually on one of the
+uncovered parts of the body--most commonly the skin of the hands, arms,
+or face; or on the mucous membrane of the mouth, nose, or eye. The
+disease has been acquired by accidental inoculation in the course of
+experimental investigations in the laboratory, and proved fatal. The
+incubation period is from three to five days.
+
+The _local_ manifestations are pain and swelling in the region of the
+infected wound, with inflammatory redness around it and along the lines
+of the superficial lymphatics. In the course of a week, small, firm
+nodules appear, and are rapidly transformed into pustules. These may
+occur on the face and in the vicinity of joints, and may be mistaken for
+the eruption of small-pox.
+
+After breaking down, these pustules give rise to irregular ulcers, which
+by their confluence lead to extensive destruction of skin. Sometimes the
+nasal mucous membrane becomes affected, and produces a discharge--at
+first watery, but later sanious and purulent. Necrosis of the bones of
+the nose may take place, in which case the discharge becomes peculiarly
+offensive. In nearly every case metastatic abscesses form in different
+parts of the body, such as the lungs, joints, or muscles.
+
+During the development of the disease the patient feels ill, complains
+of headache and pains in the limbs, the temperature rises to 104 or
+even to 106 F., and assumes a pyaemic type. The pulse becomes rapid and
+weak. The tongue is dry and brown. There is profuse sweating,
+albuminuria, and often insomnia with delirium. Death may take place
+within a week, but more frequently occurs during the second or third
+week.
+
+_Differential Diagnosis._--There is nothing characteristic in the site
+of the primary lesion in man, and the condition may, during the early
+stages, be mistaken for a boil or carbuncle, or for any acute
+inflammatory condition. Later, the disease may simulate acute articular
+rheumatism, or may manifest all the symptoms of acute septicaemia or
+pyaemia. The diagnosis is established by the recognition of the bacillus.
+Veterinary surgeons attach great importance to the mallein test as a
+means of diagnosis in animals, but in the human subject its use is
+attended with considerable risk and is not to be recommended.
+
+_Treatment._--Excision of the primary nodule, followed by the
+application of the thermo-cautery and sponging with pure carbolic acid,
+should be carried out, provided the condition is sufficiently limited to
+render complete removal practicable.
+
+When secondary abscesses form in accessible situations, they must be
+incised, disinfected, and drained. The general treatment is carried out
+on the same lines as in other acute infective diseases.
+
+#Chronic Glanders.#--_In the horse_ the chronic form of glanders is
+known as _farcy_, and follows infection through an abrasion of the skin,
+involving chiefly the superficial lymph vessels and glands. The
+lymphatics become indurated and nodular, constituting what veterinarians
+call _farcy pipes_ and _farcy buds_.
+
+_In man_ also the clinical features of the chronic variety of the
+disease are somewhat different from those of the acute form. Here, too,
+infection takes place through a broken cutaneous surface, and leads to a
+superficial lymphangitis with nodular thickening of the lymphatics
+(_farcy buds_). The neighbouring glands soon become swollen and
+indurated. The primary lesion meanwhile inflames, suppurates, and, after
+breaking down, leaves a large, irregular ulcer with thickened edges and
+a foul, purulent or bloody discharge. The glands break down in the same
+way, and lead to wide destruction of skin, and the resulting sinuses and
+ulcers are exceedingly intractable. Secondary deposits in the
+subcutaneous tissue, the muscles, and other parts, are not uncommon, and
+the nasal mucous membrane may become involved. The disease often runs a
+chronic course, extending to four or five months, or even longer.
+Recovery takes place in about 50 per cent. of cases, but the
+convalescence is prolonged, and at any time the disease may assume the
+characters of the acute variety and speedily prove fatal.
+
+The _differential diagnosis_ is often difficult, especially in the
+chronic nodules, in which it may be impossible to demonstrate the
+bacillus. The ulcerated lesions of farcy have to be distinguished from
+those of tubercle, syphilis, and other forms of infective granuloma.
+
+_Treatment._--Limited areas of disease should be completely excised. The
+general condition of the patient must be improved by tonics, good food,
+and favourable hygienic surroundings. In some cases potassium iodide
+acts beneficially.
+
+
+ACTINOMYCOSIS
+
+Actinomycosis is a chronic disease due to the action of an organism
+somewhat higher in the vegetable scale than ordinary bacteria--the
+_streptothrix actinomyces_ or _ray fungus_.
+
+[Illustration: FIG. 30.--Section of Actinomycosis Colony in Pus from
+Abscess of Liver, showing filaments and clubs of streptothrix
+actinomyces. x 400 diam. Gram's stain.]
+
+_Etiology and Morbid Anatomy._--The actinomyces, which has never been
+met with outside the body, gives rise in oxen, horses, and other animals
+to tumour-like masses composed of granulation tissue; and in man to
+chronic suppurative processes which may result in a condition resembling
+chronic pyaemia. The actinomyces is more complex in structure than other
+pathogenic organisms, and occurs in the tissues in the form of small,
+round, semi-translucent bodies, about the size of a pin-head or less,
+and consisting of colonies of the fungus. On account of their yellow
+tint they are spoken of as "sulphur grains." Each colony is made up of a
+series of thin, interlacing, and branching _filaments_, some of which
+are broken up so as to form masses or chains of _cocci_; and around the
+periphery of the colony are elongated, pear-shaped, hyaline, _club-like
+bodies_ (Fig. 30).
+
+Infection is believed to be conveyed by the husks of cereals, especially
+barley; and the organism has been found adhering to particles of grain
+embedded in the tissues of animals suffering from the disease. In the
+human subject there is often a history of exposure to infection from
+such sources, and the disease is said to be most common during the
+harvesting months.
+
+Around each colony of actinomyces is a zone of granulation tissue in
+which suppuration usually occurs, so that the fungus comes to lie in a
+bath of greenish-yellow pus. As the process spreads these purulent foci
+become confluent and form abscess cavities. When metastasis takes place,
+as it occasionally does, the fungus is transmitted by the blood vessels,
+as in pyaemia.
+
+_Clinical features._--In man the disease may be met with in the skin,
+the organisms gaining access through an abrasion, and spreading by the
+formation of new nodules in the same way as tuberculosis.
+
+The region of the mouth and jaws is one of the commonest sites of
+surgical actinomycosis. Infection takes place, as a rule, along the side
+of a carious tooth, and spreads to the lower jaw. A swelling is slowly
+and insidiously developed, but when the loose connective tissue of the
+neck becomes infiltrated, the spread is more rapid. The whole region
+becomes infiltrated and swollen, and the skin ultimately gives way and
+free suppuration occurs, resulting in the formation of sinuses. The
+characteristic greenish-grey or yellow granules are seen in the pus, and
+when examined microscopically reveal the colonies of actinomyces.
+
+Less frequently the maxilla becomes affected, and the disease may spread
+to the base of the skull and brain. The vertebrae may become involved by
+infection taking place through the pharynx or oesophagus, and leading to
+a condition simulating tuberculous disease of the spine. When it
+implicates the intestinal canal and its accessory glands, the lungs,
+pleura, and bronchial tubes, or the brain, the disease is not amenable
+to surgical treatment.
+
+_Differential Diagnosis._--The conditions likely to be mistaken for
+surgical actinomycosis are sarcoma, tubercle, and syphilis. In the early
+stages the differential diagnosis is exceedingly difficult. In many
+cases it is only possible when suppuration has occurred and the fungus
+can be demonstrated.
+
+The slow destruction of the affected tissue by suppuration, the absence
+of pain, tenderness, and redness, simulate tuberculosis, but the absence
+of glandular involvement helps to distinguish it.
+
+Syphilitic lesions are liable to be mistaken for actinomycosis, all the
+more that in both diseases improvement follows the administration of
+iodides. When it affects the lower jaw, in its early stages,
+actinomycosis may closely simulate a periosteal sarcoma.
+
+[Illustration: FIG. 31.--Actinomycosis of Maxilla. The disease spread to
+opposite side; finally implicated base of skull, and proved fatal.
+Treated by radium.
+
+(Mr. D. P. D. Wilkie's case.)]
+
+The recognition of the fungus is the crucial point in diagnosis.
+
+_Prognosis._--Spontaneous cure rarely occurs. When the disease
+implicates internal organs, it is almost always fatal. On external parts
+the destructive process gradually spreads, and the patient eventually
+succumbs to superadded septic infection. When, from its situation, the
+primary focus admits of removal, the prognosis is more favourable.
+
+_Treatment._--The surgical treatment is early and free removal of the
+affected tissues, after which the wound is cauterised by the actual
+cautery, and sponged over with pure carbolic acid. The cavity is packed
+with iodoform gauze, no attempt being made to close the wound.
+
+Success has attended the use of a vaccine prepared from cultures of the
+organism; and the X-rays and radium, combined with the administration of
+iodides in large doses, or with intra-muscular injections of a 10 per
+cent. solution of cacodylate of soda, have proved of benefit.
+
+MYCETOMA, OR MADURA FOOT.--Mycetoma is a chronic disease due to
+an organism resembling that of actinomycosis, but not identical with it.
+It is endemic in certain tropical countries, and is most frequently met
+with in India. Infection takes place through an abrasion of the skin,
+and the disease usually occurs on the feet of adult males who work
+barefooted in the fields.
+
+_Clinical Features._--The disease begins on the foot as an indurated
+patch, which becomes discoloured and permeated by black or yellow
+nodules containing the organism. These nodules break down by
+suppuration, and numerous minute abscesses lined by granulation tissues
+are thus formed. In the pus are found yellow particles likened to
+fish-roe, or black pigmented granules like gunpowder. Sinuses form, and
+the whole foot becomes greatly swollen and distorted by flattening of
+the sole and dorsiflexion of the toes. Areas of caries or necrosis occur
+in the bones, and the disease gradually extends up the leg (Fig. 32).
+There is but little pain, and no glandular involvement or constitutional
+disturbance. The disease runs a prolonged course, sometimes lasting for
+twenty or thirty years. Spontaneous cure never takes place, and the risk
+to life is that of prolonged suppuration.
+
+If the disease is localised, it may be removed by the knife or sharp
+spoon, and the part afterwards cauterised. As a rule, amputation well
+above the disease is the best line of treatment. Unlike actinomycosis,
+this disease does not appear to be benefited by iodides.
+
+[Illustration: FIG. 32.--Mycetoma, or Madura Foot. (Museum of Royal
+College of Surgeons, Edinburgh.)]
+
+DELHI BOIL.--_Synonyms_--Aleppo boil, Biskra button, Furunculus
+orientalis, Natal sore.
+
+Delhi boil is a chronic inflammatory disease, most commonly met with in
+India, especially towards the end of the wet season. The disease occurs
+oftenest on the face, and is believed to be due to an organism, although
+this has not been demonstrated. The infection is supposed to be conveyed
+through water used for washing, or by the bites of insects.
+
+_Clinical Features._--A red spot, resembling the mark of a mosquito
+bite, appears on the affected part, and is attended with itching. After
+becoming papular and increasing to the size of a pea, desquamation takes
+place, leaving a dull-red surface, over which in the course of several
+weeks there develops a series of small yellowish-white spots, from which
+serum exudes, and, drying, forms a thick scab. Under this scab the skin
+ulcerates, leaving small oval sores with sharply bevelled edges, and an
+uneven floor covered with yellow or sanious pus. These sores vary in
+number from one to forty or fifty. They may last for months and then
+heal spontaneously, or may continue to spread until arrested by suitable
+treatment. There is no enlargement of adjacent glands, and but little
+inflammatory reaction in the surrounding tissues; nor is there any
+marked constitutional disturbance. Recovery is often followed by
+cicatricial contraction leading to deformity of the face.
+
+The _treatment_ consists in destroying the original papule by the actual
+cautery, acid nitrate of mercury, or pure carbolic acid. The ulcers
+should be scraped with the sharp spoon, and cauterised.
+
+CHIGOE.--Chigoe or jigger results from the introduction of the
+eggs of the sand-flea (_Pulex penetrans_) into the tissues. It occurs in
+tropical Africa, South America, and the West Indies. The impregnated
+female flea remains attached to the part till the eggs mature, when by
+their irritation they cause localised inflammation with pustules or
+vesicles on the surface. Children are most commonly attacked,
+particularly about the toe-nails and on the scrotum. The treatment
+consists in picking out the insect with a blunt needle, special care
+being taken not to break it up. The puncture is then cauterised. The
+application of essential oils to the feet acts as a preventive.
+
+POISONING BY INSECTS.--The bites of certain insects, such as
+mosquitoes, midges, different varieties of flies, wasps, and spiders,
+may be followed by serious complications. The effects are mainly due to
+the injection of an irritant acid secretion, the exact nature of which
+has not been ascertained.
+
+The local lesion is a puncture, surrounded by a zone of hyperaemia,
+wheals, or vesicles, and is associated with burning sensations and
+itching which usually pass off in a few hours, but may recur at
+intervals, especially when the patient is warm in bed. Scratching also
+reproduces the local signs and symptoms. Where the connective tissue is
+loose--for example, in the eyelid or scrotum--there is often
+considerable swelling; and in the mouth and fauces this may lead to
+oedema of the glottis, which may prove fatal.
+
+The _treatment_ consists in the local application of dilute alkalies
+such as ammonia water, solutions of carbonate or bicarbonate of soda, or
+sal-volatile. Weak carbolic lotions, or lead and opium lotion, are
+useful in allaying the local irritation. One of the best means of
+neutralising the poison is to apply to the sting a drop of a mixture
+containing equal parts of pure carbolic acid and liquor ammoniae.
+
+Free stimulation is called for when severe constitutional symptoms are
+present.
+
+SNAKE-BITES.--We are here only concerned with the injuries
+inflicted by the venomous varieties of snakes, the most important of
+which are the hooded snakes of India, the rattle-snakes of America, the
+horned snakes of Africa, the viper of Europe, and the adder of the
+United Kingdom.
+
+While the virulence of these creatures varies widely, they are all
+capable of producing in a greater or less degree symptoms of acute
+poisoning in man and other animals. By means of two recurved fangs
+attached to the upper jaw, and connected by a duct with poison-secreting
+glands, they introduce into their prey a thick, transparent, yellowish
+fluid, of acid reaction, probably of the nature of an albumose, and
+known as the _venom_.
+
+The _clinical features_ resulting from the injection of the venom vary
+directly in intensity with the amount of the poison introduced, and the
+rapidity with which it reaches the circulating blood, being most marked
+when it immediately enters a large vein. The poison is innocuous when
+taken into the stomach.
+
+_Locally_ the snake inflicts a double wound, passing vertically into the
+subcutaneous tissue; the edges of the punctures are ecchymosed, and the
+adjacent vessels the seat of thrombosis. Immediately there is intense
+pain, and considerable swelling with congestion, which tends to spread
+towards the trunk. Extensive gangrene may ensue. There is no special
+involvement of the lymphatics.
+
+The _general symptoms_ may come on at once if the snake is a
+particularly venomous one, or not for some hours if less virulent. In
+the majority of viper or adder bites the constitutional disturbance is
+slight and transient, if it appears at all. Snake-bites in children are
+particularly dangerous.
+
+The patient's condition is one of profound shock with faintness,
+giddiness, dimness of sight, and a feeling of great terror. The pupils
+dilate, the skin becomes moist with a clammy sweat, and nausea with
+vomiting, sometimes of blood, ensues. High fever, cramps, loss of
+sensation, haematuria, and melaena are among the other symptoms that may
+be present. The pulse becomes feeble and rapid, the respiratory nerve
+centres are profoundly depressed, and delirium followed by coma usually
+precedes the fatal issue, which may take place in from five to
+forty-eight hours. If the patient survives for two days the prognosis is
+favourable.
+
+_Treatment._--A broad ligature should be tied tightly round the limb
+above the seat of infection, to prevent the poison passing into the
+general circulation, and bleeding from the wound should be encouraged.
+The application of an elastic bandage from above downward to empty the
+blood out of the infected portion of the limb has been recommended. The
+whole of the bite should at once be excised, and crystals of
+permanganate of potash rubbed into the wound until it is black, or
+peroxide of hydrogen applied with the object of destroying the poison by
+oxidation.
+
+The general treatment consists in free stimulation with whisky, brandy,
+ammonia, digitalis, etc. Hypodermic injections of strychnin in doses
+sufficiently large to produce a slight degree of poisoning by the drug
+are particularly useful. The most rational treatment, when it is
+available, is the use of the _antivenin_ introduced by Fraser and
+Calmette.
+
+
+
+
+CHAPTER VIII
+
+TUBERCULOSIS
+
+
+Tubercle bacillus--Methods of infection--Inherited and acquired
+    predisposition--Relationship of tuberculosis to injury--Human and
+    bovine tuberculosis--Action of the bacillus upon the
+    tissues--Tuberculous granulation tissue--Natural cure--Recrudescence
+    of the disease--THE TUBERCULOUS ABSCESS--Contents and wall of the
+    abscess--Tuberculous sinuses.
+
+Tuberculosis occurs more frequently in some situations than in others;
+it is common, for example, in lymph glands, in bones and joints, in the
+peritoneum, the intestine, the kidney, prostate and testis, and in the
+skin and subcutaneous cellular tissue; it is seldom met with in the
+breast or in muscles, and it rarely affects the ovary, the pancreas, the
+parotid, or the thyreoid.
+
+_Tubercle bacilli_ vary widely in their virulence, and they are more
+tenacious of life than the common pyogenic bacteria. In a dry state, for
+example, they can retain their vitality for months; and they can also
+survive immersion in water for prolonged periods. They resist the action
+of the products of putrefaction for a considerable time, and are not
+destroyed by digestive processes in the stomach and intestine. They may
+be killed in a few minutes by boiling, or by exposure to steam under
+pressure, or by immersion for less than a minute in 1 in 20 carbolic
+lotion.
+
+#Methods of Infection.#--In marked contrast to what obtains in the
+infective diseases that have already been described, tuberculosis rarely
+results from the _infection of a wound_. In exceptional instances,
+however, this does occur, and in illustration of the fact may be cited
+the case of a servant who cut her finger with a broken spittoon
+containing the sputum of her consumptive master; the wound subsequently
+showed evidence of tuberculous infection, which ultimately spread up
+along the lymph vessels of the arm. Pathologists, too, whose hands,
+before the days of rubber gloves, were frequently exposed to the contact
+of tuberculous tissues and pus, were liable to suffer from a form of
+tuberculosis of the skin of the finger, known as _anatomical tubercle_.
+Slight wounds of the feet in children who go about barefoot in towns
+sometimes become infected with tubercle. Operation wounds made with
+instruments contaminated with tuberculous material have also been known
+to become infected. It is highly probable that the common form of
+tuberculosis of the skin known as "lupus" arises by direct infection
+from without.
+
+[Illustration: FIG. 33.--Tubercle Bacilli in caseous material
+x 1000 diam. Z. Neilsen stain.]
+
+In the vast majority of cases the tubercle bacillus gains entrance to
+the body by way of the mucous surfaces, the organisms being either
+inhaled or swallowed; those inhaled are mostly derived from the human
+subject, those swallowed, from cattle. Bacilli, whether inhaled or
+swallowed, are especially apt to lodge about the pharynx and pass to the
+pharyngeal lymphoid tissue and tonsils, and by way of the lymph vessels
+to the glands. The glands most frequently infected in this way are the
+cervical glands, and those within the cavity of the chest--particularly
+the bronchial glands at the root of the lung. From these, infection
+extends at any later period in life to the bones, joints, and internal
+organs.
+
+There is reason to believe that the organisms may lie in a dormant
+condition for an indefinite period in these glands, and only become
+active long afterwards, when some depression of the patient's health
+produces conditions which favour their growth. When the organisms become
+active in this way, the tuberculous tissue undergoes softening and
+disintegration, and the infective material, by bursting into an adjacent
+vein, may enter the blood-stream, in which it is carried to distant
+parts of the body. In this way a _general tuberculosis_ may be set up,
+or localised foci of tuberculosis may develop in the tissues in which
+the organisms lodge. Many tuberculous patients are to be regarded as
+possessing in their bronchial glands, or elsewhere, an internal store of
+bacilli, to which the disease for which advice is sought owes its
+origin, and from which similar outbreaks of tuberculosis may originate
+in the future.
+
+_The alimentary mucous membrane_, especially that of the lower ileum and
+caecum, is exposed to infection by swallowed sputum and by food
+materials, such as milk, containing tubercle bacilli. The organisms may
+lodge in the mucous membrane and cause tuberculous ulceration, or they
+may be carried through the wall of the bowel into the lacteals, along
+which they pass to the mesenteric glands where they become arrested and
+give rise to tuberculous disease.
+
+#Relationship of Tuberculosis to Trauma.#--Any tissue whose vitality has
+been lowered by injury or disease furnishes a favourable nidus for the
+lodgment and growth of tubercle bacilli. The injury or disease, however,
+is to be looked upon as determining the _localisation_ of the
+tuberculous lesion rather than as an essential factor in its causation.
+In a person, for example, in whose blood tubercle bacilli are
+circulating and reaching every tissue and organ of the body, the
+occurrence of tuberculous disease in a particular part may be determined
+by the depression of the tissues resulting from an injury of that part.
+There can be no doubt that excessive movement and jarring of a limb
+aggravates tuberculous disease of a joint; also that an injury may light
+up a focus that has been long quiescent, but we do not agree with
+those--Da Costa, for example--who maintain that injury may be a
+determining cause of tuberculosis. The question is not one of mere
+academic interest, but one that may raise important issues in the law
+courts.
+
+#Human and Bovine Tuberculosis.#--The frequency of the bovine bacillus
+in the abdominal and in the glandular and osseous tuberculous lesions of
+children would appear to justify the conclusion that the disease is
+transmissible from the ox to the human subject, and that the milk of
+tuberculous cows is probably a common vehicle of transmission.
+
+#Changes in the Tissues following upon the successful Lodgment of
+Tubercle Bacilli.#--The action of the bacilli on the tissues results in
+the formation of granulation tissue comprising characteristic tissue
+elements and with a marked tendency to undergo caseation.
+
+The recognition of the characteristic elements, with or without
+caseation, is usually sufficient evidence of the tuberculous nature of
+any portion of tissue examined for diagnostic purposes. The recognition
+of the bacillus itself by appropriate methods of staining makes the
+diagnosis a certainty; but as it is by no means easy to identify the
+organism in many forms of surgical tuberculosis, it may be necessary to
+have recourse to experimental inoculation of susceptible animals such as
+guinea-pigs.
+
+The changes subsequent to the formation of tuberculous granulation
+tissue are liable to many variations. It must always be borne in mind
+that although the bacilli have effected a lodgment and have inaugurated
+disease, the relation between them and the tissues remains one of mutual
+antagonism; which of them is to gain and keep the upper hand in the
+conflict depends on their relative powers of resistance.
+
+If the tissues prevail, there ensues a process of repair. In the
+immediate vicinity of the area of infection young connective tissue, and
+later, fibrous tissue, is formed. This may replace the tuberculous
+tissue and bring about repair--a fibrous cicatrix remaining to mark the
+scene of the previous contest. Scars of this nature are frequently
+discovered at the apex of the lung after death in persons who have at
+one time suffered from pulmonary phthisis. Under other circumstances,
+the tuberculous tissue that has undergone caseation, or even
+calcification, is only encapsulated by the new fibrous tissue, like a
+foreign body. Although this may be regarded as a victory for the
+tissues, the cure, if such it may be called, is not necessarily a
+permanent one, for at any subsequent period, if the part affected is
+disturbed by injury or through some other influence, the encapsulated
+tubercle may again become active and get the upper hand of the tissues,
+and there results a relapse or recrudescence of the disease. This
+_tendency to relapse_ after apparent cure is a notable feature of
+tuberculous disease as it is met with in the spine, or in the
+hip-joint, and it necessitates a prolonged course of treatment to give
+the best chance of a lasting cure.
+
+If, however, at the inauguration of the tuberculous disease the bacilli
+prevail, the infection tends to spread into the tissues surrounding
+those originally infected, and more and more tuberculous granulation
+tissue is formed. Finally the tuberculous tissue breaks down and
+liquefies, resulting in the formation of a cold abscess. In their
+struggle with the tissues, tubercle bacilli receive considerable support
+and assistance from any pyogenic organisms that may be present. A
+tuberculous infection may exhibit its aggressive qualities in a more
+serious manner by sending off detachments of bacilli, which are carried
+by the lymphatics to the nearest glands, or by the blood-stream to more
+distant, and it may be to all, parts of the body. When the infection is
+thus generalised, the condition is called _general tuberculosis_.
+Considering the extraordinary frequency of localised forms of surgical
+tuberculosis, general dissemination of the disease is rare.
+
+#The clinical features# of surgical tuberculosis will be described with
+the individual tissues and organs, as they vary widely according to the
+situation of the lesion.
+
+#The general treatment# consists in combating the adverse influences
+that have been mentioned as increasing the liability to tuberculous
+infection. Within recent years the value of the "open-air" treatment has
+been widely recognised. An open-air life, even in the centre of a city,
+may be followed by marked improvement, especially in the hospital class
+of patient, whose home surroundings tend to favour the progress of the
+disease. The purer air of places away from centres of population is
+still better; and, according to the idiosyncrasies of the individual
+patient, mountain air or that of the sea coast may be preferred. In view
+of the possible discomforts and gastric disturbance which may attend a
+sea-voyage, this should be recommended to patients suffering from
+tuberculous lesions with more caution than has hitherto been exercised.
+The diet must be a liberal one, and should include those articles which
+are at the same time easily digested and nourishing, especially proteids
+and fats; milk obtained from a reliable source and underdone
+butcher-meat are among the best. When the ordinary nourishment taken is
+insufficient, it may be supplemented by such articles as malt extract,
+stout, and cod-liver oil. The last is specially beneficial in patients
+who do not take enough fat in other forms. It is noteworthy that many
+tuberculous patients show an aversion to fat.
+
+For _the use of tuberculin in diagnosis_ and for _the vaccine treatment
+of tuberculosis_ the reader is referred to text-books on medicine.
+
+In addition to increasing the resisting power of the patient, it is
+important to enable the fluids of the body, so altered, to come into
+contact with the tuberculous focus. One of the obstacles to this is that
+the focus is often surrounded by tissues or fluids which have been
+almost entirely deprived of bactericidal substances. In the case of
+caseated glands in the neck, for example, it is obvious that the removal
+of this inert material is necessary before the tissues can be irrigated
+with fluids of high bactericidal value. Again, in tuberculous ascites
+the abdominal cavity is filled with a fluid practically devoid of
+anti-bacterial substances, so that the bacilli are able to thrive and
+work their will on the tissues. When the stagnant fluid is got rid of by
+laparotomy, the parts are immediately douched with lymph charged with
+protective substances, the bactericidal power of which may be many times
+that of the fluid displaced.
+
+It is probable that the beneficial influence of _counter-irritants_,
+such as blisters, and exposure to the _Finsen light_ and other forms of
+_rays_, is to be attributed in part to the increased flow of blood to
+the infected tissues.
+
+_Artificial Hyperaemia._--As has been explained, the induction of
+hyperaemia by the method devised by Bier, constitutes one of our most
+efficient means of combating bacterial infection. The treatment of
+tuberculosis on this plan has been proved by experience to be a valuable
+addition to our therapeutic measures, and the simplicity of its
+application has led to its being widely adopted in practice. It results
+in an increase in the reactive changes around the tuberculous focus, an
+increase in the immigration of leucocytes, and infiltration with the
+lymphocytes.
+
+The constricting bandage should be applied at some distance above the
+seat of infection; for instance, in disease of the wrist, it is put on
+above the elbow, and it must not cause pain either where it is applied
+or in the diseased part. The bandage is only applied for a few hours
+each day, either two hours at a time or twice a day for one hour, and,
+while it is on, all dressings are removed save a piece of sterile gauze
+over any wound or sinus that may be present. The process of cure takes a
+long time--nine or even twelve months in the case of a severe joint
+affection.
+
+In cases in which a constricting bandage is inapplicable, for example,
+in cold abscesses, tuberculous glands or tendon sheaths, Klapp's suction
+bell is employed. The cup is applied for five minutes at a time and then
+taken off for three minutes, and this is repeated over a period of
+about three-quarters of an hour. The pus is allowed to escape by a small
+incision, and no packing or drain should be introduced.
+
+It has been found that tuberculous lesions tend to undergo cure
+when the infected tissues are exposed to the rays of the
+sun--_heliotherapy_--therefore whenever practicable this therapeutic
+measure should be had recourse to.
+
+Since the introduction of the methods of treatment described above, and
+especially by their employment at an early stage in the disease, the
+number of cases of tuberculosis requiring operative interference has
+greatly diminished. There are still circumstances, however, in which an
+operation is required; for example, in disease of the lymph glands for
+the removal of inert masses of caseous material, in disease of bone for
+the removal of sequestra, or in disease of joints to improve the
+function of the limb. It is to be understood, however, that operative
+treatment must always be preceded by and combined with other therapeutic
+measures.
+
+
+TUBERCULOUS ABSCESS
+
+The caseation of tuberculous granulation tissue and its liquefaction is
+a slow and insidious process, and is unattended with the classical signs
+of inflammation--hence the terms "cold" and "chronic" applied to the
+tuberculous abscess.
+
+In a cold abscess, such as that which results from tuberculous disease
+of the vertebrae, the clinical appearances are those of a soft, fluid
+swelling without heat, redness, pain, or fever. When toxic symptoms are
+present, they are usually due to a mixed infection.
+
+A tuberculous abscess results from the disintegration and liquefaction
+of tuberculous granulation tissue which has undergone caseation. Fluid
+and cells from the adjacent blood vessels exude into the cavity, and
+lead to variations in the character of its contents. In some cases the
+contents consist of a clear amber-coloured fluid, in which are suspended
+fragments of caseated tissue; in others, of a white material like
+cream-cheese. From the addition of a sufficient number of leucocytes,
+the contents may resemble the pus of an ordinary abscess.
+
+The wall of the abscess is lined with tuberculous granulation tissue,
+the inner layers of which are undergoing caseation and disintegration,
+and present a shreddy appearance; the outer layers consist of
+tuberculous tissue which has not yet undergone caseation. The abscess
+tends to increase in size by progressive liquefaction of the inner
+layers, caseation of the outer layers, and the further invasion of the
+surrounding tissues by tubercle bacilli. In this way a tuberculous
+abscess is capable of indefinite extension and increase in size until it
+reaches a free surface and ruptures externally. The direction in which
+it spreads is influenced by the anatomical arrangement of the tissues,
+and possibly to some extent by gravity, and the abscess may reach the
+surface at a considerable distance from its seat of origin. The best
+illustration of this is seen in the psoas abscess, which may originate
+in the dorsal vertebrae, extend downwards within the sheath of the psoas
+muscle, and finally appear in the thigh.
+
+#Clinical Features.#--The insidious development of the tuberculous
+abscess is one of its characteristic features. The swelling may attain a
+considerable size without the patient being aware of its existence, and,
+as a matter of fact, it is often discovered accidentally. The absence of
+toxaemia is to be associated with the incapacity of the wall of the
+abscess to permit of absorption; this is shown also by the fact that
+when even a large quantity of iodoform is inserted into the cavity of
+the abscess, there are no symptoms of poisoning. The abscess varies in
+size from a small cherry to a cavity containing several pints of pus.
+Its shape also varies; it is usually that of a flattened sphere, but it
+may present pockets or burrows running in various directions. Sometimes
+it is hour-glass or dumb-bell shaped, as is well illustrated in the
+region of the groin in disease of the spine or pelvis, where there may
+be a large sac occupying the venter ilii, and a smaller one in the
+thigh, the two communicating by a narrow channel under Poupart's
+ligament. By pressing with the fingers the pus may be displaced from one
+compartment to the other. The usual course of events is that the abscess
+progresses slowly, and finally reaches a free surface--generally the
+skin. As it does so there may be some pain, redness, and local elevation
+of temperature. Fluctuation becomes evident and superficial, and the
+skin becomes livid and finally gives way. If the case is left to nature,
+the discharge of pus continues, and the track opening on the skin
+remains as a _sinus_. The persistence of suppuration is due to the
+presence in the wall of the abscess and of the sinus, of tuberculous
+granulation tissue, which, so long as it remains, continues to furnish
+discharge, and so prevents healing. Sooner or later pyogenic organisms
+gain access to the sinus, and through it to the wall of the abscess.
+They tend further to depress the resisting power of the tissues, and
+thereby aggravate and perpetuate the tuberculous disease. This
+superadded infection with pyogenic organisms exposes the patient to the
+further risks of septic intoxication, especially in the form of hectic
+fever and septicaemia, and increases the liability to general
+tuberculosis, and to waxy degeneration of the internal organs. The mixed
+infection is chiefly responsible for the pyrexia, sweating, and
+emaciation which the laity associate with consumptive disease. A
+tuberculous abscess may in one or other of these ways be a cause of
+death.
+
+_Residual abscess_ is the name given to an abscess that makes its
+appearance months, or even years, after the apparent cure of tuberculous
+disease--as, for example, in the hip-joint or spine. It is called
+residual because it has its origin in the remains of the original
+disease.
+
+[Illustration: FIG. 34.--Tuberculous Abscess in right lumbar region in a
+woman aged thirty.]
+
+#Diagnosis.#--A cold abscess is to be diagnosed from a syphilitic gumma,
+a cyst, and from lipoma and other soft tumours. The differential
+diagnosis of these affections will be considered later; it is often made
+easier by recognising the presence of a lesion that is likely to cause a
+cold abscess, such as tuberculous disease of the spine or of the
+sacro-iliac joint. When it is about to burst externally, it may be
+difficult to distinguish a tuberculous abscess from one due to infection
+with pyogenic organisms. Even when the abscess is opened, the
+appearances of the pus may not supply the desired information, and it
+may be necessary to submit it to bacteriological examination. When the
+pus is found to be sterile, it is usually safe to assume that the
+condition is tuberculous, as in other forms of suppuration the causative
+organisms can usually be recognised. Experimental inoculation will
+establish a definite diagnosis, but it implies a delay of two to three
+weeks.
+
+#Treatment.#--The tuberculous abscess may recede and disappear under
+general treatment. Many surgeons advise that so long as the abscess is
+quiescent it should be left alone. All agree, however, that if it shows
+a tendency to spread, to increase in size, or to approach the skin or a
+mucous membrane, something should be done to avoid the danger of its
+bursting and becoming infected with pyogenic organisms. Simple
+evacuation of the abscess by a hollow needle may suffice, or bismuth or
+iodoform may be introduced after withdrawal of the contents.
+
+_Evacuation of the Abscess and Injection of Iodoform._--The iodoform is
+employed in the form of a 10 per cent. solution in ether or the same
+proportion suspended in glycerin. Either form becomes sterile soon after
+it is prepared. Its curative effects would appear to depend upon the
+liberation of iodine, which restrains the activity of the bacilli, and
+upon its capacity for irritating the tissues and so inducing a
+protective leucocytosis, and also of stimulating the formation of scar
+tissue. An anaesthetic is rarely called for, except in children. The
+abscess is first evacuated by means of a large trocar and cannula
+introduced obliquely through the overlying soft parts, avoiding any part
+where the skin is thin or red. If the cannula becomes blocked with
+caseous material, it may be cleared with a probe, or a small quantity of
+saline solution is forced in by the syringe. The iodoform is injected by
+means of a glass-barrelled syringe, which is firmly screwed on to the
+cannula. The amount injected varies with the size of the abscess and the
+age of the patient; it may be said to range from two or three drams in
+the case of children to several ounces in large abscesses in adults. The
+cannula is withdrawn, the puncture is closed by a Michel's clip, and a
+dressing applied so as to exert a certain amount of compression. If the
+abscess fills up again, the procedure should be repeated; in doing so,
+the contents show the coloration due to liberated iodine. When the
+contents are semi-solid, and cannot be withdrawn even through a large
+cannula, an incision must be made, and, after the cavity has been
+emptied, the iodoform is introduced through a short rubber tube attached
+to the syringe. Experience has shown that even large abscesses, such as
+those associated with spinal disease, may be cured by iodoform
+injection, and this even when rupture of the abscess on the skin surface
+has appeared to be imminent.
+
+Another method of treatment which is less popular now than it used to
+be, and which is chiefly applicable in abscesses of moderate size, is by
+_incision of the abscess and removal of the tuberculous tissue in its
+wall_ with the sharp spoon. An incision is made which will give free
+access to the interior of the abscess, so that outlying pockets or
+recesses may not be overlooked. After removal of the pus, the wall of
+the abscess is scraped with the Volkmann spoon or with Barker's flushing
+spoon, to get rid of the tuberculous tissue with which it is lined. In
+using the spoon, care must be taken that its sharp edge does not
+perforate the wall of a vein or other important structure. Any debris
+which may adhere to the walls is removed by rubbing with dry gauze. The
+oozing of blood is arrested by packing the cavity for a few minutes with
+gauze. After the packing is removed, iodoform powder is rubbed into the
+raw surface. The soft parts divided by the incision are sutured in
+layers so as to ensure primary union. If, on the other hand, there is
+fear of a mixed infection, especially in abscesses near the rectum or
+anus, it is safer to treat it by the open method, packing the cavity
+with iodoform worsted or bismuth gauze, which is renewed at intervals of
+a week or ten days as the cavity heals from the bottom.
+
+Another method is to incise the abscess, cleanse the cavity with gauze,
+irrigate with Carrel-Dakin solution and pack with gauze smeared with the
+dilute non-toxic B.I.P.P. (bismuth and iodoform 2 parts, vaseline 12
+parts, hard paraffin, sufficient to give the consistence of butter). The
+wound is closed with "bipped" silk sutures; one of these--the "waiting
+suture"--is left loose to permit of withdrawal of the gauze after
+forty-eight hours; the waiting suture is then tied, and delayed primary
+union is thus effected.
+
+When the skin over the abscess is red, thin, and about to give way, as
+is frequently the case when the abscess is situated in the subcutaneous
+cellular tissue, any skin which is undermined and infected with tubercle
+should be removed with the scissors at the same time that the abscess is
+dealt with.
+
+In abscesses treated by the open method, when the cavity has become
+lined with healthy granulations, it may be closed by secondary suture,
+or, if the granulating surface is flush with the skin, healing may be
+hastened by skin-grafting.
+
+If the tuberculous abscess has burst and left a _sinus_, this is apt to
+persist because of the presence of tuberculous tissue in its wall, and
+of superadded pyogenic infection, or because it serves as an avenue for
+the escape of discharge from a focus of tubercle in a bone or a lymph
+gland.
+
+[Illustration: FIG. 35.--Tuberculous Sinus injected through its opening
+in the forearm with bismuth paste.
+
+(Mr. Pirie Watson's case--Radiogram by Dr. Hope Fowler.)]
+
+The treatment varies with the conditions present, and must include
+measures directed to the lesion from which the sinus has originated. The
+extent and direction of any given sinus may be demonstrated by the use
+of the probe, or, more accurately, by injecting the sinus with a paste
+consisting of white vaseline containing 10 to 30 per cent. of bismuth
+subcarbonate, and following its track with the X-rays (Fig. 35).
+
+It was found by Beck of Chicago that the injection of bismuth paste is
+frequently followed by healing of the sinus, and that, if one injection
+fails to bring about a cure, repeating the injection every second day
+may be successful. Some caution must be observed in this treatment, as
+symptoms of poisoning have been observed to follow its use. If they
+manifest themselves, an injection of warm olive oil should be given; the
+oil, left in for twelve hours or so, forms an emulsion with the bismuth,
+which can be withdrawn by aspiration. Iodoform suspended in glycerin may
+be employed in a similar manner. When these and other non-operative
+measures fail, and the whole track of the sinus is accessible, it should
+be laid open, scraped, and packed with bismuth or iodoform gauze until
+it heals from the bottom.
+
+The _tuberculous ulcer_ is described in the chapter on ulcers.
+
+
+
+
+CHAPTER IX
+
+SYPHILIS
+
+
+Definition.--Virus.--ACQUIRED SYPHILIS--Primary period:
+    _Incubation, primary chancre, glandular enlargement_;
+    _Extra-genital chancres_--Treatment--Secondary period: _General
+    symptoms, skin affections, mucous patches, affections of bones,
+    joints, eyes_, etc.--Treatment: _Salvarsan_--_Methods of
+    administering mercury_--Syphilis and marriage--Intermediate
+    stage--_Reminders_--Tertiary period: _General symptoms_,
+    _gummata_, _tertiary ulcers_, _tertiary lesions of skin, mucous
+    membrane, bones, joints_, etc.--Second attacks.--INHERITED
+    SYPHILIS--Transmission--_Clinical features in infancy, in later
+    life_--Contagiousness--Treatment.
+
+Syphilis is an infective disease due to the entrance into the body of a
+specific virus. It is nearly always communicated from one individual to
+another by contact infection, the discharge from a syphilitic lesion
+being the medium through which the virus is transmitted, and the seat of
+inoculation is almost invariably a surface covered by squamous
+epithelium. The disease was unknown in Europe before the year 1493, when
+it was introduced into Spain by Columbus' crew, who were infected in
+Haiti, where the disease had been endemic from time immemorial (Bloch).
+
+The granulation tissue which forms as a result of the reaction of the
+tissues to the presence of the virus is chiefly composed of lymphocytes
+and plasma cells, along with an abundant new formation of capillary
+blood vessels. Giant cells are not uncommon, but the endothelioid cells,
+which are so marked a feature of tuberculous granulation tissue, are
+practically absent.
+
+When syphilis is communicated from one individual to another by contact
+infection, the condition is spoken of as _acquired syphilis_, and the
+first visible sign of the disease appears at the site of inoculation,
+and is known as _the primary lesion_. Those who have thus acquired the
+disease may transmit it to their offspring, who are then said to suffer
+from _inherited syphilis_.
+
+#The Virus of Syphilis.#--The cause of syphilis, whether acquired or
+inherited, is the organism, described by Schaudinn and Hoffman, in 1905,
+under the name of _spirochaeta pallida_ or _spironema pallidum_. It is a
+delicate, thread-like spirilla, in length averaging from 8 to 10
+[micron] and in width about 0.25 [micron], and is distinguished from
+other spirochaetes by its delicate shape, its dead-white appearance,
+together with its closely twisted spiral form, with numerous undulations
+(10 to 26), which are perfectly regular, and are characteristic in that
+they remain the same during rest and in active movement (Fig. 36). In a
+fresh specimen, such as a scraping from a hard chancre suspended in a
+little salt solution, it shows active movements. The organism is readily
+destroyed by heat, and perishes in the absence of moisture. It has been
+proved experimentally that it remains infective only up to six hours
+after its removal from the body. Noguchi has succeeded in obtaining pure
+cultures from the infected tissues of the rabbit.
+
+[Illustration: FIG. 36.--Spirochaeta pallida from scraping of hard
+Chancre of Prepuce. x 1000 diam. Burri method.]
+
+The spirochaete may be recognised in films made by scraping the deeper
+parts of the primary lesion, from papules on the skin, or from blisters
+artificially raised on lesions of the skin or on the immediately
+adjacent portion of healthy skin. It is readily found in the mucous
+patches and condylomata of the secondary period. It is best stained by
+Giemsa's method, and its recognition is greatly aided by the use of the
+ultra-microscope.
+
+The spirochaete has been demonstrated in every form of syphilitic lesion,
+and has been isolated from the blood--with difficulty--and from lymph
+withdrawn by a hollow needle from enlarged lymph glands. The saliva of
+persons suffering from syphilitic lesions of the mouth also contains the
+organism.
+
+[Illustration: FIG. 37.--Spirochaeta refrigerans from scraping of Vagina.
+x 1000 diam. Burri method.]
+
+In tertiary lesions there is greater difficulty in demonstrating the
+spirochaete, but small numbers have been found in the peripheral parts of
+gummata and in the thickened patches in syphilitic disease of the aorta.
+Noguchi and Moore have discovered the spirochaete in the brain in a
+number of cases of general paralysis of the insane. The spirochaete may
+persist in the body for a long time after infection; its presence has
+been demonstrated as long as sixteen years after the original
+acquisition of the disease.
+
+In inherited syphilis the spirochaete is present in enormous numbers
+throughout all the organs and fluids of the body.
+
+Considerable interest attaches to the observations of Metchnikoff, Roux,
+and Neisser, who have succeeded in conveying syphilis to the chimpanzee
+and other members of the ape tribe, obtaining primary and secondary
+lesions similar to those observed in man, and also containing the
+spirochaete. In animals the disease has been transmitted by material from
+all kinds of syphilitic lesions, including even the blood in the
+secondary and tertiary stages of the disease. The primary lesion is in
+the form of an indurated papule, in every respect resembling the
+corresponding lesion in man, and associated with enlargement and
+induration of the lymph glands. The primary lesion usually appears about
+thirty days after inoculation, to be followed, in about half the cases,
+by secondary manifestations, which are usually of a mild character; in
+no instance has any tertiary lesion been observed. The severity of the
+affection amongst apes would appear to be in proportion to the nearness
+of the relationship of the animal to the human subject. The eye of the
+rabbit is also susceptible to inoculation from syphilitic lesions; the
+material in a finely divided state is introduced into the anterior
+chamber of the eye.
+
+Attempts to immunise against the disease have so far proved negative,
+but Metchnikoff has shown that the inunction of the part inoculated with
+an ointment containing 33 per cent. of calomel, within one hour of
+infection, suffices to neutralise the virus in man, and up to eighteen
+hours in monkeys. He recommends the adoption of this procedure in the
+prophylaxis of syphilis.
+
+Noguchi has made an emulsion of dead spirochaetes which he calls
+_luetin_, and which gives a specific reaction resembling that of
+tuberculin in tuberculosis, a papule or a pustule forming at the site of
+the intra-dermal injection. It is said to be most efficacious in the
+tertiary and latent forms of syphilis, which are precisely those forms
+in which the diagnosis is surrounded with difficulties.
+
+
+ACQUIRED SYPHILIS
+
+In the vast majority of cases, infection takes place during the congress
+of the sexes. Delicate, easily abraded surfaces are then brought into
+contact, and the discharge from lesions containing the virus is placed
+under favourable conditions for conveying the disease from one person to
+the other. In the male the possibility of infection taking place is
+increased if the virus is retained under cover of a long and tight
+prepuce, and if there are abrasions on the surface with which it comes
+in contact. The frequency with which infection takes place on the
+genitals during sexual intercourse warrants syphilis being considered a
+venereal disease, although there are other ways in which it may be
+contracted.
+
+Some of these imply direct contact--such, for example, as kissing, the
+digital examination of syphilitic patients by doctors or nurses, or
+infection of the surgeon's fingers while operating upon a syphilitic
+patient. In suckling, a syphilitic wet nurse may infect a healthy
+infant, or a syphilitic infant may infect a healthy wet nurse. In other
+cases the infection is by indirect contact, the virus being conveyed
+through the medium of articles contaminated by a syphilitic
+patient--such, for example, as surgical instruments, tobacco pipes, wind
+instruments, table utensils, towels, or underclothing. Physiological
+secretions, such as saliva, milk, or tears, are not capable of
+communicating the disease unless contaminated by discharge from a
+syphilitic sore. While the saliva itself is innocuous, it can be, and
+often is, contaminated by the discharge from mucous patches or other
+syphilitic lesions in the mouth and throat, and is then a dangerous
+medium of infection. Unless these extra-genital sources of infection are
+borne in mind, there is a danger of failing to recognise the primary
+lesion of syphilis in unusual positions, such as the lip, finger, or
+nipple. When the disease is thus acquired by innocent transfer, it is
+known as _syphilis insontium_.
+
+#Stages or Periods of Syphilis.#--Following the teaching of Ricord, it
+is customary to divide the life-history of syphilis into three periods
+or stages, referred to, for convenience, as primary, secondary, and
+tertiary. This division is to some extent arbitrary and artificial, as
+the different stages overlap one another, and the lesions of one stage
+merge insensibly into those of another. Wide variations are met with in
+the manifestations of the secondary stage, and histologically there is
+no valid distinction to be drawn between secondary and tertiary lesions.
+
+_The primary period_ embraces the interval that elapses between the
+initial infection and the first constitutional manifestations,--roughly,
+from four to eight weeks,--and includes the period of incubation, the
+development of the primary sore, and the enlargement of the nearest
+lymph glands.
+
+_The secondary period_ varies in duration from one to two years, during
+which time the patient is liable to suffer from manifestations which are
+for the most part superficial in character, affecting the skin and its
+appendages, the mucous membranes, and the lymph glands.
+
+_The tertiary period_ has no time-limit except that it follows upon the
+secondary, so that during the remainder of his life the patient is
+liable to suffer from manifestations which may affect the deeper tissues
+and internal organs as well as the skin and mucous membranes.
+
+#Primary Syphilis.#--_The period of incubation_ represents the interval
+that elapses between the occurrence of infection and the appearance of
+the primary lesion at the site of inoculation. Its limits may be stated
+as varying from two to six weeks, with an average of from twenty-one to
+twenty-eight days. While the disease is incubating, there is nothing to
+show that infection has occurred.
+
+_The Primary Lesion._--The incubation period having elapsed, there
+appears at the site of inoculation a circumscribed area of infiltration
+which represents the reaction of the tissues to the entrance of the
+virus. The first appearance is that of a sharply defined papule, rarely
+larger than a split pea. Its surface is at first smooth and shiny, but
+as necrosis of the tissue elements takes place in the centre, it becomes
+concave, and in many cases the epithelium is shed, and an ulcer is
+formed. Such an ulcer has an elevated border, sharply cut edges, an
+indurated base, and exudes a scanty serous discharge; its surface is at
+first occupied by yellow necrosed tissue, but in time this is replaced
+by smooth, pale-pink granulation tissue; finally, epithelium may spread
+over the surface, and the ulcer heals. As a rule, the patient suffers
+little discomfort, and may even be ignorant of the existence of the
+lesion, unless, as a result of exposure to mechanical or septic
+irritation, ulceration ensues, and the sore becomes painful and tender,
+and yields a purulent discharge. The primary lesion may persist until
+the secondary manifestations make their appearance, that is, for several
+weeks.
+
+It cannot be emphasised too strongly that the induration of the primary
+lesion, which has obtained for it the name of "hard chancre," is its
+most important characteristic. It is best appreciated when the sore is
+grasped from side to side between the finger and thumb. The sensation on
+grasping it has been aptly compared to that imparted by a nodule of
+cartilage, or by a button felt through a layer of cloth. The evidence
+obtained by touch is more valuable than that obtained by inspection, a
+fact which is made use of in the recognition of _concealed
+chancres_--that is, those which are hidden by a tight prepuce. The
+induration is due not only to the dense packing of the connective-tissue
+spaces with lymphocytes and plasma cells, but also to the formation of
+new connective-tissue elements. It is most marked in chancres situated
+in the furrow between the glans and the prepuce.
+
+_In the male_, the primary lesion specially affects certain
+_situations_, and the appearances vary with these: (1) On the inner
+aspect of the prepuce, and in the fold between the prepuce and the
+glans; in the latter situation the induration imparts a "collar-like"
+rigidity to the prepuce, which is most apparent when it is rolled back
+over the corona. (2) At the orifice of the prepuce the primary lesion
+assumes the form of multiple linear ulcers or fissures, and as each of
+these is attended with infiltration, the prepuce cannot be pulled
+back--a condition known as _syphilitic phimosis_. (3) On the glans penis
+the infiltration may be so superficial that it resembles a layer of
+parchment, but if it invades the cavernous tissue there is a dense mass
+of induration. (4) On the external aspect of the prepuce or on the skin
+of the penis itself. (5) At either end of the torn fraenum, in the form
+of a diamond-shaped ulcer raised above the surroundings. (6) In relation
+to the meatus and canal of the urethra, in either of which situations
+the swelling and induration may lead to narrowing of the urethra, so
+that the urine is passed with pain and difficulty and in a minute
+stream; stricture results only in the exceptional cases in which the
+chancre has ulcerated and caused destruction of tissue. A chancre within
+the orifice of the urethra is rare, and, being concealed from view, it
+can only be recognised by the discharge from the meatus and by the
+induration felt between the finger and thumb on palpating the urethra.
+
+_In the female_, the primary lesion is not so typical or so easily
+recognised as in men; it is usually met with on the labia; the
+induration is rarely characteristic and does not last so long. The
+primary lesion may take the form of condylomata. Indurated oedema, with
+brownish-red or livid discoloration of one or both labia, is diagnostic
+of syphilis.
+
+The hard chancre is usually solitary, but sometimes there are two or
+more; when there are several, they are individually smaller than the
+solitary chancre.
+
+It is the exception for a hard chancre to leave a visible scar, hence,
+in examining patients with a doubtful history of syphilis, little
+reliance can be placed on the presence or absence of a scar on the
+genitals. When the primary lesion has taken the form of an open ulcer
+with purulent discharge, or has sloughed, there is a permanent scar.
+
+_Infection of the adjacent lymph glands_ is usually found to have taken
+place by the time the primary lesion has acquired its characteristic
+induration. Several of the glands along Poupart's ligament, on one or on
+both sides, become enlarged, rounded, and indurated; they are usually
+freely movable, and are rarely sensitive unless there is superadded
+septic infection. The term _bullet-bubo_ has been applied to them, and
+their presence is of great value in diagnosis. In a certain number of
+cases, one of the main _lymph vessels_ on the dorsum of the penis is
+transformed into a fibrous cord easily recognisable on palpation, and
+when grasped between the fingers appears to be in size and consistence
+not unlike the vas deferens.
+
+_Concealed chancre_ is the term applied when one or more chancres are
+situated within the sac of a prepuce which cannot be retracted. If the
+induration is well marked, the chancre can be palpated through the
+prepuce, and is tender on pressure. As under these conditions it is
+impossible for the patient to keep the parts clean, septic infection
+becomes a prominent feature, the prepuce is oedematous and inflamed, and
+there is an abundant discharge of pus from its orifice. It occasionally
+happens that the infection assumes a virulent character and causes
+sloughing of the prepuce--a condition known as _phagedaena_. The
+discharge is then foul and blood-stained, and the prepuce becomes of a
+dusky red or purple colour, and may finally slough, exposing the glans.
+
+_Extra-genital or Erratic Chancres_ (Fig. 38).--Erratic chancre is the
+term applied by Jonathan Hutchinson to the primary lesion of syphilis
+when it appears on parts of the body other than the genitals. It differs
+in some respects from the hard chancre as met with on the penis; it is
+usually larger, the induration is more diffused, and the enlarged glands
+are softer and more sensitive. The glands in nearest relation to the
+sore are those first affected, for example, the epitrochlear or axillary
+glands in chancre of the finger; the submaxillary glands in chancre of
+the lip or mouth; or the pre-auricular gland in chancre of the eyelid or
+forehead. In consequence of their divergence from the typical chancre,
+and of their being often met with in persons who, from age,
+surroundings, or moral character, are unlikely subjects of venereal
+disease, the true nature of erratic chancres is often overlooked until
+the persistence of the lesion, its want of resemblance to anything else,
+or the onset of constitutional symptoms, determines the diagnosis of
+syphilis. A solitary, indolent sore occurring on the lip, eyelid,
+finger, or nipple, which does not heal but tends to increase in size,
+and is associated with induration and enlargement of the adjacent
+glands, is most likely to be the primary lesion of syphilis.
+
+[Illustration: FIG. 38.--Primary Lesion on Thumb, with Secondary
+Eruption on Forearm.[1]]
+
+[1] From _A System of Syphilis_, vol. ii., edited by D'Arcy Power and
+J. Keogh Murphy, Oxford Medical Publications.
+
+#The Soft Sore, Soft Chancre, or Chancroid.#--The differential diagnosis
+of syphilis necessitates the consideration of the _soft sore_, _soft
+chancre_, or _chancroid_, which is also a common form of venereal
+disease, and is due to infection with a virulent pus-forming bacillus,
+first described by Ducrey in 1889. Ducrey's bacillus occurs in the form
+of minute oval rods measuring about 1.5 [micron] in length, which stain
+readily with any basic aniline dye, but are quickly decolorised by
+Gram's method. They are found mixed with other organisms in the purulent
+discharge from the sore, and are chiefly arranged in small groups or in
+short chains. Soft sores are always contracted by direct contact from
+another individual, and the incubation period is a short one of from two
+to five days. They are usually situated in the vicinity of the fraenum,
+and, in women, about the labia minora or fourchette; they probably
+originate in abrasions in these situations. They appear as pustules,
+which are rapidly converted into small, acutely inflamed ulcers with
+sharply cut, irregular margins, which bleed easily and yield an abundant
+yellow purulent discharge. They are devoid of the induration of
+syphilis, are painful, and nearly always multiple, reproducing
+themselves in successive crops by auto-inoculation. Soft sores are often
+complicated by phimosis and balanitis, and they frequently lead to
+infection of the glands in the groin. The resulting bubo is ill-defined,
+painful, and tender, and suppuration occurs in about one-fourth of the
+cases. The overlying skin becomes adherent and red, and suppuration
+takes place either in the form of separate foci in the interior of the
+individual glands, or around them; in the latter case, on incision, the
+glands are found lying bathed in pus. Ducrey's bacillus is found in pure
+culture in the pus. Sometimes other pyogenic organisms are superadded.
+After the bubo has been opened the wound may take on the characters of a
+soft sore.
+
+_Treatment._--Soft sores heal rapidly when kept clean. If concealed
+under a tight prepuce, an incision should be made along the dorsum to
+give access to the sores. They should be washed with eusol, and dusted
+with a mixture of one part iodoform and two parts boracic or salicylic
+acid, or, when the odour of iodoform is objected to, of equal parts of
+boracic acid and carbonate of zinc. Immersion of the penis in a bath of
+eusol for some hours daily is useful. The sore is then covered with a
+piece of gauze kept in position by drawing the prepuce over it, or by a
+few turns of a narrow bandage. Sublimed sulphur frequently rubbed into
+the sore is recommended by C. H. Mills. If the sores spread in spite of
+this, they should be painted with cocaine and then cauterised. When the
+glands in the groin are infected, the patient must be confined to bed,
+and a dressing impregnated with ichthyol and glycerin (10 per cent.)
+applied; the repeated use of a suction bell is of great service.
+Harrison recommends aspiration of a bubonic abscess, followed by
+injection of 1 in 20 solution of tincture of iodine into the cavity;
+this is in turn aspirated, and then 1 or 2 c.c. of the solution injected
+and left in. This is repeated as often as the cavity refills. It is
+sometimes necessary to let the pus out by one or more small incisions
+and continue the use of the suction bell.
+
+_Diagnosis of Primary Syphilis._--In cases in which there is a history
+of an incubation period of from three to five weeks, when the sore is
+indurated, persistent, and indolent, and attended with bullet-buboes in
+the groin, the diagnosis of primary syphilis is not difficult. Owing,
+however, to the great importance of instituting treatment at the
+earliest possible stage of the infection, an effort should be made to
+establish the diagnosis without delay by demonstrating the spirochaete.
+Before any antiseptic is applied, the margin of the suspected sore is
+rubbed with gauze, and the serum that exudes on pressure is collected
+in a capillary tube and sent to a pathologist for microscopical
+examination. A better specimen can sometimes be obtained by puncturing
+an enlarged lymph gland with a hypodermic needle, injecting a few minims
+of sterile saline solution and then aspirating the blood-stained fluid.
+
+The Wassermann test must not be relied upon for diagnosis in the early
+stage, as it does not appear until the disease has become generalised
+and the secondary manifestations are about to begin. The practice of
+waiting in doubtful cases before making a diagnosis until secondary
+manifestations appear is to be condemned.
+
+Extra-genital chancres, _e.g._ sores on the fingers of doctors or
+nurses, are specially liable to be overlooked, if the possibility of
+syphilis is not kept in mind.
+
+It is important to bear in mind _the possibility of a patient having
+acquired a mixed infection_ with the virus of soft chancre, which will
+manifest itself a few days after infection, and the virus of syphilis,
+which shows itself after an interval of several weeks. This occurrence
+was formerly the source of much confusion in diagnosis, and it was
+believed at one time that syphilis might result from soft sores, but it
+is now established that syphilis does not follow upon soft sores unless
+the virus of syphilis has been introduced at the same time. The
+practitioner must be on his guard, therefore, when a patient asks his
+advice concerning a venereal sore which has appeared within a few days
+of exposure to infection. Such a patient is naturally anxious to know
+whether he has contracted syphilis or not, but neither a positive nor a
+negative answer can be given--unless the spirochaete can be identified.
+
+Syphilis is also to be diagnosed from _epithelioma_, the common form of
+cancer of the penis. It is especially in elderly patients with a tight
+prepuce that the induration of syphilis is liable to be mistaken for
+that associated with epithelioma. In difficult cases the prepuce must be
+slit open.
+
+Difficulty may occur in the diagnosis of primary syphilis from _herpes_,
+as this may appear as late as ten days after connection; it commences as
+a group of vesicles which soon burst and leave shallow ulcers with a
+yellow floor; these disappear quickly on the use of an antiseptic
+dusting powder.
+
+Apprehensive patients who have committed sexual indiscretions are apt to
+regard as syphilitic any lesion which happens to be located on the
+penis--for example, acne pustules, eczema, psoriasis papules, boils,
+balanitis, or venereal warts.
+
+_The local treatment_ of the primary sore consists in attempting to
+destroy the organisms _in situ_. An ointment made up of calomel 33
+parts, lanoline 67 parts, and vaseline 10 parts (Metchnikoff's cream) is
+rubbed into the sore several times a day. If the surface is unbroken, it
+may be dusted lightly with a powder composed of equal parts of calomel
+and carbonate of zinc. A gauze dressing is applied, and the penis and
+scrotum should be supported against the abdominal wall by a triangular
+handkerchief or bathing-drawers; if there is inflammatory oedema the
+patient should be confined to bed.
+
+In _concealed chancres_ with phimosis, the sac of the prepuce should be
+slit up along the dorsum to admit of the ointment being applied. If
+phagedaena occurs, the prepuce must be slit open along the dorsum, or if
+sloughing, cut away, and the patient should have frequent sitz baths of
+weak sublimate lotion. When the chancre is within the meatus, iodoform
+bougies are inserted into the urethra, and the urine should be rendered
+bland by drinking large quantities of fluid.
+
+General treatment is considered on p. 149.
+
+#Secondary Syphilis.#--The following description of secondary syphilis
+is based on the average course of the disease in untreated cases. The
+onset of constitutional symptoms occurs from six to twelve weeks after
+infection, and the manifestations are the result of the entrance of the
+virus into the general circulation, and its being carried to all parts
+of the body. The period during which the patient is liable to suffer
+from secondary symptoms ranges from six months to two years.
+
+In some cases the general health is not disturbed; in others the patient
+is feverish and out of sorts, losing appetite, becoming pale and anaemic,
+complaining of lassitude, incapacity for exertion, headache, and pains
+of a rheumatic type referred to the bones. There is a moderate degree of
+leucocytosis, but the increase is due not to the polymorpho-nuclear
+leucocytes but to lymphocytes. In isolated cases the temperature rises
+to 101 or 102 F. and the patient loses flesh. The lymph glands,
+particularly those along the posterior border of the sterno-mastoid,
+become enlarged and slightly tender. The hair comes out, eruptions
+appear on the skin and mucous membranes, and the patient may suffer from
+sore throat and affections of the eyes. The local lesions are to be
+regarded as being of the nature of reactions against accumulations of
+the parasite, lymphocytes and plasma cells being the elements chiefly
+concerned in the reactive process.
+
+_Affections of the Skin_ are among the most constant manifestations. An
+evanescent macular rash, not unlike that of measles--_roseola_--is the
+first to appear, usually in from six to eight weeks from the date of
+infection; it is widely diffused over the trunk, and the original dull
+rose-colour soon fades, leaving brownish stains, which in time
+disappear. It is usually followed by a _papular eruption_, the
+individual papules being raised above the surface of the skin, smooth or
+scaly, and as they are due to infiltration of the skin they are more
+persistent than the roseoles. They vary in size and distribution, being
+sometimes small, hard, polished, and closely aggregated like lichen,
+sometimes as large as a shilling-piece, with an accumulation of scales
+on the surface like that seen in psoriasis. The co-existence of scaly
+papules and faded roseoles is very suggestive of syphilis.
+
+Other types of eruption are less common, and are met with from the third
+month onwards. A _pustular_ eruption, not unlike that of acne, is
+sometimes a prominent feature, but is not characteristic of syphilis
+unless it affects the scalp and forehead and is associated with the
+remains of the papular eruption. The term _ecthyma_ is applied when the
+pustules are of large size, and, after breaking on the surface, give
+rise to superficial ulcers; the discharge from the ulcer often dries up
+and forms a scab or crust which is continually added to from below as
+the ulcer extends in area and depth. The term _rupia_ is applied when
+the crusts are prominent, dark in colour, and conical in shape, roughly
+resembling the shell of a limpet. If the crust is detached, a sharply
+defined ulcer is exposed, and when this heals it leaves a scar which is
+usually circular, thin, white, shining like satin, and the surrounding
+skin is darkly pigmented; in the case of deep ulcers, the scar is
+depressed and adherent (Fig. 39).
+
+[Illustration: FIG. 39.--Syphilitic Rupia, showing the limpet-shaped
+crusts or scabs.]
+
+In the later stages there may occur a form of creeping or _spreading
+ulceration of the skin_ of the face, groin, or scrotum, healing at one
+edge and spreading at another like tuberculous lupus, but distinguished
+from this by its more rapid progress and by the pigmentation of the
+scar.
+
+_Condylomata_ are more characteristic of syphilis than any other type of
+skin lesion. They are papules occurring on those parts of the body where
+the skin is habitually moist, and especially where two skin surfaces are
+in contact. They are chiefly met with on the external genitals,
+especially in women, around the anus, beneath large pendulous mammae,
+between the toes, and at the angles of the mouth, and in these
+situations their development is greatly favoured by neglect of
+cleanliness. They present the appearance of well-defined circular or
+ovoid areas in which the skin is thickened and raised above the surface;
+they are covered with a white sodden epidermis, and furnish a scanty but
+very infective discharge. Under the influence of irritation and want of
+rest, as at the anus or at the angle of the mouth, they are apt to
+become fissured and superficially ulcerated, and the discharge then
+becomes abundant and may crust on the surface, forming yellow scabs. At
+the angle of the mouth the condylomatous patches may spread to the
+cheek, and when they ulcerate may leave fissure-like scars radiating
+from the mouth--an appearance best seen in inherited syphilis (Fig. 44).
+
+_The Appendages of the Skin._--The _hair_ loses its gloss, becomes dry
+and brittle, and readily falls out, either as an exaggeration of the
+normal shedding of the hair, or in scattered areas over the scalp
+(_syphilitic alopoecia_). The hair is not re-formed in the scars which
+result from ulcerated lesions of the scalp. The _nail-folds_
+occasionally present a pustular eruption and superficial ulceration, to
+which the name _syphilitic onychia_ has been applied; more commonly the
+nails become brittle and ragged, and they may even be shed.
+
+_The Mucous Membranes_, and especially those of the _mouth_ and
+_throat_, suffer from lesions similar to those met with on the skin. On
+a mucous surface the papular eruption assumes the form of _mucous
+patches_, which are areas with a congested base covered with a thin
+white film of sodden epithelium like wet tissue-paper. They are best
+seen on the inner aspect of the cheeks, the soft palate, uvula, pillars
+of the fauces, and tonsils. In addition to mucous patches, there may be
+a number of small, _superficial, kidney-shaped ulcers_, especially along
+the margins of the tongue and on the tonsils. In the absence of mucous
+patches and ulcers, the sore throat may be characterised by a bluish
+tinge of the inflamed mucous membrane and a thin film of shed epithelium
+on the surface. Sometimes there is an elongated sinuous film which has
+been likened to the track of a snail. In the _larynx_ the presence of
+congestion, oedema, and mucous patches may be the cause of persistent
+hoarseness. The _tongue_ often presents a combination of lesions,
+including ulcers, patches where the papillae are absent, fissures, and
+raised white papules resembling warts, especially towards the centre of
+the dorsum. These lesions are specially apt to occur in those who smoke,
+drink undiluted alcohol or spirits, or eat hot condiments to excess, or
+who have irregular, sharp-cornered teeth. At a later period, and in
+those who are broken down in health from intemperance or other cause,
+the sore throat may take the form of rapidly spreading, penetrating
+ulcers in the soft palate and pillars of the fauces, which may lead to
+extensive destruction of tissue, with subsequent scars and deformity
+highly characteristic of previous syphilis.
+
+In the _Bones_, lesions occur which assume the clinical features of an
+evanescent periostitis, the patient complaining of nocturnal pains over
+the frontal bone, sternum, tibiae, and ulnae, and localised tenderness on
+tapping over these bones.
+
+In the _Joints_, a serous synovitis or hydrops may occur, chiefly in the
+knee, on one or on both sides.
+
+_The Affections of the Eyes_, although fortunately rare, are of great
+importance because of the serious results which may follow if they are
+not recognised and treated. _Iritis_ is the commonest of these, and may
+occur in one or in both eyes, one after the other, from three to eight
+months after infection. The patient complains of impairment of sight and
+of frontal or supraorbital pain. The eye waters and is hypersensitive,
+the iris is discoloured and reacts sluggishly to light, and there is a
+zone of ciliary congestion around the cornea. The appearance of minute
+white nodules or flakes of lymph at the margin of the pupil is
+especially characteristic of syphilitic iritis. When adhesions have
+formed between the iris and the structures in relation to it, the pupil
+dilates irregularly under atropin. Although complete recovery is to be
+expected under early and energetic treatment, if neglected, _iritis_ may
+result in occlusion of the pupil and permanent impairment or loss of
+sight.
+
+The other lesions of the eye are much rarer, and can only be discovered
+on ophthalmoscopic examination.
+
+The virus of syphilis exerts a special influence upon the _Blood
+Vessels_, exciting a proliferation of the endothelial lining which
+results in narrowing of their lumen, _endarteritis_, and a perivascular
+infiltration in the form of accumulations of plasma cells around the
+vessels and in the lymphatics that accompany them.
+
+In the _Brain_, in the later periods of secondary and in tertiary
+syphilis, changes occur as a result of the narrowing of the lumen of the
+arteries, or of their complete obliteration by thrombosis. By
+interfering with the nutrition of those parts of the brain supplied by
+the affected arteries, these lesions give rise to clinical features of
+which severe headache and paralysis are the most prominent.
+
+Affections of the _Spinal Cord_ are extremely rare, but paraplegia from
+myelitis has been observed.
+
+Lastly, attention must be directed to the remarkable variations observed
+in different patients. Sometimes the virulent character of the disease
+can only be accounted for by an idiosyncrasy of the patient.
+Constitutional symptoms, particularly pyrexia and anaemia, are most often
+met with in young women. Patients over forty years of age have greater
+difficulty in overcoming the infection than younger adults. Malarial and
+other infections, and the conditions attending life in tropical
+countries, from the debility which they cause, tend to aggravate and
+prolong the disease, which then assumes the characters of what has been
+called _malignant syphilis_. All chronic ailments have a similar
+influence, and alcoholic intemperance is universally regarded as a
+serious aggravating factor.
+
+_Diagnosis of Secondary Syphilis._--A routine examination should be made
+of the parts of the body which are most often affected in this
+disease--the scalp, mouth, throat, posterior cervical glands, and the
+trunk, the patient being stripped and examined by daylight. Among the
+_diagnostic features of the skin affections_ the following may be
+mentioned: They are frequently, and sometimes to a marked degree,
+symmetrical; more than one type of eruption--papules and pustules, for
+example--are present at the same time; there is little itching; they are
+at first a dull-red colour, but later present a brown pigmentation which
+has been likened to the colour of raw ham; they exhibit a predilection
+for those parts of the forehead and neck which are close to the roots of
+the hair; they tend to pass off spontaneously; and they disappear
+rapidly under treatment.
+
+#Serum Diagnosis--Wassermann Reaction.#--Wassermann found that if an
+extract of syphilitic liver rich in spirochaetes is mixed with the serum
+from a syphilitic patient, a large amount of complement is fixed. The
+application of the test is highly complicated and can only be carried
+out by an expert pathologist. For the purpose he is supplied with from 5
+c.c. to 10 c.c. of the patient's blood, withdrawn under aseptic
+conditions from the median basilic vein by means of a serum syringe, and
+transferred to a clean and dry glass tube. There is abundant evidence
+that the Wassermann test is a reliable means of establishing a diagnosis
+of syphilis.
+
+A definitely positive reaction can usually be obtained between the
+fifteenth and thirtieth day after the appearance of the primary lesion,
+and as time goes on it becomes more marked. During the secondary period
+the reaction is practically always positive. In the tertiary stage also
+it is positive except in so far as it is modified by the results of
+treatment. In para-syphilitic lesions such as general paralysis and
+tabes a positive reaction is almost always present. In inherited
+syphilis the reaction is positive in every case. A positive reaction may
+be present in other diseases, for example, frambesia, trypanosomiasis,
+and leprosy.
+
+As the presence of the reaction is an evidence of the activity of the
+spirochaetes, repeated applications of the test furnish a valuable means
+of estimating the efficacy of treatment. The object aimed at is to
+change a persistently positive reaction to a permanently negative one.
+
+#Treatment of Syphilis.#--In the treatment of syphilis the two main
+objects are to maintain the general health at the highest possible
+standard, and to introduce into the system therapeutic agents which will
+inhibit or destroy the invading parasite.
+
+The second of these objects has been achieved by the researches of
+Ehrlich, who, in conjunction with his pupil, Hata, has built up a
+compound, the dihydrochloride of dioxydiamido-arseno-benzol, popularly
+known as salvarsan or "606." Other preparations, such as kharsivan,
+arseno-billon, and diarsenol, are chemically equivalent to salvarsan,
+containing from 27 to 31 per cent. of arsenic, and are equally
+efficient. The full dose is 0.6 grm. All these members of the "606"
+group form an acid solution when dissolved in water, and must be
+rendered alkaline before being injected. As subcutaneous and
+intra-muscular injections cause considerable pain, and may cause
+sloughing of the tissues, "606" preparations must be injected
+intravenously. Ehrlich has devised a preparation--neo-salvarsan, or
+"914," which is more easily prepared and forms a neutral solution. It
+contains from 18 to 20 per cent. of arsenic. Neo-kharsivan,
+novo-arseno-billon, and neo-diarsenol belong to the "914" group, the
+full dosage of which is 0.9 grm. As subcutaneous and intra-muscular
+injections of the "914" group are not painful, and even more efficient
+than intravenous injections, the administration is simpler.
+
+Galyl, luargol, and other preparations act in the same way as the "606"
+and "914" groups.
+
+The "606" preparations may be introduced into the veins by injection or
+by means of an apparatus which allows the solution to flow in by
+gravity. The left median basilic vein is selected, and a platino-iridium
+needle with a short point and a bore larger than that of the ordinary
+hypodermic syringe is used. The needle is passed for a few millimetres
+along the vein, and the solution is then slowly introduced; before
+withdrawing the needle some saline is run in to diminish the risk of
+thrombosis.
+
+The "914" preparations may be injected either into the subcutaneous
+tissue of the buttock or into the substance of the gluteus muscle. The
+part is then massaged for a few minutes, and the massage is repeated
+daily for a few days.
+
+No hard-and-fast rules can be laid down as to what constitutes a
+complete course of treatment. Harrison recommends as a _minimum_ course
+of one of the "914" preparations in _early primary cases_ an initial
+dose of 0.45 grm. given intra-muscularly or into the deep subcutaneous
+tissue; the same dose a week later; 0.6 grm. the following week; then
+miss a week and give 9.6 grms. on two successive weeks; then miss two
+weeks and give 0.6 grm. on two more successive weeks.
+
+When a _positive Wassermann reaction_ is present before treatment is
+commenced, the above course is prolonged as follows: for three weeks is
+given a course of potassium iodide, after which four more weekly
+injections of 0.6 grm. of "914" are given.
+
+With each injection of "914" after the first, throughout the whole
+course 1 grain of mercury is injected intra-muscularly.
+
+In the course of a few hours, there is usually some indisposition, with
+a feeling of chilliness and slight rise of temperature; these symptoms
+pass off within twenty-four hours, and in a few days there is a decided
+improvement of health. Three or four days after an intra-muscular
+injection there may be pain and stiffness in the gluteal region.
+
+These preparations are the most efficient therapeutic agents that have
+yet been employed in the treatment of syphilis.
+
+The manifestations of the disease disappear with remarkable rapidity.
+Observations show that the spirochaetes lose their capacity for movement
+within an hour or two of the administration, and usually disappear
+altogether in from twenty-four to thirty-six hours. Wassermann's
+reaction usually yields a negative result in from three weeks to two
+months, but later may again become positive. Subsequent doses of the
+arsenical preparation are therefore usually indicated, and should be
+given in from 7 to 21 days according to the dose.
+
+When syphilis occurs in a _pregnant woman_, she should be given in the
+early months an ordinary course of "914," followed by 10-grain doses of
+potassium iodide twice daily. The injections may be repeated two months
+later, and during the remainder of the pregnancy 2-grain mercury pills
+are given twice daily (A. Campbell). The presence of albumen in the
+urine contra-indicates arsenical treatment.
+
+It need scarcely be pointed out that the use of powerful drugs like
+"606" and "914" is not free from risk; it may be mentioned that each
+dose contains nearly three grains of arsenic. Before the administration
+the patient must be overhauled; its administration is contra-indicated
+in the presence of disease of the heart and blood vessels, especially a
+combination of syphilitic aortitis and sclerosis of the coronary
+arteries, with degeneration of the heart muscle; in affections of the
+central nervous system, especially advanced paralysis, and in such
+disturbances of metabolism as are associated with diabetes and Bright's
+disease. Its use is not contra-indicated in any lesion of active
+syphilis.
+
+The administration is controlled by the systematic examination of the
+urine for arsenic.
+
+_The Administration of Mercury._--The success of the arsenical
+preparations has diminished the importance of mercury in the treatment
+of syphilis, but it is still used to supplement the effect of the
+injections. The amount of mercury to be given in any case must be
+proportioned to the idiosyncrasies of the patient, and it is advisable,
+before commencing the treatment, to test his urine and record his
+body-weight. The small amount of mercury given at the outset is
+gradually increased. If the body-weight falls, or if the gums become
+sore and the breath foul, the mercury should be stopped for a time. If
+salivation occurs, the drinking of hot water and the taking of hot baths
+should be insisted upon, and half-dram doses of the alkaline sulphates
+prescribed.
+
+_Methods of Administering Mercury._--(1) _By the Mouth._--This was for
+long the most popular method in this country, the preparation usually
+employed being grey powder, in pills or tablets, each of which contains
+one grain of the powder. Three of these are given daily in the first
+instance, and the daily dose is increased to five or even seven grains
+till the standard for the individual patient is arrived at. As the grey
+powder alone sometimes causes irritation of the bowels, it should be
+combined with iron, as in the following formula: Hydrarg. c. cret. gr. 1;
+ferri sulph. exsiccat. gr. 1 or 2.
+
+(2) _By Inunction._--Inunction consists in rubbing into the pores of the
+skin an ointment composed of equal parts of 20 per cent. oleate of
+mercury and lanolin. Every night after a hot bath, a dram of the
+ointment (made up by the chemist in paper packets) is rubbed for fifteen
+minutes into the skin where it is soft and comparatively free from
+hairs. When the patient has been brought under the influence of the
+mercury, inunction may be replaced by one of the other methods, of
+administering the drug.
+
+(3) _By Intra-muscular Injection._--This consists in introducing the
+drug by means of a hypodermic syringe into the substance of the gluteal
+muscles. The syringe is made of glass, and has a solid glass piston; the
+needle of platino-iridium should be 5 cm. long and of a larger calibre
+than the ordinary hypodermic needle. The preparation usually employed
+consists of: metallic mercury or calomel 1 dram, lanolin and olive oil
+each 2 drams; it must be warmed to allow of its passage through the
+needle. Five minims--containing one grain of metallic mercury--represent
+a dose, and this is injected into the muscles above and behind the great
+trochanter once a week. The contents of the syringe are slowly
+expressed, and, after withdrawing the needle, gentle massage of the
+buttock should be employed. Four courses each of ten injections are
+given the first year, three courses of the same number during the second
+and third years, and two courses during the fourth year (Lambkin).
+
+_The General Health._--The patient must lead a regular life and
+cultivate the fresh-air habit, which is as beneficial in syphilis as in
+tuberculosis. Anaemia, malaria, and other sources of debility must
+receive appropriate treatment. The diet should be simple and easily
+digested, and should include a full supply of milk. Alcohol is
+prohibited. The excretory organs are encouraged to act by the liberal
+drinking of hot water between meals, say five or six tumblerfuls in the
+twenty-four hours. The functions of the skin are further aided by
+frequent hot baths, and by the wearing of warm underclothing. While the
+patient should avoid exposure to cold, and taxing his energies by undue
+exertion, he should be advised to take exercise in the open air. On
+account of the liability to lesions of the mouth and throat, he should
+use tobacco in moderation, his teeth should be thoroughly overhauled by
+the dentist, and he should brush them after every meal, using an
+antiseptic tooth powder or wash. The mouth and throat should be rinsed
+out night and morning with a solution of chlorate of potash and alum, or
+with peroxide of hydrogen.
+
+_Treatment of the Local Manifestations._--_The skin lesions_ are treated
+on the same lines as similar eruptions of other origin. As local
+applications, preparations of mercury are usually selected, notably the
+ointments of the red oxide of mercury, ammoniated mercury, or oleate of
+mercury (5 per cent.), or the mercurial plaster introduced by Unna. In
+the treatment of condylomata the greatest attention must be paid to
+cleanliness and dryness. After washing and drying the affected patches,
+they are dusted with a powder consisting of equal parts of calomel and
+carbonate of zinc; and apposed skin surfaces, such as the nates or
+labia, are separated by sublimate wool. In the ulcers of later secondary
+syphilis, crusts are got rid of in the first instance by means of a
+boracic poultice, after which a piece of lint or gauze cut to the size
+of the ulcer and soaked in black wash is applied and covered with
+oil-silk. If the ulcer tends to spread in area or in depth, it should be
+scraped with a sharp spoon, and painted over with acid nitrate of
+mercury, or a local hyperaemia may be induced by Klapp's suction
+apparatus.
+
+_In lesions of the mouth and throat_, the teeth should be attended to;
+the best local application is a solution of chromic acid--10 grains to
+the ounce--painted on with a brush once daily. If this fails, the
+lesions may be dusted with calomel the last thing at night. For deep
+ulcers of the throat the patient should gargle frequently with chlorine
+water or with perchloride of mercury (1 in 2000); if the ulcer continues
+to spread it should be painted with acid nitrate of mercury.
+
+In the treatment of _iritis_ the eyes are shaded from the light and
+completely rested, and the pupil is well dilated by atropin to prevent
+adhesions. If there is much pain, a blister may be applied to the
+temple.
+
+_The Relations of Syphilis to Marriage._--Before the introduction of the
+Ehrlich-Hata treatment no patient was allowed to marry until three years
+had elapsed after the disappearance of the last manifestation. While
+marriage might be entered upon under these conditions without risk of
+the husband infecting the wife, the possibility of his conveying the
+disease to the offspring cannot be absolutely excluded. It is
+recommended, as a precautionary measure, to give a further mercurial
+course of two or three months' duration before marriage, and an
+intravenous injection of an arsenical preparation.
+
+#Intermediate Stage.#--After the dying away of the secondary
+manifestations and before the appearance of tertiary lesions, the
+patient may present certain symptoms which Hutchinson called
+_reminders_. These usually consist of relapses of certain of the
+affections of the skin, mouth, or throat, already described. In the
+skin, they may assume the form of peeling patches in the palms, or may
+appear as spreading and confluent circles of a scaly papular eruption,
+which if neglected may lead to the formation of fissures and superficial
+ulcers. Less frequently there is a relapse of the eye affections, or of
+paralytic symptoms from disease of the cerebral arteries.
+
+#Tertiary Syphilis.#--While the manifestations of primary and secondary
+syphilis are common, those of the tertiary period are by comparison
+rare, and are observed chiefly in those who have either neglected
+treatment or who have had their powers of resistance lowered by
+privation, by alcoholic indulgence, or by tropical disease.
+
+It is to be borne in mind that in a certain proportion of men and in a
+larger proportion of women, the patient has no knowledge of having
+suffered from syphilis. Certain slight but important signs may give the
+clue in a number of cases, such as irregularity of the pupils or failure
+to react to light, abnormality of the reflexes, and the discovery of
+patches of leucoplakia on the tongue, cheek, or palate.
+
+The _general character of tertiary manifestations_ may be stated as
+follows: They attack by preference the tissues derived from the
+mesoblastic layer of the embryo--the cellular tissue, bones, muscles,
+and viscera. They are often localised to one particular tissue or organ,
+such, for example, as the subcutaneous cellular tissue, the bones, or
+the liver, and they are rarely symmetrical. They are usually aggressive
+and persistent, with little tendency to natural cure, and they may be
+dangerous to life, because of the destructive changes produced in such
+organs as the brain or the larynx. They are remarkably amenable to
+treatment if instituted before the stage which is attended with
+destruction of tissue is reached. Early tertiary lesions may be
+infective, and the disease may be transmitted by the discharges from
+them; but the later the lesions the less is the risk of their containing
+an infective virus.
+
+The most prominent feature of tertiary syphilis consists in the
+formation of granulation tissue, and this takes place on a scale
+considerably larger than that observed in lesions of the secondary
+period. The granulation tissue frequently forms a definite swelling or
+tumour-like mass (syphiloma), which, from its peculiar elastic
+consistence, is known as a _gumma_. In its early stages a gumma is a
+firm, semi-translucent greyish or greyish-red mass of tissue; later it
+becomes opaque, yellow, and caseous, with a tendency to soften and
+liquefy. The gumma does harm by displacing and replacing the normal
+tissue elements of the part affected, and by involving these in the
+degenerative changes, of the nature of caseation and necrosis, which
+produce the destructive lesions of the skin, mucous membranes, and
+internal organs. This is true not only of the circumscribed gumma, but
+of the condition known as _gummatous infiltration_ or _syphilitic
+cirrhosis_, in which the granulation tissue is diffused throughout the
+connective-tissue framework of such organs as the tongue or liver. Both
+the gummatous lesions and the fibrosis of tertiary syphilis are directly
+excited by the spirochaetes.
+
+The life-history of an untreated gumma varies with its environment. When
+protected from injury and irritation in the substance of an internal
+organ such as the liver, it may become encapsulated by fibrous tissue,
+and persist in this condition for an indefinite period, or it may be
+absorbed and leave in its place a fibrous cicatrix. In the interior of a
+long bone it may replace the rigid framework of the shaft to such an
+extent as to lead to pathological fracture. If it is near the surface of
+the body--as, for example, in the subcutaneous or submucous cellular
+tissue, or in the periosteum of a superficial bone, such as the palate,
+the skull, or the tibia--the tissue of which it is composed is apt to
+undergo necrosis, in which the overlying skin or mucous membrane
+frequently participates, the result being an ulcer--the tertiary
+syphilitic ulcer (Figs. 40 and 41).
+
+_Tertiary Lesions of the Skin and Subcutaneous Cellular Tissue._--The
+clinical features of a _subcutaneous gumma_ are those of an indolent,
+painless, elastic swelling, varying in size from a pea to an almond or
+walnut. After a variable period it usually softens in the centre, the
+skin over it becomes livid and dusky, and finally separates as a slough,
+exposing the tissue of the gumma, which sometimes appears as a mucoid,
+yellowish, honey-like substance, more frequently as a sodden, caseated
+tissue resembling wash-leather. The caseated tissue of a gumma differs
+from that of a tuberculous lesion in being tough and firm, of a buff
+colour like wash-leather, or whitish, like boiled fish. The degenerated
+tissue separates slowly and gradually, and in untreated cases may be
+visible for weeks in the floor of the ulcer.
+
+[Illustration: FIG. 40.--Ulcerating Gumma of Lips.
+
+(From a photograph lent by Dr. Stopford Taylor and Dr. R. W. Mackenna.)]
+
+_The tertiary ulcer_ may be situated anywhere, but is most frequently
+met with on the leg, especially in the region of the knee (Fig. 42) and
+over the calf. There may be one or more ulcers, and also scars of
+antecedent ulcers. The edges are sharply cut, as if punched out; the
+margins are rounded in outline, firm, and congested; the base is
+occupied by gummatous tissue, or, if this has already separated and
+sloughed out, by unhealthy granulations and a thick purulent discharge.
+When the ulcer has healed it leaves a scar which is depressed, and if
+over a bone, is adherent to it. The features of the tertiary ulcer,
+however, are not always so characteristic as the above description would
+imply. It is to be diagnosed from the "leg ulcer," which occurs almost
+exclusively on the lower third of the leg; from Bazin's disease (p. 74);
+from the ulcers that result from certain forms of malignant disease,
+such as rodent cancer, and from those met with in chronic glanders.
+
+_Gummatous Infiltration of the Skin_ ("Syphilitic Lupus").--This is a
+lesion, met with chiefly on the face and in the region of the external
+genitals, in which the skin becomes infiltrated with granulation tissue
+so that it is thickened, raised above the surface, and of a brownish-red
+colour. It appears as isolated nodules, which may fuse together; the
+epidermis becomes scaly and is shed, giving rise to superficial ulcers
+which are usually covered by crusted discharge. The disease tends to
+spread, creeping over the skin with a serpiginous, crescentic, or
+horse-shoe margin, while the central portion may heal and leave a scar.
+From the fact of its healing in the centre while it spreads at the
+margin, it may resemble tuberculous disease of the skin. It can usually
+be differentiated by observing that the infiltration is on a larger
+scale; the progress is much more rapid, involving in the course of
+months an area which in the case of tuberculosis would require as many
+years; the scars are sounder and are less liable to break down again;
+and the disease rapidly yields to anti-syphilitic treatment.
+
+[Illustration: FIG. 41.--Ulceration of nineteen year's duration
+in a woman aet. 24, the subject of inherited syphilis, showing active
+ulceration, cicatricial contraction, and sabre-blade deformity of
+tibiae.]
+
+_Tertiary lesions of mucous membrane and of the submucous cellular
+tissue_ are met with chiefly in the tongue, nose, throat, larynx, and
+rectum. They originate as gummata or as gummatous infiltrations, which
+are liable to break down and lead to the formation of ulcers which may
+prove locally destructive, and, in such situations as the larynx, even
+dangerous to life. In the tongue the tertiary ulcer may prove the
+starting-point of cancer; and in the larynx or rectum the healing of the
+ulcer may lead to cicatricial stenosis.
+
+Tertiary lesions of the _bones and joints_, of the _muscles_, and of the
+_internal organs_, will be described under these heads. The part played
+by syphilis in the production of disease of arteries and of aneurysm
+will be referred to along with diseases of blood vessels.
+
+[Illustration: FIG. 42.--Tertiary Syphilitic Ulceration in region of
+Knee and on both Thumbs of woman aet. 37.]
+
+_Treatment._--The most valuable drugs for the treatment of the
+manifestations of the tertiary period are the arsenical preparations and
+the iodides of sodium and potassium. On account of their depressing
+effects, the latter are frequently prescribed along with carbonate of
+ammonium. The dose is usually a matter of experiment in each individual
+case; 5 grains three times a day may suffice, or it may be necessary to
+increase each dose to 20 or 25 grains. The symptoms of iodism which may
+follow from the smaller doses usually disappear on giving a larger
+amount of the drug. It should be taken after meals, with abundant water
+or other fluid, especially if given in tablet form. It is advisable to
+continue the iodides for from one to three months after the lesions for
+which they are given have cleared up. If the potassium salt is not
+tolerated, it may be replaced by the ammonium or sodium iodide.
+
+_Local Treatment._--The absorption of a subcutaneous gumma is often
+hastened by the application of a fly-blister. When a gumma has broken on
+the surface and caused an ulcer, this is treated on general principles,
+with a preference, however, for applications containing mercury or
+iodine, or both. If a wet dressing is required to cleanse the ulcer,
+black wash may be used; if a powder to promote dryness, one containing
+iodoform; if an ointment is indicated, the choice lies between the red
+oxide of mercury or the dilute nitrate of mercury ointment, and one
+consisting of equal parts of lanolin and vaselin with 2 per cent. of
+iodine. Deep ulcers, and obstinate lesions of the bones, larynx, and
+other parts may be treated by excision or scraping with the sharp spoon.
+
+#Second Attacks of Syphilis.#--Instances of re-infection of syphilis
+have been recorded with greater frequency since the more general
+introduction of arsenical treatment. A remarkable feature in such cases
+is the shortness of the interval between the original infection and the
+alleged re-infection; in a recent series of twenty-eight cases, this
+interval was less than a year. Another feature of interest is that when
+patients in the tertiary stage of syphilis are inoculated with the virus
+from lesions from these in the primary and secondary stage lesions of
+the tertiary type are produced.
+
+Reference may be made to the #relapsing false indurated chancre#,
+described by Hutchinson and by Fournier, as it may be the source of
+difficulty in diagnosis. A patient who has had an infecting chancre one
+or more years before, may present a slightly raised induration on the
+penis at or close to the site of his original sore. This relapsed
+induration is often so like that of a primary chancre that it is
+impossible to distinguish between them, except by the history. If there
+has been a recent exposure to venereal infection, it is liable to be
+regarded as the primary lesion of a second attack of syphilis, but the
+further progress shows that neither bullet-buboes nor secondary
+manifestations develop. These facts, together with the disappearance of
+the induration under treatment, make it very likely that the lesion is
+really gummatous in character.
+
+
+INHERITED SYPHILIS
+
+One of the most striking features of syphilis is that it may be
+transmitted from infected parents to their offspring, the children
+exhibiting the manifestations that characterise the acquired form of the
+disease.
+
+The more recent the syphilis in the parent, the greater is the risk of
+the disease being communicated to the offspring; so that if either
+parent suffers from secondary syphilis the infection is almost
+inevitably transmitted.
+
+While it is certain that either parent may be responsible for
+transmitting the disease to the next generation, the method of
+transmission is not known. In the case of a syphilitic mother it is most
+probable that the infection is conveyed to the foetus by the placental
+circulation. In the case of a syphilitic father, it is commonly believed
+that the infection is conveyed to the ovum through the seminal fluid at
+the moment of conception. If a series of children, one after the other,
+suffer from inherited syphilis, it is almost invariably the case that
+the mother has been infected.
+
+In contrast to the acquired form, inherited syphilis is remarkable for
+the absence of any primary stage, the infection being a general one from
+the outset. The spirochaete is demonstrated in incredible numbers in the
+liver, spleen, lung, and other organs, and in the nasal secretion, and,
+from any of these, successful inoculations in monkeys can readily be
+made. The manifestations differ in degree rather than in kind from those
+of the acquired disease; the difference is partly due to the fact that
+the virus is attacking developing instead of fully formed tissues.
+
+The virus exercises an injurious influence on the foetus, which in many
+cases dies during the early months of intra-uterine life, so that
+miscarriage results, and this may take place in repeated pregnancies,
+the date at which the miscarriage occurs becoming later as the virus in
+the mother becomes attenuated. Eventually a child is carried to full
+term, and it may be still-born, or, if born alive, may suffer from
+syphilitic manifestations. It is difficult to explain such vagaries of
+syphilitic inheritance as the infection of one twin and the escape of
+the other.
+
+_Clinical Features._--We are not here concerned with the severe forms of
+the disease which prove fatal, but with the milder forms in which the
+infant is apparently healthy when born, but after from two to six weeks
+begins to show evidence of the syphilitic taint.
+
+The usual phenomena are that the child ceases to thrive, becomes thin
+and sallow, and suffers from eruptions on the skin and mucous membranes.
+There is frequently a condition known as _snuffles_, in which the nasal
+passages are obstructed by an accumulation of thin muco-purulent
+discharge which causes the breathing to be noisy. It usually begins
+within a month after birth and before the eruptions on the skin appear.
+When long continued it is liable to interfere with the development of
+the nasal bones, so that when the child grows up there results a
+condition known as the "saddle-nose" deformity (Figs. 43 and 44).
+
+[Illustration: FIG. 43.--Facies of Inherited Syphilis.
+
+(From Dr. Byrom Bramwell's _Atlas of Clinical Medicine_.)]
+
+_Affections of the Skin._--Although all types of skin affection are met
+with in the inherited disease, the most important is a _papular_
+eruption, the papules being of large size, with a smooth shining top and
+of a reddish-brown colour. It affects chiefly the buttocks and thighs,
+the genitals, and other parts which are constantly moist. It is
+necessary to distinguish this specific eruption from a form of eczema
+which occurs in these situations in non-syphilitic children, the points
+that characterise the syphilitic condition being the infiltration of the
+skin and the coppery colour of the eruption. At the anus the papules
+acquire the characters of _condylomata_, also at the angles of the
+mouth, where they often ulcerate and leave radiating scars.
+
+_Affections of the Mucous Membranes._--The inflammation of the nasal
+mucous membrane that causes snuffles has already been referred to. There
+may be mucous patches in the mouth, or a stomatitis which is of
+importance, because it results in interference with the development of
+the permanent teeth. The mucous membrane of the larynx may be the seat
+of mucous patches or of catarrh, and as a result the child's cry is
+hoarse.
+
+_Affections of the Bones._--Swellings at the ends of the long bones, due
+to inflammation at the epiphysial junctions, are most often observed at
+the upper end of the humerus and in the bones in the region of the
+elbow. Partial displacement and mobility at the ossifying junction may
+be observed. The infant cries when the part is touched; and as it does
+not move the limb voluntarily, the condition is spoken of as _the
+pseudo-paralysis of syphilis_. Recovery takes place under
+anti-syphilitic treatment and immobilisation of the limb.
+
+Diffuse thickening of the shafts of the long bones, due to a deposit of
+new bone by the periosteum, is sometimes met with.
+
+[Illustration: FIG. 44.--Facies of Inherited Syphilis.]
+
+The conditions of the skull known as Parrot's nodes or bosses, and
+craniotabes, were formerly believed to be characteristic of inherited
+syphilis, but they are now known to occur, particularly in rickety
+children, from other causes. The _bosses_ result from the heaping up of
+new spongy bone beneath the pericranium, and they may be grouped
+symmetrically around the anterior fontanelle, or may extend along either
+side of the sagittal suture, which appears as a deep groove--the
+"natiform skull." The bosses disappear in time, but the skull may remain
+permanently altered in shape, the frontal and parietal eminences
+appearing unduly prominent. The term _craniotabes_ is applied when the
+bone becomes thin and soft, reverting to its original membranous
+condition, so that the affected areas dimple under the finger like
+parchment or thin cardboard; its localisation in the posterior parts of
+the skull suggests that the disappearance of the osseous tissue is
+influenced by the pressure of the head on the pillow. Craniotabes is
+recovered from as the child improves in health.
+
+Between the ages of three and six months, certain other phenomena may be
+met with, such as _effusion into the joints_, especially the knees;
+_iritis_, in one or in both eyes, and enlargement of the spleen and
+liver.
+
+In the majority of cases the child recovers from these early
+manifestations, especially when efficiently treated, and may enjoy an
+indefinite period of good health. On the other hand, when it attains the
+age of from two to four years, it may begin to manifest lesions which
+correspond to those of the tertiary period of acquired syphilis.
+
+#Later Lesions.#--In the skin and subcutaneous tissue, the later
+manifestations may take the form of localised gummata, which tend to
+break down and form ulcers, on the leg for example, or of a spreading
+gummatous infiltration which is also liable to ulcerate, leaving
+disfiguring scars, especially on the face. The palate and fauces may be
+destroyed by ulceration. In the nose, especially when the ulcerative
+process is associated with a putrid discharge--ozaena--the destruction of
+tissue may be considerable and result in unsightly deformity. The entire
+palatal portions of the upper jaws, the vomer, turbinate, and other
+bones bounding the nasal and oral cavities, may disappear, so that on
+looking into the mouth the base of the skull is readily seen. Gummatous
+disease is frequently observed also in the flat bones of the skull, in
+the bones of the hand, as syphilitic dactylitis, and in the bones of the
+forearm and leg. When the tibia is affected the disease is frequently
+bilateral, and may assume the form of gummatous ulcers and sinuses. In
+later years the tibia may present alterations in shape resulting from
+antecedent gummatous disease--for example, nodular thickenings of the
+shaft, flattening of the crest, or a more uniform increase in thickness
+and length of the shaft of the bone, which, when it is curved in
+addition, is described as the "sabre-blade" deformity. Among lesions of
+the viscera, mention should be made of gumma of the testis, which causes
+the organ to become enlarged, uneven, and indurated. This has even been
+observed in infants a few months old.
+
+Occasionally a syphilitic child suffers from a succession of these
+gummatous lesions with resulting ill-health, and, it may be, waxy
+disease of the internal organs; on the other hand, it may recover and
+present no further manifestations of the inherited taint.
+
+_Affections of the Eyes._--At or near puberty there is frequently
+observed an affection of the eyes, known as _chronic interstitial
+keratitis_, the relationship of which to inherited syphilis was first
+established by Hutchinson. It occurs between the ages of six and sixteen
+years, and usually affects one eye before the other. It commences as a
+diffuse haziness or steaminess near the centre of the cornea, and as it
+spreads the entire cornea assumes the appearance of ground glass. The
+chief complaint is of dimness of sight, which may almost amount to
+blindness, but there is little pain or photophobia; a certain amount of
+conjunctival and ciliary congestion is usually present, and there may be
+_iritis_ in addition. The cornea, or parts of it, may become of a deep
+pink or salmon colour from the formation in it of new blood vessels. The
+affection may last for from eighteen months to two years. Complete
+recovery usually takes place, but slight opacities, especially in the
+site of former salmon patches, may persist, and the disease occasionally
+relapses. _Choroiditis_ and _retinitis_ may also occur, and leave
+permanent changes easily recognised on examination with the
+ophthalmoscope.
+
+Among the rarer and more serious lesions of the inherited disease may be
+mentioned gummatous disease in the _larynx and trachea_, attended with
+ulceration and resulting in stenosis; and lesions of the _nervous
+system_ which may result in convulsions, paralysis, or dementia.
+
+In a limited number of cases, about the period of puberty there may
+develop _deafness_, which is usually bilateral and may become absolute.
+
+_Changes in the Permanent Teeth._--These affect specially the upper
+central incisors, which are dwarfed and stand somewhat apart in the gum,
+with their free edges converging towards one another. They are tapering
+or peg-shaped, and present at their cutting margin a deep semilunar
+notch. These appearances are commonly associated with the name of
+Hutchinson, who first described them. Affecting as they do the
+permanent teeth, they are not available for diagnosis until the child is
+over eight years of age. Henry Moon drew attention to a change in the
+first molars; these are reduced in size and dome-shaped through dwarfing
+of the central tubercle of each cusp.
+
+#Diagnosis of Inherited Syphilis.#--When there is a typical eruption on
+the buttocks and snuffles there is no difficulty in recognising the
+disease. When, however, the rash is scanty or is obscured by co-existing
+eczema, most reliance should be placed on the distribution of the
+eruption, on the brown stains which are left after it has passed off, on
+the presence of condylomata, and of fissuring and scarring at the angles
+of the mouth. The history of the mother relative to repeated
+miscarriages and still-born children may afford confirmatory evidence.
+In doubtful cases, the diagnosis may be aided by the Wassermann test and
+by noting the therapeutic effects of grey powder, which, in syphilitic
+infants, usually effects a marked and rapid improvement both in the
+symptoms and in the general health.
+
+While a considerable number of syphilitic children grow up without
+showing any trace of their syphilitic inheritance, the majority retain
+throughout life one or more of the following characteristics, which may
+therefore be described as _permanent signs of the inherited disease_:
+Dwarfing of stature from interference with growth at the epiphysial
+junctions; the forehead low and vertical, and the parietal and frontal
+eminences unduly prominent; the bridge of the nose sunken and rounded;
+radiating scars at the angles of the mouth; perforation or destruction
+of the hard palate; Hutchinson's teeth; opacities of the cornea from
+antecedent keratitis; alterations in the fundus oculi from choroiditis;
+deafness; depressed scars or nodes on the bones from previous gummata;
+"sabre-blade" or other deformity of the tibiae.
+
+#The Contagiousness of Inherited Syphilis.#--In 1837, Colles of Dublin
+stated his belief that, while a syphilitic infant may convey the disease
+to a healthy wet nurse, it is incapable of infecting its own mother if
+nursed by her, even although she may never have shown symptoms of the
+disease. This doctrine, which is known as _Colles' law_, is generally
+accepted in spite of the alleged occurrence of occasional exceptions.
+The older the child, the less risk there is of its communicating the
+disease to others, until eventually the tendency dies out altogether, as
+it does in the tertiary period of acquired syphilis. It should be
+added, however, that the contagiousness of inherited syphilis is denied
+by some observers, who affirm that, when syphilitic infants prove
+infective, the disease has been really acquired at or soon after birth.
+
+There is general agreement that the subjects of inherited syphilis
+cannot transmit the disease by inheritance to their offspring, and that,
+although they very rarely acquire the disease _de novo_, it is possible
+for them to do so.
+
+#Prognosis of Inherited Syphilis.#--Although inherited syphilis is
+responsible for a large but apparently diminishing mortality in infancy,
+the subjects of this disease may grow up to be as strong and healthy as
+their neighbours. Hutchinson insisted on the fact that there is little
+bad health in the general community that can be attributed to inherited
+syphilis.
+
+#Treatment.#--Arsenical injections are as beneficial in the inherited as
+in the acquired disease. An infant the subject of inherited syphilis
+should, if possible, be nursed by its mother, and failing this it should
+be fed by hand. In infants at the breast, the drug may be given to the
+mother; in others, it is administered in the same manner as already
+described--only in smaller doses. On the first appearance of syphilitic
+manifestations it should be given 0.05 grm, novarsenbillon, injected
+into the deep subcutaneous tissues every week for six weeks, followed by
+one year's mercurial inunction--a piece of mercurial ointment the size
+of a pea being inserted under the infant's binder. In older children the
+dose is proportionately increased. The general health should be improved
+in every possible direction; considerable benefit may be derived from
+the use of cod-liver oil, and from preparations containing iron and
+calcium. Surgical interference may be required in the destructive
+gummatous lesions of the nose, throat, larynx, and bones, either with
+the object of arresting the spread of the disease, or of removing or
+alleviating the resulting deformities. In children suffering from
+keratitis, the eyes should be protected from the light by smoked or
+coloured glasses, and the pupils should be dilated with atropin from
+time to time, especially in cases complicated with iritis.
+
+#Acquired Syphilis in Infants and Young Children.#--When syphilis is met
+with in infants and young children, it is apt to be taken for granted
+that the disease has been inherited. It is possible, however, for them
+to acquire the disease--as, for example, while passing through the
+maternal passages during birth, through being nursed or kissed by
+infected women, or through the rite of circumcision. The risk of
+infection which formerly existed by the arm-to-arm method of
+vaccination has been abolished by the use of calf lymph.
+
+The clinical features of the acquired disease in infants and young
+children are similar to those observed in the adult, with a tendency,
+however, to be more severe, probably because the disease is often late
+in being recognised and treated.
+
+
+
+
+CHAPTER X
+
+TUMOURS[2]
+
+
+Definition--Etiology--General characters of innocent and malignant
+    tumours. CLASSIFICATION OF TUMOURS: I. Connective-tissue tumours:
+    (1) _Innocent_: _Lipoma_, _Xanthoma_, _Chondroma_, _Osteoma_,
+    _Odontoma_, _Fibroma_, _Myxoma_, _Endothelioma_, etc.; (2)
+    _Malignant_: _Sarcoma_--II. Epithelial tumours: (1) _Innocent_:
+    _Papilloma_, _Adenoma_, _Cystic Adenoma_; (2) _Malignant_:
+    _Epithelioma_, _Glandular Cancer_, _Rodent Cancer_, _Melanotic
+    Cancer_--III. Dermoids--IV. Teratoma. Cysts: _Retention_,
+    _Exudation_, _Implantation_, _Parasitic_, _Lymphatic or Serous_.
+    Ganglion.
+
+[2] For the histology of tumours the reader is referred to a text-book
+of pathology.
+
+A tumour or neoplasm is a localised swelling composed of newly formed
+tissue which fulfils no physiological function. Tumours increase in size
+quite independently of the growth of the body, and there is no natural
+termination to their growth. They are to be distinguished from such
+over-growths as are of the nature of simple hypertrophy or local
+giantism, and also from inflammatory swellings, which usually develop
+under the influence of a definite cause, have a natural termination, and
+tend to disappear when the cause ceases to act.
+
+The _etiology of tumours_ is imperfectly understood. Various factors,
+acting either singly or in combination, may be concerned in their
+development. Certain tumours, for example, are the result of some
+congenital malformation of the particular tissue from which they take
+origin. This would appear to be the case in many tumours of blood
+vessels (angioma), of cartilage (chondroma), of bone (osteoma), and of
+secreting gland tissue (adenoma). The theory that tumours originate from
+foetal residues or "rests," is associated with the name of Cohnheim.
+These rests are supposed to be undifferentiated embryonic cells which
+remain embedded amongst fully formed tissue elements, and lie dormant
+until they are excited into active growth and give rise to a tumour.
+This mode of origin is illustrated by the development of dermoids from
+sequestrated portions of epidermis.
+
+Among the local factors concerned in the development of tumours,
+reference must be made to the influence of irritation. This is probably
+an important agent in the causation of many of the tumours met with in
+the skin and in mucous membranes--for example, cancer of the skin, of
+the lip, and of the tongue. The part played by injury is doubtful. It
+not infrequently happens that the development of a tumour is preceded by
+an injury of the part in which it grows, but it does not necessarily
+follow that the injury and the tumour are related as cause and effect.
+It is possible that an injury may stimulate into active growth
+undifferentiated tissue elements or "rests," and so determine the growth
+of a tumour, or that it may alter the characters of a tumour which
+already exists, causing it to grow more rapidly.
+
+The popular belief that there is some constitutional peculiarity
+concerned in the causation of tumours is largely based on the fact that
+certain forms of new growth--for example, cancer--are known to occur
+with undue frequency in certain families. The same influence is more
+striking in the case of certain innocent tumours--particularly multiple
+osteomas and lipomas--which are hereditary in the same sense as
+supernumerary or webbed fingers, and appear in members of the same
+family through several generations.
+
+
+INNOCENT AND MALIGNANT TUMOURS
+
+For clinical purposes, tumours are arbitrarily divided into two
+classes--the innocent and the malignant. The outstanding difference
+between them is, that while the evil effects of innocent tumours are
+entirely local and depend for their severity on the environment of the
+growth, malignant tumours wherever situated, in addition to producing
+similar local effects, injure the general health and ultimately cause
+death.
+
+_Innocent_, benign, or simple tumours present a close structural
+resemblance to the normal tissues of the body. They grow slowly, and are
+usually definitely circumscribed by a fibrous capsule, from which they
+are easily enucleated, and they do not tend to recur after removal. In
+their growth they merely push aside and compress adjacent parts, and
+they present no tendency to ulcerate and bleed unless the overlying skin
+or mucous membrane is injured. Although usually solitary, some are
+multiple from the outset--for example, fatty, fibrous, and bony tumours,
+warts, and fibroid tumours of the uterus. They produce no constitutional
+disturbance. They only threaten life when growing in the vicinity of
+vital organs, and then only in virtue of their situation--for example,
+death may result from an innocent tumour in the air-passage causing
+suffocation, in the intestine causing obstruction of the bowels, or in
+the vertebral canal causing pressure on the spinal medulla.
+
+_Malignant tumours_ usually show a marked departure from the structure
+and arrangement of the normal tissues of the body. Although the cells of
+which they are composed are derived from normal tissue cells, they tend
+to take on a lower, more vegetative form; they may be regarded as
+parasites living at the expense of the organism, multiplying
+indefinitely and destroying everything with which they come in contact.
+
+Malignant tumours grow more rapidly than innocent tumours, and tend to
+infiltrate their surroundings by sending out prolongations or offshoots;
+they are therefore liable to recur after an operation which is
+restricted to the removal of the main tumour. They are not encapsulated,
+although they may appear to be circumscribed by condensation of the
+surrounding tissues; they are rarely multiple at the outset, but show a
+marked tendency to spread to other parts of the body. Fragments of the
+parent tumour may become separated and be carried off in the lymph or
+blood-stream and deposited in other parts of the body, where they give
+rise to secondary growths. Malignant tumours tend to invade and destroy
+the overlying skin or mucous membrane, and thus give rise to bleeding
+ulcers; if the tumour tissue protrudes through the gap in the skin, it
+is said to _fungate_. In course of time they give rise to a condition of
+ill-health or _cachexia_, the patient becoming pale, sallow, feverish,
+and emaciated, probably as a result of chronic poisoning from the
+absorption of toxic products from the tumour. They ultimately destroy
+life, it may be by their local effects, such as ulceration and
+haemorrhage, by favouring the entrance of septic infection, by
+interfering with the function of organs which are essential to life, by
+cachexia, or by a combination of these effects.
+
+The situation of a malignant tumour exercises considerable influence on
+the rapidity, as well as on the mode, in which it causes death. Some
+cancers, such as that known as "rodent," show malignant features which
+are entirely local, while others, such as melanotic cancer, exhibit a
+malignancy characterised by rapid generalisation of growths throughout
+the body. Tumours that are structurally alike may show variations in
+malignancy, according to their situation and to the age of the patient,
+as well as to other factors which are as yet unknown.
+
+In attempting to arrive at a conclusion as to the innocence or
+malignancy of any tumour, too much reliance must not be placed on its
+histological features; its situation, rate of growth, and other clinical
+features must also be taken into consideration. It cannot be too
+emphatically stated that there is no hard-and-fast line between innocent
+and malignant growths; there is an indefinite transition from one to the
+other. The possibility of the transformation of a benign into a
+malignant tumour must be admitted. Such a transformation implies a
+change in the structure of the growth, and has been observed especially
+in fibrous and cartilaginous tumours, in tumours of the thyreoid gland,
+and in uterine fibroids. The alteration in character may take place
+under the influence of injury, prolonged or repeated irritation,
+incomplete removal of the benign tumour by operation, or the altered
+physiological conditions of the tissues which attend upon advancing
+years.
+
+After a tumour has been removed by operation it should as a routine
+measure be subjected to microscopical examination; the results are often
+instructive and sometimes other than what was expected.
+
+#Varieties of Tumours.#--In the following description, tumours are
+classified on an anatomical basis, taking in order first the
+connective-tissue group and subsequently those that originate in
+epithelium.
+
+
+INNOCENT CONNECTIVE-TISSUE TUMOURS
+
+#Lipoma.#--A lipoma is composed of fat resembling that normally present
+in the body. The commonest variety is the _subcutaneous lipoma_, which
+grows from the subcutaneous fat, and forms a soft, irregularly lobulated
+tumour (Fig. 45). The fat is arranged in lobules separated by
+connective-tissue septa, which are continuous with the capsule
+surrounding the tumour and with the overlying skin, which becomes
+dimpled or puckered when an attempt is made to pinch it up. As the fat
+is almost fluid at the body temperature, fluctuation can usually be
+detected. These tumours vary greatly in size, occur at all ages, grow
+slowly, and, while generally solitary, are sometimes multiple. They are
+most commonly met with on the shoulder, buttock, or back. In certain
+situations, such as the thigh and perineum, they tend to become
+pedunculated (Fig. 46).
+
+A fatty tumour is to be diagnosed from a cold abscess and from a cyst.
+The distinguishing features of the lipoma are the tacking down and
+dimpling of the overlying skin, the lobulation of the tumour, which is
+recognised when it is pressed upon with the flat of the hand, and, more
+reliable than either of these, the mobility, the tumour slipping away
+when pressed upon at its margin.
+
+[Illustration: FIG. 45.--Subcutaneous Lipoma showing lobulation.]
+
+The prognosis is more favourable than in any other tumour as it never
+changes its characters; the only reasons for its removal by operation
+are its unsightliness and its probable increase in size in the course of
+years. The operation consists in dividing the skin and capsule over the
+tumour and shelling it out. Care must be taken that none of the outlying
+lobules are left behind. If the overlying skin is damaged or closely
+adherent, it should be removed along with the tumour.
+
+[Illustration: FIG. 46.--Pedunculated Lipoma of Buttock of forty years'
+duration in a woman aet. 68.]
+
+_Multiple subcutaneous lipomas_ are frequently symmetrical, and in a
+certain group of cases, met with chiefly in women, pain is a prominent
+symptom, hence the term _adiposis dolorosa_ (Dercum). These multiple
+tumours show little or no tendency to increase in size, and the pain
+which attends their development does not persist.
+
+In the neck, axilla, and pubes a diffuse overgrowth of the subcutaneous
+fat is sometimes met with, forming symmetrical tumour-like masses, known
+as _diffuse lipoma_. As this is not, strictly speaking, a tumour, the
+term _diffuse lipomatosis_ is to be preferred. A similar condition was
+described by Jonathan Hutchinson as being met with in the domestic
+animals. If causing disfigurement, the mass of fat may be removed by
+operation.
+
+[Illustration: FIG. 47.--Diffuse Lipomatosis of Neck.]
+
+_Lipoma in other Situations._--The _periosteal lipoma_ is usually
+congenital, and is most often met with in the hand; it forms a
+projecting lobulated tumour, which, when situated in the palm, resembles
+an angioma or a lymphangioma. The _subserous lipoma_ arises from the
+extra-peritoneal fat in the posterior abdominal wall, in which case it
+tends to grow forwards between the layers of the mesentery and to give
+rise to an abdominal tumour; or it may grow from the extra-peritoneal
+fat in the anterior abdominal wall and protrude from one of the hernial
+openings or through an abnormal opening in the parietes, constituting a
+_fatty hernia_. A _subsynovial lipoma_ grows from the fat surrounding
+the synovial membrane of a joint, and projects into its interior, giving
+rise to the symptoms of loose body. Lipomas are also met with growing
+from the adipose connective tissue _between or in the substance of
+muscles_, and, when situated beneath the deep fascia, such as the fascia
+lata of the thigh, the characteristic signs are obscured and a
+differential diagnosis is difficult. It may be differentiated from a
+cold abscess by puncture with an exploring needle.
+
+[Illustration: FIG. 48.--Zanthoma of Hands in a girl aet. 14, showing
+multiple subcutaneous tumours (cf. Fig. 49).
+
+(Sir H. J. Stiles' case.)]
+
+#Zanthoma# is a rare but interesting form of tumour, composed of a
+fibrous and fatty tissue, containing a granular orange-yellow pigment,
+resembling that of the corpus luteum. It originates in the corium and
+presents two clinical varieties. In the first of these, it occurs in the
+form of raised yellow patches, usually in the skin of the eyelids of
+persons after middle life, and in many instances is associated with
+chronic jaundice; the patches are often symmetrical, and as they
+increase in size they tend to fuse with another.
+
+The second form occurs in children and adolescents; it may affect
+several generations of the same family, and is often multiple, there
+being a combination of thickened yellow patches of skin and projecting
+tumours, some of which may attain a considerable size (Figs. 48 and 49).
+On section, the tumour tissue presents a brilliant orange or saffron
+colour.
+
+There is no indication for removing the tumours unless for the deformity
+which they cause; exposure to the X-rays is to be preferred to
+operation.
+
+[Illustration: FIG. 49.--Zanthoma showing Subcutaneous Tumours on
+Buttocks. From same patient as Fig. 48.]
+
+#Chondroma.#--A chondroma is mainly composed of cartilage. Processes of
+vascular connective tissue pass in between the nodules of cartilage
+composing the tumour from the fibrous capsule which surrounds it. On
+section it is of a greyish-blue colour and semi-translucent. The tumour
+is firm and elastic in consistence, but certain portions may be densely
+hard from calcification or ossification, while other portions may be
+soft and fluctuating as a result of myxomatous degeneration and
+liquefaction. These tumours grow slowly and painlessly, and may surround
+nerves and arteries without injuring them. They may cause a deep hollow
+in the bone from which they originate. All intermediate forms between
+the innocent chondroma and the malignant chondro-sarcoma are met with.
+Chondroma may occur in a multiple form, especially in relation to the
+phalanges and metacarpal bones. When growing in the interior of a bone
+it causes a spindle-shaped enlargement of the shaft, which in the case
+of a phalanx or metacarpal bone may resemble the dactylitis resulting
+from tubercle or syphilis. A chondroma appears as a clear area in a
+skiagram.
+
+A _skiagram_ of a bone in which there is a chondroma shows a clear
+rounded area in the position of the tumour, which must be differentiated
+from similar clear areas due to other kinds of tumour, especially the
+myeloma; when it has undergone calcification or ossification, it gives a
+shadow as dark as bone.
+
+[Illustration: FIG. 50.--Chondroma growing from infraspinous fossa of
+Scapula.]
+
+[Illustration: FIG. 51.--Chondroma of Metacarpal Bone of Thumb.]
+
+_Treatment._--In view of the unstable quality of the chondroma,
+especially of its liability to become malignant, it should be removed as
+soon as it is recognised. In those projecting from the surface of a
+bone, both the tumour and its capsule should be removed. If in the
+interior, a sufficient amount of the cortex should be removed to allow
+of the tumour being scraped out, and care must be taken that no nodules
+of cartilage are left behind. In multiple chondromas of the hand, when
+the fingers are crippled and useless, exposure to the X-rays should be
+given a trial, and in extreme cases the question of amputation may have
+to be considered. When a cartilaginous tumour takes on active growth, it
+must be treated as malignant.
+
+The chondromas that are met with at the ends of the long bones in
+children and young adults form a group by themselves. They are usually
+related to the epiphysial cartilage, and it was suggested by Virchow
+that they take origin from islands of cartilage which have not been used
+up in the process of ossification. They are believed to occur more
+frequently in those who have suffered from rickets. They have no
+malignant tendencies and tend to undergo ossification concurrently with
+the epiphysial cartilage from which they take origin, and constitute
+what are known as _cartilaginous exostoses_. These are sometimes met
+with in a multiple form, and may occur in several generations of the
+same family. They are considered in greater detail in the chapter
+dealing with tumours of bone.
+
+Minute nodules of cartilage sometimes form in the synovial membrane of
+joints and lining of tendon sheaths and bursae: they tend to become
+detached from the membrane and constitute loose bodies; they also
+undergo a variable amount of calcification and ossification, so as to be
+visible in skiagrams. They are further considered with loose bodies in
+joints.
+
+Cartilaginous tumours in the parotid, submaxillary gland, and testicle
+belong to a class of "mixed tumours" that will be referred to later.
+
+#Osteoma.#--The true osteoma is composed of bony tissue, and originates
+from the skeleton. Two varieties are recognised--the spongy or
+cancellous, and the ivory or compact. The _spongy_ or _cancellous
+osteoma_ is really an ossified chondroma, and is met with at the ends of
+the long bones (Fig. 52). From the fact that it projects from the
+surface of the bone it is often spoken of as an _exostosis_. It grows
+slowly, and rarely causes any discomfort unless it presses upon a
+nerve-trunk or upon a bursa which has developed over it. The Rontgen
+rays show a dark shadow corresponding to the ossified portion of the
+tumour, and continuous with that of the bone from which it is growing
+(Fig. 138). Operative interference is only indicated when the tumour is
+giving rise to inconvenience. It is then removed, its base or neck being
+divided by means of the chisel. The multiple variety of osteoma is
+considered with the diseases of bone.
+
+The bony outgrowth from the terminal phalanx of the great toe--known as
+the _subungual exostosis_--is described and figured on p. 404. Bony
+projections or "spurs" sometimes occur on the under surface of the
+calcaneus, and, projecting downwards and forwards from the greater
+process, cause pain on putting the heel to the ground.
+
+[Illustration: FIG. 52.--Cancellous Osteoma of lower end of Femur.]
+
+The _ivory_ or _compact osteoma_ is composed of dense bone, and usually
+grows from the skull. It is generally sessile and solitary, and may grow
+into the interior of the skull, into the frontal sinus, into the cavity
+of the orbit or nose, or may fill up the external auditory meatus,
+causing most unsightly deformity and interference with sight, breathing,
+and hearing.
+
+Bony formations occur in _muscles and tendons_, especially at their
+points of attachment to the skeleton, and are known as false exostoses;
+they are described with the diseases of muscles.
+
+#Odontoma.#--An odontoma is composed of dental tissues in varying
+proportions and different degrees of development, arising from
+tooth-germs or from teeth still in process of growth (Bland Sutton).
+Odontomas resemble teeth in so far that during their development they
+remain hidden below the mucous membrane and give no evidence of their
+existence. There then succeeds, usually between the twentieth and
+twenty-fifth years, an eruptive stage, which is often attended with
+suppuration, and this may be the means of drawing attention to the
+tumour. Following Bland Sutton, several varieties of odontoma may be
+distinguished according to the part of the tooth-germ concerned in their
+formation.
+
+The _epithelial odontoma_ is derived from persistent portions of the
+epithelium of the enamel organ, and constitutes a multilocular cystic
+tumour which is chiefly met with in the mandible. The cystic spaces of
+the tumour contain a brownish glairy fluid. These tumours have been
+described by Eve under the name of multilocular cystic epithelial
+tumours of the jaw.
+
+The _follicular odontoma_, also known as a _dentigerous cyst_, is
+derived from the distension of a tooth follicle. It constitutes a cyst
+containing a viscid fluid, and an imperfectly formed tooth is often
+found embedded in its wall. The cyst usually forms in relation to one of
+the permanent molars, and may attain considerable dimensions.
+
+The _fibrous odontoma_ is the result of an overgrowth of fibrous tissue
+surrounding the tooth sac, which encapsulates the tooth and prevents its
+eruption. The thickened tooth sac is usually mistaken for a fibrous
+tumour, until, after removal, the tooth is recognised in its interior.
+
+_Composite Odontoma._--This is a convenient term to apply to certain
+hard dental tumours which are met with in the jaws, and consist of
+enamel, dentine, and cement. The tumour is to be regarded as being
+derived from an abnormal growth of all the elements of a tooth germ, or
+of two or more tooth germs, indiscriminately fused with one another. It
+may appear in childhood, and form a smooth unyielding tumour, often of
+considerable size, replacing the corresponding permanent tooth. It may
+cause a purulent discharge, and in some cases it has been extruded after
+sloughing of the overlying soft parts. Many examples of this variety of
+odontoma, growing in the nasal cavity or in the maxillary sinus, have
+been erroneously regarded as osteomas even after removal.
+
+On section, the tumour is usually laminated, and is seen to consist
+mainly of dentine with a partial covering of enamel and cement.
+
+_Diagnosis._--Odontomas are often only diagnosed after removal. When
+attended with suppuration, the condition has been mistaken for disease
+of the jaw. Fibrous odontomas have been mistaken for sarcoma, and
+portions of the maxilla removed unnecessarily. Any circumscribed tumour
+of the jaw, particularly when met with in a young adult, should suggest
+the possibility of an odontoma. Skiagrams often give useful information
+both for diagnosis and for treatment.
+
+_Treatment._--The solid varieties of odontoma can usually be shelled out
+after dividing the overlying soft parts. In the follicular variety, it
+is usually sufficient to excise a portion of the wall, scrape out the
+interior, and remove any tooth that may be present. The cavity is then
+packed and allowed to heal from the bottom.
+
+#Fibroma.#--A fibroma is a tumour composed of fibrous connective tissue.
+A distinction may be made between the _soft fibroma_, which is
+comparatively rich in cells and blood vessels, and in which the fibres
+are arranged loosely; and the _hard fibroma_, which is composed of
+closely packed bundles of fibres often arranged in a concentric fashion
+around the blood vessels. The cut surface of the soft fibroma presents a
+pinkish-white, fleshy appearance, resembling the slowly growing forms of
+sarcoma; that of a hard fibroma presents a dry, glistening appearance,
+aptly compared to watered silk. The soft variety grows much more rapidly
+than the hard. In certain fibromas--in those, for example, which grow
+from the periosteum of the base of the skull and project into the
+naso-pharynx--the blood vessels are dilated into sinuses and have no
+proper sheaths; they therefore tend to remain open when divided, and to
+bleed excessively. Transition forms between soft fibroma and sarcoma are
+met with, so that in operating for their removal it is safer to take
+away the capsule along with the tumour, and the patient should be kept
+under observation in view of the risk of recurrence.
+
+The skin--especially the skin of the buttock--is one of the favourite
+seats of fibroma, and it may occur in a multiple form. It is met with
+also in the subcutaneous and intermuscular cellular tissue, and in the
+abdominal wall, where it sometimes attains considerable dimensions.
+Various forms of fibroma are met with in the mamma and are described
+with diseases of that organ. The fibrous overgrowths in the skin, known
+as _keloid_ and _molluscum fibrosum_, and those met with in the _sheaths
+of nerves_, are described elsewhere. Fibroid tumours of the uterus are
+described with myoma.
+
+_Diffuse fibroma_ or _Fibromatosis_, analogous to lipomatosis, is met
+with in the connective tissue of the skin and sheaths of nerves, and
+constitutes one form of neuro-fibromatosis; a similar change is also met
+with in the stomach and colon.
+
+#Myxoma.#--A myxoma is composed of tissue of a soft gelatinous,
+semifluid consistence. The pure myxoma is extremely rare, and
+clinically resembles the lipoma. Myxomatous tissue is, however,
+frequently found in other connective-tissue tumours as a result of
+degeneration, for example, in cartilaginous tumours and in sarcomas.
+Myxomatous tissue is also a prominent constituent of the "innocent
+parotid tumour." Mucous polypus of the nose, which is often described as
+a myxoma, is merely a pendulous process of oedematous mucous membrane.
+
+[Illustration: FIG. 53.--Myeloma of Shaft of Humerus, causing
+pathological fracture. (Mr. J. W. Struthers' case.)
+
+(The unusual site of the tumour is to be noted.)]
+
+#Myeloma.#--A myeloma is composed of large multinuclear giant cells
+surrounded by round and spindle cells. The cut surface of the tumour
+presents a deep red or maroon colour. While occasionally met with in
+tendon sheaths and bursae, and is then of an orange-yellow colour, the
+myeloma occurs most frequently in the cancellous tissue at the ends of
+the long bones, its favourite site being the upper end of the tibia.
+Although formerly classified as a sarcoma, it is the exception for it to
+present malignant features, and it can usually be extirpated by local
+measures without fear of recurrence. The diagnosis, X-ray appearances,
+and the method of removal are considered with the diseases of bone.
+Sometimes the myeloma is met with in multiple form in the skeleton, in
+association with an unusual form of protein in the urine (Bence Jones).
+
+#Myoma.#--A myoma is composed of non-striped muscle fibres. A pure myoma
+is very rare, and is met with in organs possessed of non-striped muscle,
+such as the stomach, intestine, urinary bladder, and prostate. In the
+uterus, which is the most common situation, these tumours contain a
+considerable admixture of fibrous tissue, and are known as _fibroids_ or
+_fibro-myomas_. They present on section a fasciculated appearance, which
+may resemble that of a section of balls of cotton (Fig. 54). They are
+encapsulated and vascular, frequently attain a large size, and may be
+single or multiple. While they may occasion neither inconvenience nor
+suffering, they frequently give rise to profuse haemorrhage from the
+uterus, and may cause serious symptoms by pressing injuriously on the
+ureters or the intestine, or by complicating pregnancy and parturition.
+
+The #Rhabdomyoma# is an extremely rare form of tumour, met with in the
+kidney, uterus, and testicle. It contains striped muscle fibres, and is
+supposed to originate from a residue of muscular tissue which has become
+sequestrated during development.
+
+[Illustration: FIG. 54.--Fibro-myoma of Uterus.
+
+(Anatomical Museum, University of Edinburgh.)]
+
+#Glioma.#--A glioma is a tumour composed of neuroglia. It is met with
+exclusively in the central nervous system, retina, and optic nerve. It
+is a slowly growing, soft, ill-defined tumour, which displaces the
+adjacent nerve centres and nerve tracts, and is liable to become the
+seat of haemorrhage and thus to give rise to pressure symptoms resembling
+apoplexy. The glioma of the retina tends to grow into the vitreous
+humour and to perforate the globe. It is usually of the nature of a
+glio-sarcoma and is highly malignant.
+
+#Endotheliomas# take origin from the endothelium of lymph vessels and
+blood vessels, and serous cavities. They show great variation in type,
+partly because of the number of different kinds of endothelium from
+which they are derived, and partly because the new connective tissue
+which is formed is liable to undergo transformation into other tissues.
+They may be soft or hard, solid or cystic, diffuse or circumscribed;
+they grow very slowly, and are almost always innocent, although
+recurrence has been occasionally observed. Cases of multiple
+endotheliomata of the skin have recently been described by Wise.
+
+_Angioma_, _lymphangioma_, and _neuroma_ are described with the disease
+of the individual tissues.
+
+
+MALIGNANT CONNECTIVE-TISSUE TUMOURS--SARCOMA
+
+The term sarcoma is applied to any connective-tissue tumour which
+exhibits malignant characters. The essential structural feature is the
+predominance of the cellular elements over the intercellular substance
+or stroma, in which respect a sarcoma resembles the connective tissue of
+the embryo. The typical sarcoma consists chiefly of immature or
+embryonic connective tissue. It most frequently originates from fascia,
+intermuscular connective tissue, periosteum, bone-marrow, and skin, and
+forms a rounded or nodulated tumour which appears to be encapsulated,
+but the capsule merely consists of the condensed surrounding tissues,
+and usually contains sarcomatous elements. The consistence of the tumour
+depends on the nature and amount of the stroma, and on the presence of
+degenerative changes. The softer medullary forms are composed almost
+exclusively of cells; while the harder forms--such as the fibro-,
+chondro-, and osteo-sarcoma--are provided with an abundant stroma and
+are relatively poor in cells. Degenerative changes may produce areas of
+softening or liquefaction which result in the formation of cystic
+cavities in the interior of the tumour. The colour depends on the amount
+of blood in the tumour, and on the presence of the products of
+degeneration.
+
+The blood vessels are usually represented by mere chinks or spaces
+between the cells. This peculiarity accounts for the facility with which
+haemorrhage takes place into the substance of the tumour, the persistence
+of the bleeding when it is incised or ulcerates through the skin, and
+the readiness with which the sarcomatous cells are carried off and
+infect distant parts through the blood-stream. Sarcomas are devoid of
+lymphatics, and unless originating in lymphatic structures--for example,
+in the tonsil--they rarely infect the lymph glands. Minute portions of
+the tumour grow into the small veins, and, becoming detached, are
+transported by the blood-current to distant organs, where they are
+arrested in the capillaries and give rise to secondary growths. These
+are most frequently situated in the lungs, except when the primary
+growth lies within the territory of the portal circulation, in which
+case they occur in the liver. The secondary growths closely resemble the
+parent tumour. Sarcoma may invade an adjacent vein on such a scale that
+if the invading portion becomes detached it may constitute a dangerous
+embolus. This may be observed in sarcoma of the kidney, the growth
+taking place along the renal vein until it projects into the vena cava.
+
+[Illustration: FIG. 55.--Recurrent Sarcoma of Sciatic Nerve in a woman
+aet. 27. Recurrence twenty months after removal of primary growth.]
+
+In its growth, a sarcoma compresses and destroys neighbouring parts,
+surrounds vessels and nerves, and may lead to destruction of the skin,
+either by invading it, or more commonly by causing sloughing from
+pressure. Inflammatory and suppurative changes may take place as a
+result of pyogenic infection following upon sloughing of the overlying
+skin or upon an exploratory incision. Once the skin is broken the tumour
+fungates through the opening. Sarcomas vary in malignancy, especially as
+regards rapidity of growth and capacity for dissemination. Certain of
+them, such as the so-called "recurrent fibroid of Paget," grow
+comparatively slowly, and are only malignant in the sense that they tend
+to recur locally after removal; others--especially the more cellular
+ones--grow with extreme rapidity, and are early disseminated throughout
+the body, resembling in these respects the most malignant forms of
+cancer. They are usually solitary in the first instance, although
+primary multiple growths are occasionally met with in the skin and in
+the bones.
+
+Many varieties of sarcoma are recognised, according to its structural
+peculiarities. Thus, in virtue of the size and character of the cells,
+we have the _small round-celled_ and the _large round-celled_ sarcoma,
+the _small_ and the _large spindle-celled_, the _giant-celled_ and the
+_mixed-celled_ sarcoma. The _lympho-sarcoma_ presents a structure
+similar to that of lymph-follicular tissue, and the _alveolar sarcoma_
+an arrangement of cells in alveoli resembling that seen in cancers. When
+there is a considerable amount of intercellular fibrous tissue, the
+tumour is called a _fibro-sarcoma_.
+
+[Illustration: FIG. 56.--Fungating Sarcoma of Arm.
+
+(Dr. J. M'Watt's case.)]
+
+The term _lymphangio-sarcoma_ is applied when the cells of the tumour
+are derived from the endothelium of lymph spaces and vessels. The
+_angio-sarcomas_ are those in which blood vessels form a prominent
+element in the structure of the tumour. They are sometimes derived from
+innocent angiomas, and they may be so vascular as to pulsate and on
+auscultation yield a blowing murmur like an aneurysm. The
+_glio-sarcoma_, _myxo-sarcoma_, _chondro-sarcoma_, and _myo-sarcoma_ are
+mixed forms which usually develop in pre-existing innocent tumours. The
+_osteo-sarcoma_ is characterised by the formation in the tumour of bone,
+the medullary spaces being occupied by sarcomatous cells in place of
+marrow. The _osteoid sarcoma_ is characterised by the formation of a
+tissue resembling bone but deficient in lime salts, and the _petrifying
+sarcoma_ by the formation of calcified areas in the stroma. These
+varieties, although met with chiefly in the bones, may occur in soft
+tissues such as muscle, and in such organs as the mamma. The pigmented
+varieties include the _chloroma_, which is of a light-green colour, and
+the _melanotic sarcoma_, which is brown or black. The _psammoma_ is a
+sarcoma containing a material resembling sand; it is chiefly met with in
+the membranes of the brain. The _chordoma_ is a rare form of tumour
+originating from the remains of the notochord in the region of the
+spheno-occipital synchondrosis or in the sacro-coccygeal region.
+
+_Diagnosis of Sarcoma._--A sarcoma is to be differentiated from an
+inflammatory swelling such as results from tubercle, actinomycosis, or
+syphilis, from an innocent tumour, and from a cancer. The points on
+which the diagnosis is founded are discussed with the different tissues
+and organs.
+
+_Treatment._--The removal of the tumour by operation is the most
+reliable method of treatment; in order to be successful it must be
+undertaken before dissemination has taken place, and a considerable area
+of healthy tissue beyond the apparent margin of the growth must be
+removed, and in tumours near the surface of the body, the overlying skin
+also.
+
+In order to prevent recurrence, a tube of _radium_, to which a silk
+thread is attached, is inserted into the space from which the tumour was
+removed; the thread is brought out at the drain-opening, and at the end
+of a week or ten days the tube of radium is removed by pulling on the
+thread. Radium causes a reaction in the tissues attended with exudation
+from the vessels, for the escape of which provision must be made. If
+radium is not available, the affected area is repeatedly exposed to the
+action of the _X-rays_ as soon as the wound has healed. The employment
+of these measures has diminished to a remarkable degree the recurrence
+of sarcoma after operation.
+
+It will readily be understood that the less thoroughly or radically the
+growth has been removed, the more do we depend upon radium or the X-rays
+for bringing about a permanent cure, and that in advanced cases of
+sarcoma and in cases in which, on account of their anatomical situation,
+removal by operation is necessarily incomplete, the prospect of cure is
+still more dependent on the use of radium or of the X-rays. Finally,
+there are cases in which removal by operation is impossible, the
+so-called _inoperable sarcoma_; a tube of radium, to which a silk thread
+is attached, is inserted into the substance of the tumour, either
+through an opening made by a large trocar, or, when necessary, by open
+dissection. A second tube of radium is placed upon the skin over the
+tumour and is secured there by a stitch or by a strip of plaster, thus
+securing a cross-fire action of the radium rays, both from within and
+without, as this is found to be much more efficacious in destroying or
+inhibiting the cellular elements of the growth. The tubes of radium are
+left _in situ_ for from eight to fourteen days, according to the power
+of the radium employed, but are moved about every second day or so in
+order that every part of the tumour may be efficiently radiated. If the
+tumour shrinks in size after the use of radium and becomes operable, it
+should be removed before time is given it to resume its growth. It will
+depend upon the subsequent course of the disease, whether or not a
+second, or it may be even a third, application of radium will be
+required.
+
+Where neither radium nor X-rays is available or applicable, recourse may
+be had to the injection of Coley's fluid, a preparation containing the
+mixed toxins of the streptococcus of erysipelas and the bacillus
+prodigiosus; or of selenium.
+
+
+EPITHELIAL TUMOURS
+
+An excessive and erratic growth of epithelium is the essential and
+distinguishing feature of these tumours. The innocent forms are the
+papilloma and the adenoma; the malignant, the carcinoma or cancer.
+
+#Papilloma.#--A papilloma is a tumour which projects from a cutaneous or
+mucous surface, and consists of a central axis of vascular fibrous
+tissue with a covering of epithelium resembling that of the surface from
+which the tumour grows. In the papillomas of the skin--commonly known as
+_warts_--the covering consists of epidermis; in those growing from
+mucous surfaces it consists of the epithelium covering the mucous
+membrane. When the surface epithelium projects as filiform processes,
+the tumour is called a _villous papilloma_, the best-known example of
+which is met with in the urinary bladder. Papillomatous growths are
+also met with in the larynx, in the ducts of the breast, and in the
+interior of certain cystic tumours of the breast and of the ovary.
+Although papillomas are primarily innocent, they may become the
+starting-point of cancer, especially in persons past middle life and if
+the papilloma has been subjected to irritation and has ulcerated. The
+clinical features and treatment of the various forms of papilloma are
+considered with the individual tissues and organs.
+
+#Adenoma.#--An adenoma is a tumour constructed on the type of, and
+growing in connection with, a secreting gland. In the substance of such
+glands as the mamma, parotid, thyreoid, and prostate, adenomas are met
+with as encapsulated tumours. When they originate from the glands of the
+skin or of a mucous membrane, they tend to project from the surface, and
+form pedunculated tumours or polypi.
+
+Adenomas may be single or multiple, and they vary greatly in size. The
+tumour is seldom composed entirely of gland tissue; it usually contains
+a considerable proportion of fibrous tissue, and is then called a
+_fibro-adenoma_. When it contains myxomatous tissue it is called a
+_myxo-adenoma_, and when the gland spaces of the tumour become distended
+with accumulated secretion, a _cystic adenoma_, the best examples of
+which are met with in the mamma and ovary. A characteristic feature of
+the cystic variety is the tendency the tumour tissue exhibits to project
+into the interior of the cysts, constituting what are known as
+_intracystic growths_. They are essentially innocent, but intracystic
+growths, especially in the mamma of women over fifty, should be regarded
+with suspicion and therefore should be removed on radical lines.
+Transition forms between adenoma and carcinoma are also met with in the
+rectum and large intestine, and these should be treated on the same
+lines as cancer.
+
+
+CARCINOMA OR CANCER
+
+A cancer is a malignant tumour which originates in epithelium. The
+cancer cells are derived by proliferation from already existing
+epithelium, and they invade the sub-epithelial connective tissue in the
+form of simple or branching columns. These columns are enclosed in
+spaces--termed alveoli--which are probably dilated lymph spaces, and
+which communicate freely with the lymph vessels. The cells composing the
+columns and filling the alveoli vary with the character of the
+epithelium in which the cancer originates. The malignancy of cancer
+depends on the tendency which the epithelium has of invading the tissues
+in its neighbourhood, and on the capacity of the cells, when
+transported elsewhere by the lymph or blood-stream, of giving rise to
+secondary growths.
+
+Cancer may arise on any surface covered by epithelium or in any of the
+secreting glands of the body, but it is much more common in some
+situations than in others. It is frequently met with, for example, in
+the skin, in the stomach and large intestine, in the breast, the uterus,
+and the external genitals; less frequently in the gall-bladder, larynx,
+thyreoid, prostate, and urinary bladder.
+
+Tissues appear to be most liable to cancer when, having attained
+maturity, they enter upon the phase of decadence or involution, and this
+phase is reached by different tissues at different periods. It is not so
+much, therefore, the age of the person in whom it occurs, as the age of
+the tissue in which it arises, that determines the maximum incidence of
+cancer. Cancer of the stomach appears and attains a maximum frequency
+earlier than cancer of the skin; cancer of the uterus and mamma is more
+frequent towards the decline of reproductive activity than in the later
+years of life; rectal cancer is not infrequently met with during the
+second and third decades. There is evidence that the irritation caused
+by alcohol and tobacco plays a part in the causation of cancer, in the
+fact that a large proportion of those who become the subjects of cancer
+of the mouth are excessive drinkers and smokers.
+
+A cancer may appear as a papillary growth on a mucous or a skin surface,
+as a nodule in the substance of an organ, or as a diffuse thickening of
+a tubular organ such as the stomach or intestine. The absence of
+definition in cancerous tumours explains the difficulty of completely
+removing them by surgical measures, and has led to the practice of
+complete extirpation of cancerous organs wherever this is possible. The
+boundaries of the affected organ, moreover, are frequently transgressed
+by the disease, and the epithelial infiltration implicates the
+surrounding parts. In cancer of the breast, for example, the disease
+often extends to the adjacent skin, fat, and muscle; in cancer of the
+lip or tongue, to the mandible; in cancer of the uterus or intestine, to
+the investing peritoneum.
+
+In addition to its tendency to infiltrate adjacent tissues and organs,
+cancer is also liable to give rise to _secondary growths_. These are
+most often met with in the nearest lymph glands; those in the neck, for
+example, becoming infected from cancer of the lip, tongue, or throat;
+those in the axilla, from cancer of the breast; those along the
+curvatures of the stomach, from cancer of the pylorus; and those in the
+groin, from cancer of the external genitals. In lymph vessels the cancer
+cells may merely accumulate so as to fill the lumen and form indurated
+cords, or they may proliferate and give rise to secondary nodules along
+the course of the vessels. When the lymphatic network in the skin is
+diffusely infected, the appearance is either that of a multitude of
+secondary nodules or of a diffuse thickening, so that the skin comes to
+resemble coarse leather. On the wall of the chest this condition is
+known as _cancer en cuirasse_. Although the cancer cells constantly
+attack the walls of the adjacent veins and spread into their interior at
+a comparatively early period, secondary growths due to dissemination by
+the blood-stream rarely show themselves clinically until late in the
+course of the disease. It is probable that many of the cancer cells
+which are carried away in the blood or lymph stream undergo necrosis and
+fail to give rise to secondary growths. Secondary growths present a
+faithful reproduction of the structure of the primary tumour. Apart from
+the lymph glands, the chief seats of secondary growths are the liver,
+lungs, serous membranes, and bone marrow.
+
+It is generally believed that the secondary growths in cancer that
+develop at a distance from the primary tumour, those, for example, in
+the medullary canal of the femur or in the diploe of the skull occurring
+in advanced cases of cancer of the breast, are the result of
+dissemination of cancer cells by way of the blood-stream and are to be
+regarded as emboli. Sampson Handley disagrees with this view; he
+believes that the dissemination is accomplished in a more subtle way,
+namely, by the actual growth of cancer cells along the finer vessels of
+the lymph plexuses that ramify in the deep fascia, a method of spread
+which he calls _permeation_. It is maintained also that permeation
+occurs as readily against the lymph stream as with it. He compares the
+spread of cancer to that of an invisible annular ringworm. The growing
+edge extends in a wider and wider circle, within which a healing process
+may occur, so that the area of permeation is a ring, rather than a disc.
+Healing occurs by a process of "peri-lymphatic fibrosis," but as the
+natural process of healing may fail at isolated points, nodules of
+cancer appear, which, although apparently separate from the primary
+growth, have developed in continuity with it, peri-lymphatic fibrosis
+having destroyed the cancer chain connecting the nodule with the primary
+growth. This centrifugal spread of cancer is clearly seen in the
+distribution of the subcutaneous secondary nodules so frequently met
+with in the late stages of mammary cancer. The area within which the
+secondary nodules occur is a circle of continually increasing diameter
+with the primary growth in the centre.
+
+In the rare cases in which the skin of the greater part of the body is
+affected, the nodules rarely appear below the level of the deltoid or
+the middle third of the thigh, the patient dying before the spread can
+reach the distal portions of the limbs.
+
+Handley argues against the embolic origin of the metastases in the bones
+because of the rarity of these in the bones of the distal parts of the
+limbs, because of the fact that secondary cancer of the femur nearly
+always commences in the upper third of the shaft, which harmonises with
+the intimate connection of the deep fascia with the periosteum over the
+great trochanter, thus favouring invasion of the bone marrow when
+permeation has spread thus far. He claims support for the permeation
+theory from the fact that the humerus is rarely involved below the
+insertion of the deltoid, and that spontaneous fracture of the femur is
+three times more common on the side on which the breast cancer is
+situated.
+
+The tumour tissue may undergo necrosis, and when the overlying skin or
+mucous membrane gives way an ulcer is formed. The margins of a
+_cancerous ulcer_ (Fig. 57) are made up of tumour tissue which has not
+broken down. Usually they are irregular, nodularly thickened or
+indurated; sometimes they are raised and crater-like. The floor of the
+ulcer is smooth and glazed, or occupied by necrosed tissue, and the
+discharge is watery and blood-stained, and as a result of putrefactive
+changes may become offensive. Haemorrhage is rarely a prominent feature,
+but discharge of blood may constitute a symptom of considerable
+diagnostic importance in cancer of internal organs such as the rectum,
+the bladder, or the uterus.
+
+[Illustration: FIG. 57.--Carcinoma of Breast with Cancerous Ulcer.]
+
+_The Contagiousness of Cancer._--A limited number of cases are on record
+in which a cancer appears to have been transferred by contact, as from
+the lower to the upper lip, from one labium majus to the other, from the
+tongue to the cheek, and from one vocal cord to the other; these being
+all examples of cancer involving surfaces which are constantly or
+frequently in contact. The transference of cancer from one human being
+to another, whether by accident, as in the case of a surgeon wounding
+his finger while operating for cancer, or by the deliberate introduction
+of a portion of cancerous tumour into the tissues, has never been known
+to occur. It is by no means infrequent, however, that when recurrence
+takes place after an operation for the removal of cancer, the recurrent
+nodules make their appearance in the main scar or in the scars of
+stitches in its neighbourhood. In the lower animals the grafting of
+cancer only succeeds in animals of the same species; for example, a
+cancer taken from a mouse will not grow in the tissues of a rat, but
+only in a mouse of the same variety as that from which the graft was
+taken.
+
+While cancer cannot be regarded as either contagious or infectious, it
+is important to bear in mind the possibility of infection of a wound
+with cancer when operating for the disease. A cancer should not be cut
+into unless this is essential for purposes of diagnosis, and the wound
+made for exploration should be tightly closed by stitches before the
+curative operation is proceeded with; the instruments used for the
+exploration must not be used again until they have been boiled. The
+greatest care should be taken that a cancer which has softened or broken
+down is not opened into during the operation.
+
+Investigations regarding the cause of cancer have been prosecuted with
+great energy during recent years, but as yet without positive result. It
+is recognised that there are a number of conditions which favour the
+development of cancer, such as prolonged irritation, and a considerable
+number of cases have been recorded in which cancer of the skin of the
+hands has followed prolonged and repeated exposure to the Rontgen rays.
+
+_The Alleged Increase of Cancer._--Regarding the alleged increase of
+cancer, it may be pointed out that it is impossible to ascertain how
+much of the apparent increase is due to more accurate diagnosis and
+improved registration. It is probable also that some increase has taken
+place in consequence of the increased average duration of life; a larger
+proportion of persons now reach the age at which cancer is frequent.
+
+_The prognosis_ largely depends on the variety of cancer and on its
+situation. Certain varieties--such as the atrophic cancer of the breast
+which occurs in old people, and some forms of cancer in the rectum--are
+so indolent in their progress that they can scarcely be said to shorten
+life; while others--such as the softer varieties of mammary cancer
+occurring in young women--are among the most malignant of tumours. The
+mode in which cancer causes death depends to a large extent upon its
+situation. In the gullet, for example, it usually causes death by
+starvation; in the larynx or thyreoid, by suffocation; in the intestine,
+by obstruction of the bowels; in the uterus, prostate, and bladder, by
+haemorrhage or by implication of the ureters and kidneys. Independently
+of their situation, however, cancers frequently cause death by giving
+rise to a progressive impairment of health known as the _cancerous
+cachexia_, a condition which is due to the continued absorption of
+poisonous products from the tumour. The patient loses appetite, becomes
+emaciated, pale, and feverish, and gradually loses strength until he
+dies. In many cases, especially those in which ulceration has occurred,
+the addition of pyogenic infection may also be concerned in the failure
+of health.
+
+_Treatment._--Removal by surgical means affords the best prospect of
+cure. If carcinomatous disease is to be rooted out, its mode of spread
+by means of the lymph vessels must be borne in mind, and as this occurs
+at an early stage, and is not evident on examination, a wide area must
+be included in the operation. The organ from which the original growth
+springs should, if practicable, be altogether removed, because its lymph
+vessels generally communicate freely with each other, and secondary
+deposits have probably already taken place in various parts of it. In
+addition, the nearest chain of lymph glands must also be removed, even
+though they may not be noticeably enlarged, and in some cases--in cancer
+of the breast, for example--the intervening lymph vessels should be
+removed at the same time.
+
+The treatment of cancer by other than operative methods has received a
+great deal of attention within recent years, and many agents have been
+put to the test, _e.g._ colloidal suspensions of selenium, but without
+any positive results. Most benefit has resulted from the use of radium
+and of the X-rays, and one or other should be employed as a routine
+measure after every operation for cancer.
+
+It has been demonstrated that cancer cells are more sensitive to radium
+and to the Rontgen rays than the normal cells of the body, and are more
+easily killed. The effect varies a good deal with the nature and seat of
+the tumour. In rodent cancers of the skin, for example, both radium and
+X-ray treatment are very successful, and are to be preferred to
+operation because they yield a better cosmetic result. While small
+epitheliomas of the skin may be cured by means of the rays, they are not
+so amenable as rodent cancers.
+
+Cancers of mucous membranes are less amenable to ray treatment because
+they are less circumscribed and are difficult of access. In cancers
+under the skin, the Rontgen rays are less efficient; if radium is
+employed, the tube containing it should be inserted into the substance
+of the tumour after the method described in connection with sarcoma--and
+another tube should be placed on the overlying skin.
+
+In the employment of X-rays and of radium in the treatment of cancer,
+experience is required, not only to obtain the maximum effect of the
+rays, but to avoid damage to the adjacent and overlying tissues.
+
+Ray treatment is not to be looked upon as a rival but as a powerful
+supplement to the operative treatment of cancer.
+
+
+VARIETIES OF CANCER
+
+The varieties of cancer are distinguished according to the character and
+arrangement of the epithelial cells.
+
+The _squamous epithelial cancer_ or _epithelioma_ originates from a
+surface covered by squamous epithelium, such as the skin, or the mucous
+membrane of the mouth, gullet, or larynx. The cancer cells retain the
+characters of squamous epithelium, and, being confined within the lymph
+spaces of the sub-epithelial connective tissue, become compressed and
+undergo a horny change. This results in the formation of concentrically
+laminated masses known as cell nests.
+
+The clinical features are those of a slowly growing indurated tumour,
+which nearly always ulcerates; there is a characteristic induration of
+the edges and floor of the ulcer, and its surface is often covered with
+warty or cauliflower-like outgrowths (Fig. 58). The infection of the
+lymph glands is early and constant, and constitutes the most dangerous
+feature of the disease; the secondary growths in the glands exhibit the
+characteristic induration, and may themselves break down and lead to the
+formation of ulcers.
+
+[Illustration: FIG. 58.--Epithelioma of Lip.]
+
+Epithelioma frequently originates in long-standing ulcers or sinuses,
+and in scars, and probably results from the displacement and
+sequestration of epithelial cells during the process of cicatrisation.
+
+The _columnar epithelial cancer_ or _columnar epithelioma_ originates in
+mucous membranes covered with columnar epithelium, and is chiefly met
+with in the stomach and intestine. As it resembles an adenoma in
+structure it is sometimes described as a _malignant adenoma_. Its
+malignancy is shown by the proliferating epithelium invading the other
+coats of the stomach or intestine, and by the development of secondary
+growths.
+
+_Glandular carcinoma_ originates in organs such as the breast, and in
+the glands of mucous membranes and skin. The epithelial cells are not
+arranged on any definite plan, but are closely packed in irregularly
+shaped alveoli. If the alveoli are large and the intervening stroma is
+scanty and delicate, the tumour is soft and brain-like, and is described
+as a _medullary_ or _encephaloid cancer_. If the alveoli are small and
+the intervening stroma is abundant and composed of dense fibrous tissue,
+the tumour is hard, and is known as a _scirrhous cancer_--a form which
+is most frequently met with in the breast. If the cells undergo
+degeneration and absorption and the stroma contracts, the tumour becomes
+still harder, and tends to shrink and to draw in the surrounding parts,
+leading, in the breast, to retraction of the nipple and overlying skin,
+and in the stomach and colon to narrowing of the lumen. When the cells
+of the tumour undergo colloid degeneration, a _colloid cancer_ results;
+if the degeneration is complete, as may occur in the breast, the
+malignancy is thereby greatly diminished; if only partial, as is more
+common in rectal cancer, the malignancy is not appreciably affected.
+Melanin pigment is formed in relation to the cells and stroma of certain
+epithelial tumours, giving rise to _melanotic cancer_, one of the most
+malignant of all new growths. Cyst-like spaces may form in the tumour by
+the accumulation of the secretion of the epithelial cells, or as a
+result of their degeneration--_cystic carcinoma_. This is met with
+chiefly in the breast and ovary, and the tumour resembles the cystic
+adenoma, but it tends to infect its surroundings and gives rise to
+secondary growths.
+
+_Rodent cancer_ originates in the glands of the skin, and presents a
+special tendency to break down and ulcerate on the surface (Figs. 102
+and 103). It almost never infects the lymph glands.
+
+
+DERMOIDS
+
+A dermoid is a tumour containing skin or mucous membrane, occurring in a
+situation where these tissues are not met under normal conditions.
+
+The _skin dermoid_, or _derma-cyst_ as it has been called by Askanazy,
+arises from a portion of epiblast, which has become sequestrated during
+the process of coalescence of two cutaneous surfaces in development.
+This form is therefore most frequently met with on the face and neck in
+the situations which correspond to the various clefts and fissures of
+the embryo. It occurs also on the trunk in situations where the lateral
+halves of the body coalesce during development. Such a dermoid usually
+takes the form of a globular cyst, the wall of which consists of skin,
+and the contents of turbid fluid containing desquamated epithelium, fat
+droplets, cholestrol crystals, and detached hairs. Delicate hairs may
+also be found projecting from the epithelial lining of the cyst.
+
+Faulty coalescence of the cutaneous covering of the back occurs most
+frequently over the lower sacral vertebrae, giving rise to small
+congenital recesses, known as post-anal dimples and coccygeal sinuses.
+These recesses are lined with skin, which is furnished with hairs,
+sebaceous and sweat glands. If the external orifice becomes occluded,
+there results a dermoid cyst.
+
+_Tubulo-dermoids_ arise from embryonic ducts and passages that are
+normally obliterated at birth, for example, _lingual dermoids_ develop
+in relation to the thyreo-glossal duct; _rectal and post-rectal_
+dermoids to the post-anal gut; and _branchial dermoids_ in relation to
+the branchial clefts. Tubulo-dermoids present the same structure as skin
+dermoids, save that mucous membrane takes the place of skin in the wall
+of the cyst, and the contents consist of the pent-up secretion of mucous
+glands.
+
+_Clinical Features._--Although dermoids are of congenital origin, they
+are rarely evident at birth, and may not give rise to visible tumours
+until puberty, when the skin and its appendages become more active, or
+not till adult life. Superficial dermoids, such as those met with at the
+outer angle of the orbit, form rounded, definitely limited tumours over
+which the skin is freely movable. They are usually adherent to the
+deeper parts, and when situated over the skull may be lodged in a
+depression or actual gap in the bone. Sometimes the cyst becomes
+infected and suppurates, and finally ruptures on the surface. This may
+lead to a natural cure, or a persistent sinus may form. Dermoids more
+deeply placed, such as those within the thorax, or those situated
+between the rectum and sacrum, give rise to difficulty in diagnosis,
+even with the help of the X-rays, and their nature is seldom recognised
+until the escape of the contents--particularly hairs--supplies the clue.
+The literature of dermoid cysts is full of accounts of puzzling tumours
+met with in all sorts of situations.
+
+The treatment is to remove the cyst. When it is impossible to remove the
+whole of the lining membrane by dissection, the portion that is left
+should be destroyed with the cautery.
+
+_Ovarian Dermoids._--Dermoids are not uncommon in the ovary (Fig. 59).
+They usually take the form of unilocular or multilocular cysts, the
+wall of which contains skin, mucous membrane, hair follicles, sebaceous,
+sweat, and mucous glands, nails, teeth, nipples, and mammary glands. The
+cavity of the cyst usually contains a pultaceous mixture of shed
+epithelium, fluid fat, and hair. If the cyst ruptures, the epithelial
+elements are diffused over the peritoneum, and may give rise to
+secondary dermoids.
+
+[Illustration: FIG. 59.--Dermoid Cyst of Ovary showing Teeth in its
+interior.]
+
+The ovarian dermoid appears clinically as an abdominal or pelvic tumour
+provided with a pedicle; if the pedicle becomes twisted, the tumour
+undergoes strangulation, an event which is attended with urgent
+symptoms, not unlike those of strangulated hernia.
+
+The treatment consists in removing the tumour by laparotomy.
+
+#Teratoma.#--A teratoma is believed to result from partial dichotomy or
+cleavage of the trunk axis of the embryo, and is found exclusively in
+connection with the skull and vertebral column. It may take the form of
+a monstrosity such as conjoined twins or a parasitic foetus, but more
+commonly it is met with as an irregularly shaped tumour, usually growing
+from the sacrum. On dissection, such a tumour is found to contain a
+curious mixture of tissues--bones, skin, and portions of viscera, such
+as the intestine or liver. The question of the removal of the tumour
+requires to be considered in relation to the conditions present in each
+individual case.
+
+
+CYSTS[3]
+
+[3] Cysts which form in relation to new-growths have been considered
+with tumours.
+
+Cysts are rounded sacs, the wall being composed of fibrous tissue lined
+by epithelium or endothelium; the contents are fluid or semi-solid, and
+vary in character according to the tissue in which the cyst has
+originated.
+
+_Retention and Exudation Cysts._--_Retention cysts_ develop when the
+duct of a secreting gland is partly obstructed; the secretion
+accumulates, and the gland and its duct become distended into a cyst.
+They are met with in the mamma and in the salivary glands. Sebaceous
+cysts or wens are described with diseases of the skin. _Exudation cysts_
+arise from the distension of cavities which are not provided with
+excretory ducts, such as those in the thyreoid.
+
+_Implantation cysts_ are caused by the accidental transference of
+portions of the epidermis into the underlying connective tissue, as may
+occur in wounds by needles, awls, forks, or thorns. The implanted
+epidermis proliferates and forms a small cyst. They are met with chiefly
+on the palmar aspect of the fingers, and vary in size from a split pea
+to a cherry. The treatment consists in removing them by dissection.
+
+_Parasitic cysts_ are produced by the growth within the tissues of
+cyst-forming parasites, the best known being the taenia echinococcus,
+which gives rise to the _hydatid cyst_. The liver is by far the most
+common site of hydatid cysts in the human subject.
+
+With regard to the further life-history of hydatids, the living elements
+of the cyst may die and degenerate, or the cyst may increase in size
+until it ruptures. As a result of pyogenic infection the cyst may be
+converted into an abscess.
+
+The _clinical features_ of hydatids vary so much with their situation
+and size, that they are best discussed with the individual organs. In
+general it may be said that there is a slow formation of a globular,
+elastic, fluctuating, painless swelling. Fluctuation is detected when
+the cyst approaches the surface, and it is then also that percussion
+may elicit the "hydatid thrill" or fremitus. This thrill is not often
+obtainable, and in any case is not pathognomonic of hydatids, as it may
+be elicited in ascites and in other abdominal cysts. Pressure of the
+cyst upon adjacent structures, and the occurrence of suppuration, are
+attended with characteristic clinical features.
+
+The _diagnosis_ of hydatids will be considered with the individual
+organs. The disease is more common in certain parts of Australia and in
+Shetland and Iceland than in countries where the association of dogs in
+the domestic life of the inhabitants is less intimate. Pfeiler, who has
+worked at the _serum diagnosis of hydatid disease_, regards the
+complement deviation method as the most reliable; he believes that a
+positive reaction may almost be regarded as absolutely diagnostic of an
+echinococcal lesion.
+
+The _treatment_ is to excise the cyst completely, or to inject into it a
+1 per cent. solution of formalin. In operating upon hydatids the utmost
+care must be taken to avoid leakage of the contents of the cyst, as
+these may readily disseminate the infection.
+
+A _blood cyst_ or haematoma results from the encapsulation of
+extravasated blood in the tissues, from haemorrhage taking place into a
+preformed cyst, or from the saccular pouching of a varicose vein.
+
+A _lymph cyst_ usually results from a contusion in which the skin is
+forcibly displaced from the subjacent tissues, and lymph vessels are
+thereby torn across. The cyst is usually situated between the skin and
+fascia, and contains clear or blood-stained serum. At first it is lax
+and fluctuates readily, later it becomes larger and more tense. The
+treatment consists in drawing off the contents through a hollow needle
+and applying firm pressure. Apart from injury, lymph cysts are met with
+as the result of the distension of lymph spaces and vessels
+(_lymphangiectasis_); and in lymphangiomas, of which the best-known
+example is the cystic hygroma or hydrocele of the neck.
+
+
+GANGLION
+
+This term is applied to a cyst filled with a clear colourless jelly or
+colloid material, met with in the vicinity of a joint or tendon sheath.
+
+The commonest variety--the _carpal ganglion_--popularly known as a
+sprained sinew--is met with as a smooth, rounded, or oval swelling on
+the dorsal aspect of the carpus, usually towards its radial side (Fig. 60).
+It is situated over one of the intercarpal or other joints in this
+region, and may be connected with one or other of the extensor tendons.
+The skin and fascia are movable over the cyst. The cyst varies in size
+from a pea to a pigeon's egg, and usually attains its maximum size
+within a few months and then remains stationary. It becomes tense and
+prominent when the hand is flexed towards the palm. Its appearance is
+usually ascribed to some strain of the wrist--for example, in girls
+learning gymnastics. It may cause no symptoms or it may interfere with
+the use of the hand, especially in grasping movements and when the hand
+is dorsiflexed. In girls it may give rise to pain which shoots up the
+arm. Ganglia are also met with on the dorsum of the metacarpus and on
+the palmar aspect of the wrist.
+
+[Illustration: FIG. 60.--Carpal Ganglion in a woman aet. 25.]
+
+The _tarsal ganglion_ is situated on the dorsum of the foot over one or
+other of the intertarsal joints. It is usually smaller, flatter, and
+more tense than that met with over the wrist, so that it is sometimes
+mistaken for a bony tumour. It rarely causes symptoms, unless so
+situated as to be pressed upon by the boot.
+
+_Ganglia in the region of the knee_ are usually situated over the
+interval between the femur and tibia, most often on the lateral aspect
+of the joint in front of the tendon of the biceps (Fig. 61). The
+swelling, which may attain the size of half a walnut, is tense and hard
+when the knee is extended, and becomes softer and more prominent when it
+is flexed. They are met with in young adults who follow laborious
+occupations or who indulge in athletics, and they cause stiffness,
+discomfort, and impairment of the use of the limb. A ganglion is
+sometimes met with on the median aspect of the head of the metatarsal
+bone of the great toe and may be the cause of considerable suffering; it
+is indistinguishable from the thickened and enlarged bursa so commonly
+present in this situation in the condition known as bunion.
+
+[Illustration: FIG. 61.--Ganglion on lateral aspect of Knee in a young
+woman.]
+
+Ganglionic cysts are met with in other situations than those mentioned,
+but they are so rare as not to require separate description.
+
+Ganglia are to be diagnosed by their situation and physical characters;
+enlarged bursae, synovial cysts, and new-growths are the swellings most
+likely to be mistaken for them. The diagnosis is sometimes only cleared
+up by withdrawing the clear, jelly-like contents through a hollow
+needle.
+
+_Pathological Anatomy._--The wall of the cyst is composed of fibrous
+tissue closely adherent to or fused with the surrounding tissues, so
+that it cannot be shelled out. There is no endothelial lining, and the
+fibrous tissue of the wall is in immediate contact with the colloid
+material in the interior, which appears to be derived by a process of
+degeneration from the surrounding connective tissue. In the region of
+the knee the ganglion is usually multilocular, and consists of a
+meshwork of fibrous tissue, the meshes of which are occupied by colloid
+material.
+
+It is often stated that a ganglion originates from a hernial protrusion
+of the synovial membrane of a joint or tendon sheath. We have not been
+able to demonstrate any communication between the cavity of the cyst
+and that of an adjacent tendon sheath or joint. It is possible, however,
+that the cyst may originate from a minute portion of synovial membrane
+being protruded and strangulated so that it becomes disconnected from
+that to which it originally belonged; it may then degenerate and give
+rise to colloid material, which accumulates and forms a cyst. Ledderhose
+and others regard ganglia as entirely new formations in the
+peri-articular tissues, resulting from colloid degeneration of the
+fibrous tissue of the capsular ligament, occurring at first in numerous
+small areas which later coalesce. Ganglia are probably, therefore, of
+the nature of degeneration cysts arising in the capsule of joints, in
+tendons, and in their sheaths.
+
+_Treatment._--A ganglion can usually be got rid of by a modification of
+the old-fashioned seton. The skin and cyst wall are transfixed by a
+stout needle carrying a double thread of silkworm gut; some of the
+colourless jelly escapes from the punctures; the ends of the thread are
+tied and cut short, and a dressing is applied. A week later the threads
+are removed and the minute punctures are sealed with collodion. The
+action of the threads is to convert the cyst wall into granulation
+tissue, which undergoes the usual conversion into scar tissue. If the
+cyst re-forms, it should be removed by open dissection under local
+anaesthesia. Puncture with a tenotomy knife and scraping the interior,
+and the injection of irritants, are alternative, but less satisfactory,
+methods of treatment.
+
+_Ganglia_ in the substance of _tendons_ are rare. The diagnosis rests on
+the observation that the small tumour is cystic, and that it follows the
+movements of the tendon. The cyst is at first multiple, but the
+partitions disappear, and the spaces are thrown into one. The tendon is
+so weakened that it readily ruptures. The best treatment is to resect
+the affected segment of tendon.
+
+The so-called "compound palmar ganglion" is a tuberculous disease of the
+tendon sheaths, and is described with diseases of tendon sheaths.
+
+
+
+
+CHAPTER XI
+
+INJURIES
+
+
+CONTUSIONS--WOUNDS: _Varieties_--WOUNDS BY FIREARMS AND
+    EXPLOSIVES: _Pistol-shot wounds_; _Wounds by sporting guns_;
+    _Wounds by rifle bullets_; _Wounds received in warfare_; _Shell
+    wounds_. _Embedded foreign bodies_--BURNS AND
+    SCALDS--INJURIES PRODUCED BY ELECTRICITY: _X-ray and
+    radium_; _Electrical burns_; _Lightning stroke_.
+
+
+CONTUSIONS
+
+A contusion or bruise is a laceration of the subcutaneous soft tissues,
+without solution of continuity of the skin. When the integument gives
+way at the same time, a _contused-wound_ results. Bruising occurs when
+force is applied to a part by means of a blunt object, whether as a
+direct blow, a crush, or a grazing form of violence. If the force acts
+at right angles to the part, it tends to produce localised lesions which
+extend deeply; while, if it acts obliquely, it gives rise to lesions
+which are more diffuse, but comparatively superficial. It is well to
+remember that those who suffer from scurvy, or haemophilia (bleeders),
+and fat and anaemic females, are liable to be bruised by comparatively
+trivial injuries.
+
+_Clinical Features._--The less severe forms of contusion are associated
+with _ecchymosis_, numerous minute and discrete punctate haemorrhages
+being scattered through the superficial layers of the skin, which is
+slightly oedematous. The effused blood is soon reabsorbed.
+
+The more severe forms are attended with _extravasation_, the
+extravasated blood being widely diffused through the cellular tissue of
+the part, especially where this is loose and lax, as in the region of
+the orbit, the scrotum and perineum, and on the chest wall. A blue or
+bluish-black discoloration occurs in patches, varying in size and depth
+with the degree of force which produced the injury, and in shape with
+the instrument employed. It is most intense in regions where the skin is
+naturally thin and pigmented. In parts where the extravasated blood is
+only separated from the oxygen of the air by a thin layer of epidermis
+or by a mucous membrane, it retains its bright arterial colour. These
+points are often well illustrated in cases of black eye, where the blood
+effused under the conjunctiva is bright red, while that in the eyelids
+is almost black. In severe contusions associated with great tension of
+the skin--for example, over the front of the tibia or around the
+ankle--blisters often form on the surface and constitute a possible
+avenue of infection. When deeply situated, the blood tends to spread
+along the lines of least resistance, partly under the influence of
+gravity, passing under fasciae, between muscles, along the sheaths of
+vessels, or in connective-tissue spaces, so that it may only reach the
+surface after some time, and at a considerable distance from the seat of
+injury. This fact is sometimes of importance in diagnosis, as, for
+example, in certain fractures of the base of the skull, where
+discoloration appears under the conjunctiva or behind the mastoid
+process some days after the accident.
+
+Blood extravasated deeply in the tissues gives rise to a firm,
+resistant, doughy swelling, in which there may be elicited on deep
+palpation a peculiar sensation, not unlike the crepitus of fracture.
+
+It frequently happens that, from the tearing of lymph vessels, serous
+fluid is extravasated, and a _lymphatic_ or _serous cyst_ may form.
+
+In all contusions accompanied by extravasation, there is marked swelling
+of the area involved, as well as pain and tenderness. The temperature
+may rise to 101 F., or, in the large extravasations that occur in
+bleeders, even higher--a form of aseptic fever. The degree of shock is
+variable, but sudden syncope frequently results from severe bruises of
+the testicle, abdomen, or head, and occasionally marked nervous
+depression follows these injuries.
+
+Contusion of muscles or nerves may produce partial atrophy and paresis,
+as is often seen after injuries in the region of the shoulder.
+
+In alcoholic or other debilitated patients, suppuration is liable to
+ensue in bruised parts, infection taking place from cocci circulating in
+the blood, or through the overlying skin.
+
+_Terminations of Contusions._--The usual termination is a complete
+return to the normal, some of the extravasated blood being organised,
+but most of it being reabsorbed. During the process characteristic
+alterations in the colour of the effused blood take place as a result of
+changes in the blood pigment. In from twenty-four to forty-eight hours
+the margins of the blue area become of a violet hue, and as time goes on
+the discoloured area increases in size, and becomes successively green,
+yellow, and lemon-coloured at its margins, the central part being the
+last to change. The rate at which this play of colours proceeds is so
+variable, and depends on so many circumstances, that no time-limits can
+be laid down. During the disintegration of the effused blood the
+adjacent lymph glands may become enlarged, and on dissection may be
+found to be pigmented. Sometimes the blood persists as a collection of
+fluid with a newly formed connective-tissue capsule, constituting a
+_haematoma_ or _blood cyst_, more often met with in the scalp than in
+other parts.
+
+The impairment of the blood supply of the skin may lead to the formation
+of _blisters_, or to _necrosis_. Death of skin is more liable to occur
+in bleeders, and when the slough separates the blood-clot is exposed and
+the reparative changes go on extremely slowly. _Suppuration_ may occur
+and lead to the formation of an abscess as a result of direct infection
+from the skin or through the circulation.
+
+_Treatment._--If the patient is seen immediately after the accident,
+elevation of the part, and firm pressure applied by means of a thick pad
+of cotton wool and an elastic bandage, are useful in preventing effusion
+of blood. Ice-bags and evaporating lotions are to be used with caution,
+as they are liable to lower the vitality of the damaged tissues and lead
+to necrosis of the skin.
+
+When extravasation has already taken place, massage is the most speedy
+and efficacious means of dispersing the effused blood. The part should
+be massaged several times a day, unless the presence of blebs or
+abrasions of the skin prevents this being done. When this is the case,
+the use of antiseptic dressings is called for to prevent infection and
+to promote healing, after which massage is employed.
+
+When the tension caused by the extravasated blood threatens the vitality
+of the skin, incisions may be made, if asepsis can be assured. The blood
+from a haematoma may be withdrawn by an exploring needle, and the
+puncture sealed with collodion. Infective complications must be looked
+for and dealt with on general principles.
+
+
+WOUNDS
+
+A wound is a solution in the continuity of the skin or mucous membrane
+and of the underlying tissues, caused by violence.
+
+Three varieties of wounds are described: incised, punctured, and
+contused and lacerated.
+
+#Incised Wounds.#--Typical examples of incised wounds are those made by
+the surgeon in the course of an operation, wounds accidentally inflicted
+by cutting instruments, and suicidal cut-throat wounds. It should be
+borne in mind in connection with medico-legal inquiries, that wounds of
+soft parts that closely overlie a bone, such as the skull, the tibia, or
+the patella, although, inflicted by a blunt instrument, may have all the
+appearances of incised wounds.
+
+_Clinical Features._--One of the characteristic features of an incised
+wound is its tendency to gape. This is evident in long skin wounds, and
+especially when the cut runs across the part, or when it extends deeply
+enough to divide muscular fibres at right angles to their long axis. The
+gaping of a wound, further, is more marked when the underlying tissues
+are in a state of tension--as, for example, in inflamed parts. Incised
+wounds in the palm of the hand, the sole of the foot, or the scalp,
+however, have little tendency to gape, because of the close attachment
+of the skin to the underlying fascia.
+
+Incised wounds, especially in inflamed tissues, tend to bleed profusely;
+and when a vessel is only partly divided and is therefore unable to
+contract, it continues to bleed longer than when completely cut across.
+
+The _special risks_ of incised wounds are: (1) division of large blood
+vessels, leading to profuse haemorrhage; (2) division of nerve-trunks,
+resulting in motor and sensory disturbances; and (3) division of tendons
+or muscles, interfering with movement.
+
+_Treatment._--If haemorrhage is still going on, it must be arrested by
+pressure, torsion, or ligature, as the accumulation of blood in a wound
+interferes with union. If necessary, the wound should be purified by
+washing with saline solution or eusol, and the surrounding skin painted
+with iodine, after which the edges are approximated by sutures. The raw
+surfaces must be brought into accurate apposition, care being taken that
+no inversion of the cutaneous surface takes place. In extensive and deep
+wounds, to ensure more complete closure and to prevent subsequent
+stretching of the scar, it is advisable to unite the different
+structures--muscles, fasciae, and subcutaneous tissue--by separate series
+of _buried sutures_ of catgut or other absorbable material. For the
+approximation of the skin edges, stitches of horse-hair, fishing-gut, or
+fine silk are the most appropriate. These _stitches of coaptation_ may
+be interrupted or continuous. In small superficial wounds on exposed
+parts, stitch marks may be avoided by approximating the edges with
+strips of gauze fixed in position by collodion, or by subcutaneous
+sutures of fine catgut. Where the skin is loose, as, for example, in the
+neck, on the limbs, or in the scrotum, the use of Michel's clips is
+advantageous in so far as these bring the deep surfaces of the skin into
+accurate apposition, are introduced with comparatively little pain, and
+leave only a slight mark if removed within forty-eight hours.
+
+When there is any difficulty in bringing the edges of the wound into
+apposition, a few interrupted _relaxation stitches_ may be introduced
+wide of the margins, to take the strain off the coaptation stitches.
+Stout silk, fishing-gut, or silver wire may be employed for this
+purpose. When the tension is extreme, Lister's button suture may be
+employed. The tension is relieved and death of skin prevented by scoring
+it freely with a sharp knife. Relaxation stitches should be removed in
+four or five days, and stitches of coaptation in from seven to ten days.
+On the face and neck, wounds heal rapidly, and stitches may be removed
+in two or three days, thus diminishing the marks they leave.
+
+_Drainage._--In wounds in which no cavity has been left, and in which
+there is no reason to suspect infection, drainage is unnecessary. When,
+however, the deeper parts of an extensive wound cannot be brought into
+accurate apposition, and especially when there is any prospect of oozing
+of blood or serum--as in amputation stumps or after excision of the
+breast--drainage is indicated. It is a wise precaution also to insert
+drainage tubes into wounds in fat patients when there is the slightest
+reason to suspect the presence of infection. Glass or rubber tubes are
+the best drains; but where it is desirable to leave little mark, a few
+strands of horse-hair, or a small roll of rubber, form a satisfactory
+substitute. Except when infection occurs, the drain is removed in from
+one to four days and the opening closed with a Michel's clip or a
+suture.
+
+#Punctured Wounds.#--Punctured wounds are produced by narrow, pointed
+instruments, and the sharper and smoother the instrument the more does
+the resulting injury resemble an incised wound; while from more rounded
+and rougher instruments the edges of the wound are more or less contused
+or lacerated. The depth of punctured wounds greatly exceeds their width,
+and the damage to subcutaneous parts is usually greater than that to the
+skin. When the instrument transfixes a part, the edges of the wound of
+entrance may be inverted, and those of the exit wound everted. If the
+instrument is a rough one, these conditions may be reversed by its
+sudden withdrawal.
+
+Punctured wounds neither gape nor bleed much. Even when a large vessel
+is implicated, the bleeding usually takes place into the tissues rather
+than externally.
+
+The _risks_ incident to this class of wounds are: (1) the extreme
+difficulty, especially when a dense fascia has been perforated, of
+rendering them aseptic, on account of the uncertainty as to their depth,
+and of the way in which the surface wound closes on the withdrawal of
+the instrument; (2) different forms of aneurysm may result from the
+puncture of a large vessel; (3) perforation of a joint, or of a serous
+cavity, such as the abdomen, thorax, or skull, materially adds to the
+danger.
+
+_Treatment._--The first indication is to purify the whole extent of the
+wound, and to remove any foreign body or blood-clot that may be in it.
+It is usually necessary to enlarge the wound, freely dividing injured
+fasciae, paring away bruised tissues, and purifying the whole
+wound-surface. Any blood vessel that is punctured should be cut across
+and tied; and divided muscles, tendons, or nerves must be sutured. After
+haemorrhage has been arrested, iodoform and bismuth paste is rubbed into
+the raw surface, and the wound closed. If there is any reason to doubt
+the asepticity of the wound, it is better treated by the open method,
+and a Bier's bandage should be applied.
+
+#Contused and Lacerated Wounds.#--These may be considered together, as
+they so occur in practice. They are produced by crushing, biting, or
+tearing forms of violence--such as result from machinery accidents,
+firearms, or the bites of animals. In addition to the irregular wound of
+the integument, there is always more or less bruising of the parts
+beneath and around, and the subcutaneous lesions are much wider than
+appears on the surface.
+
+Wounds of this variety usually gape considerably, especially when there
+is much laceration of the skin. It is not uncommon to have considerable
+portions of skin, muscle, or tendon completely torn away.
+
+Haemorrhage is seldom a prominent feature, as the crushing or tearing of
+the vessel wall leads to the obliteration of the lumen.
+
+The _special risks_ of these wounds are: (1) Sloughing of the bruised
+tissues, especially when attempts to sterilise the wound have not been
+successful. (2) Reactionary haemorrhage after the initial shock has
+passed off. (3) Secondary haemorrhage as a result of infective processes
+ensuing in the wound. (4) Loss of muscle or tendon, interfering with
+motion. (5) Cicatricial contraction. (6) Gangrene, which may follow
+occlusion of main vessels, or virulent infective processes. (7) It is
+not uncommon to have particles of carbon embedded in the tissues after
+lacerated wounds, leaving unsightly, pigmented scars. This is often seen
+in coal-miners, and in those injured by firearms, and is to be prevented
+by removing all gross dirt from the edges of the wound.
+
+_Treatment._--In severe wounds of this class implicating the
+extremities, the most important question that arises is whether or not
+the limb can be saved. In examining the limb, attention should first be
+directed to the state of the main blood vessels, in order to determine
+if the vascular supply of the part beyond the lesion is sufficient to
+maintain its vitality. Amputation is usually called for if there is
+complete absence of pulsation in the distal arteries and if the part
+beyond is cold. If at the same time important nerve-trunks are
+lacerated, so that the function of the limb would be seriously impaired,
+it is not worth running the risk of attempting to save it. If, in
+addition, there is extensive destruction of large muscular masses or of
+important tendons, or comminution of the bones, amputation is usually
+imperative. Stripping of large areas of skin is not in itself a reason
+for removing a limb, as much can be done by skin grafting, but when it
+is associated with other lesions it favours amputation. In considering
+these points, it must be borne in mind that the damage to the deeper
+tissues is always more extensive than appears on the surface, and that
+in many cases it is only possible to estimate the real extent of the
+injury by administering an anaesthetic and exploring the wound. In
+doubtful cases the possibility of rendering the parts aseptic will often
+decide the question for or against amputation. If thorough purification
+is accomplished, the success which attends conservative measures is
+often remarkable. It is permissible to run an amount of risk to save an
+upper extremity which would be unjustifiable in the case of a lower
+limb. The age and occupation of the patient must also be taken into
+account.
+
+It having been decided to try and save the limb, the question is only
+settled for the moment; it may have to be reconsidered from day to day,
+or even from hour to hour, according to the progress of the case.
+
+When it is decided to make the attempt to save the limb, the wound must
+be thoroughly purified. All bruised tissue in which gross dirt has
+become engrained should be cut away with knife or scissors. The raw
+surface is then cleansed with eusol, washed with sterilised salt
+solution followed by methylated spirit, and rubbed all over with "bipp"
+paste. If the purification is considered satisfactory the wound may be
+closed, otherwise it is left open, freely drained or packed with gauze,
+and the limb is immobilised by suitable splints.
+
+
+WOUNDS BY FIREARMS AND EXPLOSIVES
+
+It is not necessary here to do more than indicate the general characters
+of wounds produced by modern weapons. For further details the reader is
+referred to works on military surgery. Experience has shown that the
+nature and severity of the injuries sustained in warfare vary widely in
+different campaigns, and even in different fields of the same campaign.
+Slight variations in the size, shape, and weight of rifle bullets, for
+example, may profoundly modify the lesions they produce: witness the
+destructive effect of the pointed bullet compared with that of the
+conical form previously used. The conditions under which the fighting is
+carried on also influence the wounds. Those sustained in the open,
+long-range fighting of the South African campaign of 1899-1902 were very
+different from those met with in the entrenched warfare in France in
+1914-1918. It has been found also that the infective complications are
+greatly influenced by the terrain in which the fighting takes place. In
+the dry, sandy, uncultivated veldt of South Africa, bullet wounds seldom
+became infected, while those sustained in the highly manured fields of
+Belgium were almost invariably contaminated with putrefactive organisms,
+and gaseous gangrene and tetanus were common complications. It has been
+found also that wounds inflicted in naval engagements present different
+characters from those sustained on land. Many other factors, such as the
+physical and mental condition of the men, the facilities for affording
+first aid, and the transport arrangements, also play a part in
+determining the nature and condition of the wounds that have to be dealt
+with by military surgeons.
+
+Whatever the nature of the weapon concerned, the wound is of the
+_punctured, contused, and lacerated_ variety. Its severity depends on
+the size, shape, and velocity of the missile, the range at which the
+weapon is discharged, and the part of the body struck.
+
+Shock is a prominent feature, but its degree, as well as the time of its
+onset, varies with the extent and seat of the injury, and with the
+mental state of the patient when wounded. We have observed pronounced
+shock in children after being shot even when no serious injury was
+sustained. At the moment of injury the patient experiences a sensation
+which is variously described as being like the lash of a whip, a blow
+with a stick, or an electric shock. There is not much pain at first, but
+later it may become severe, and is usually associated with intense
+thirst, especially when much blood has been lost.
+
+In all forms of wounds sustained in warfare, septic infection
+constitutes the main risk, particularly that resulting from
+streptococci. The presence of anaerobic organisms introduces the
+additional danger of gaseous forms of gangrene.
+
+The earlier the wound is disinfected the greater is the possibility of
+diminishing this risk. If cleansing is carried out within the first six
+hours the chance of eliminating sepsis is good; with every succeeding
+six hours it diminishes, until after twenty-four hours it is seldom
+possible to do more than mitigate sepsis. (J. T. Morrison.)
+
+The presence of a metallic foreign body having been determined and its
+position localised by means of the X-rays, all devitalised and
+contaminated tissue is excised, the foreign material, _e.g._, a missile,
+fragments of clothing, gravel and blood-clot, removed, the wound
+purified with antiseptics and closed or drained according to
+circumstances.
+
+#Pistol-shot Wounds.#--Wounds inflicted by pistols, revolvers, and small
+air-guns are of frequent occurrence in civil practice, the weapon being
+discharged usually by accident, but frequently with suicidal, and
+sometimes with homicidal intent.
+
+With all calibres and at all ranges, except actual contact, the wound of
+entrance is smaller than the bullet. If the weapon is discharged within
+a foot of the body, the skin surrounding the wound is usually stained
+with powder and burned, and the hair singed. At ranges varying from six
+inches to thirty feet, grains of powder may be found embedded in the
+skin or lying loose on the surface, the greater the range the wider
+being the area of spread. When black powder is used, the embedded grains
+usually leave a permanent bluish-black tattooing of the skin. When the
+weapon is placed in contact with the skin, the subcutaneous tissues are
+lacerated over an area of two or three inches around the opening made by
+the bullet and smoke and powder-staining and scorching are more marked
+than at longer ranges.
+
+When the bullet perforates, the exit wound is usually larger and more
+extensively lacerated than the wound of entrance. Its margins are as a
+rule everted, and it shows no marks of flame, smoke, or powder. These
+features are common to all perforations caused by bullets.
+
+Pistol wounds only produce dangerous effects when fired at close range,
+and when the cavities of the skull, the thorax, or the abdomen are
+implicated. In the abdomen a lethal injury may readily be caused even by
+pistols of the "toy" order. These injuries will be described with
+regional surgery.
+
+Pistol-shot wounds of _joints_ and _soft parts_ are seldom of serious
+import apart from the risk of haemorrhage and of infection.
+
+_Treatment._--The treatment of wounds of the soft parts consists in
+purifying the wounds of entrance and exit and the surrounding skin, and
+in providing for drainage if this is indicated.
+
+There being no urgency for the removal of the bullet, time should be
+taken to have it localised by the X-rays, preferably by stereoscopic
+plates. In some cases it is not necessary to remove the bullet.
+
+#Wounds by Sporting Guns.#--In the common sporting or scatter gun, with
+which accidents so commonly occur during the shooting season, the charge
+of small shot or pellets leave the muzzle of the gun as a solid mass
+which makes a single ragged wound having much the appearance of that
+caused by a single bullet. At a distance of from four to five feet from
+the muzzle the pellets begin to disperse so that there are separate
+punctures around the main central wound. As the range increases, these
+outlying punctures make a wider and wider pattern, until at a distance
+of from eighteen to twenty feet from the muzzle, the scattering is
+complete, there is no longer any central wound, and each individual
+pellet makes its own puncture. From these elementary data, it is usually
+possible, from the features of the wound, to arrive at an approximately
+accurate conclusion regarding the range at which the gun was discharged,
+and this may have an important bearing on the question of accident,
+suicide, or murder.
+
+As regards the effects on the tissues at close range, that is, within a
+few feet, there is widespread laceration and disruption; if a bone is
+struck it is shattered, and portions of bone may be displaced or even
+driven out through the exit wound.
+
+When the charge impinges over one of the large cavities of the body, the
+shot may scatter widely through the contained viscera, and there is
+often no exit wound. In the thorax, for example, if a rib is struck, the
+charge and possibly fragments of bone, will penetrate the pleura, and be
+dispersed throughout the lung; in the head, the skull may be shattered
+and the brain torn up; and in the abdomen, the hollow viscera may be
+perforated in many places and the solid organs lacerated.
+
+On covered parts the clothing, by deflecting the shot, influences the
+size and shape of the wound; the entrance wound is increased in size and
+more ragged, and portions of the clothes may be driven into the tissues.
+
+[Illustration: FIG. 62.--Radiogram showing Pellets embedded in Arm.
+
+(Mr. J. W. Dowden's case.)]
+
+A charge of small shot is much more destructive to blood vessels,
+tendons, and ligaments than a single bullet, which in many cases pushes
+such structures aside without dividing them. In the abdomen and chest,
+also, the damage done by a full charge of shot is much more extensive
+than that inflicted by a single bullet, the deflection of the pellets
+leading to a greater number of perforations of the intestine and more
+widespread laceration of solid viscera.
+
+When the charge impinges on one of the extremities at close range, we
+often have the opportunity of observing that the exit wound is larger,
+more ragged than that of entrance, and that its edges are everted; the
+extensive tearing and bruising of all the tissues, including the bones,
+and the marked tendency to early and progressive septic infection,
+render amputation compulsory in the majority of such cases.
+
+At a range of from twenty to thirty feet, although the scatter is
+complete, the pellets are still close together, so that if they
+encounter the shaft of a long bone, even the femur, they fracture the
+bone across, often along with some longitudinal splintering.
+
+Individual pellets striking the shafts of long bones become flattened or
+distorted, and when cancellated bone is struck they become embedded in
+it (Fig. 62).
+
+The skin, when it is closely peppered with shot, is liable to lose its
+vitality, and with the addition of a little sepsis, readily necroses and
+comes away as a slough.
+
+When the shot have diverged so as to strike singly, they seldom do much
+harm, but fatal damage may be done to the brain or to the aorta, or the
+eye may be seriously injured by a single pellet.
+
+Small shot fired at longer ranges--over about a hundred and fifty
+feet--usually go through the skin, but seldom pierce the fascia, and lie
+embedded in the subcutaneous tissue, from which they can readily be
+extracted.
+
+The wad of the cartridge behaves erratically: so long as it remains flat
+it goes off with the rest of the charge, and is often buried in the
+wound; but if it curls up or turns on its side, it is usually deflected
+and flies clear of the shot. It may make a separate wound.
+
+Wounds from sporting guns are to be _treated_ on the usual lines, the
+early efforts being directed to the alleviation of shock and the
+prevention of septic infection. There is rarely any urgency in the
+removal of pellets from the tissues.
+
+#Wounds by Rifle Bullets.#--The vast majority of wounds inflicted by
+rifle bullets are met with in the field during active warfare, and fall
+to be treated by military surgeons. They occasionally occur
+accidentally, however, during range practice for example, and may then
+come under the notice of the civil surgeon.
+
+It is only necessary here to consider the effects of modern small-bore
+rifle or machine-gun bullets.
+
+The trajectory is practically flat up to 675 yards. In destructive
+effect there is not much difference between the various high velocity
+bullets used in different armies; they will kill up to a distance of two
+miles. The hard covering is employed to enable the bullet to take the
+grooves in the rifle, and to prevent it stripping as it passes through
+the barrel. It also increases the penetrating power of the missile, but
+diminishes its "stopping" power, unless a vital part or a long bone is
+struck. By removing the covering from the point of the bullet, as is
+done in the Dum-Dum bullet, or by splitting the end, the bullet is made
+to expand or "mushroom" when it strikes the body, and its stopping power
+is thereby greatly increased, the resulting wound being much more
+severe. These "soft-nosed" expanding bullets are to be distinguished
+from "explosive" bullets which contain substances which detonate on
+impact. High velocity bullets are unlikely to lodge in the body unless
+spent, or pulled up by a sandbag, or metal buckle on a belt, or a book
+in the pocket, or the core and the case separating--"stripping" of the
+bullet. Spent shot may merely cause bruising of the surface, or they may
+pass through the skin and lodge in the subcutaneous tissue, or may even
+damage some deeper structure such as a nerve trunk.
+
+A blank cartridge fired at close range may cause a severe wound, and, if
+charged with black powder, may leave a permanent bluish-black
+pigmentation of the skin.
+
+The lesions of individual tissues--bones, nerves, blood vessels--are
+considered with these.
+
+#Treatment of Gunshot Wounds under War Conditions.#--It is only
+necessary to indicate briefly the method of dealing with gunshot wounds
+in warfare as practised in the European War.
+
+1. _On the Field._--Haemorrhage is arrested in the limbs by an improvised
+tourniquet; in the head by a pad and bandage; in the thorax or abdomen
+by packing if necessary, but this should be avoided if possible, as it
+favours septic infection. If a limb is all but detached it should be
+completely severed. A full dose of morphin is given hypodermically. The
+ampoule of iodine carried by the wounded man is broken, and its contents
+are poured over and around the wound, after which the field dressing is
+applied. In extensive wounds, the "shell-dressing" carried by the
+stretcher bearers is preferred. All bandages are applied loosely to
+allow for subsequent swelling. The fragments of fractured bones are
+immobilised by some form of emergency splint.
+
+2. _At the Advanced Dressing Station_, after the patient has had a
+liberal allowance of warm fluid nourishment, such as soup or tea, a full
+dose of anti-tetanic serum is injected. The tourniquet is removed and
+the wound inspected. Urgent amputations are performed. Moribund patients
+are detained lest they die _en route_.
+
+3. _In the Field Ambulance or Casualty Clearing Station_ further
+measures are employed for the relief of shock, and urgent operations are
+performed, such as amputation for gangrene, tracheotomy for dyspnoea, or
+laparotomy for perforated or lacerated intestine. In the majority of
+cases the main object is to guard against infection; the skin is
+disinfected over a wide area and surrounded with towels; damaged tissue,
+especially muscle, is removed with the knife or scissors, and foreign
+bodies are extracted. Torn blood vessels, and, if possible, nerves and
+tendons are repaired. The wound is then partly closed, provision being
+made for free drainage, or some special method of irrigation, such as
+that of Carrel, is adopted. Sometimes the wound is treated with bismuth,
+iodoform, and paraffin paste (B.I.P.P.) and sutured.
+
+4. _In the Base Hospital or Hospital Ship_ various measures may be
+called for according to the progress of the wound and the condition of
+the patient.
+
+#Shell Wounds and Wounds produced by Explosions.#--It is convenient to
+consider together the effects of the bursting of shells fired from heavy
+ordnance and those resulting in the course of blasting operations from
+the discharge of dynamite or other explosives, or from the bursting of
+steam boilers or pipes, the breaking of machinery, and similar accidents
+met with in civil practice.
+
+Wounds inflicted by shell fragments and shrapnel bullets tend to be
+extensive in area, and show great contusion, laceration, and destruction
+of the tissues. The missiles frequently lodge and carry portions of the
+clothing and, it may be, articles from the man's pocket, with them.
+Shell wounds are attended with a considerable degree of shock. On
+account of the wide area of contusion which surrounds the actual wound
+produced by shell fragments, amputation, when called for, should be
+performed some distance above the torn tissues, as there is considerable
+risk of sloughing of the flaps.
+
+Wounds produced by dynamite explosions and the bursting of boilers have
+the same general characters as shell wounds. Fragments of stone, coal,
+or metal may lodge in the tissues, and favour the occurrence of
+infective complications.
+
+All such injuries are to be treated on the general principles governing
+contused and lacerated wounds.
+
+
+EMBEDDED FOREIGN BODIES
+
+In the course of many operations foreign substances are introduced into
+the tissues and intentionally left there, for example, suture and
+ligature materials, steel or aluminium plates, silver wire or ivory pegs
+used to secure the fixation of bones, or solid paraffin employed to
+correct deformities. Other substances, such as gauze, drainage tubes,
+or metal instruments, may be unintentionally left in a wound.
+
+Foreign bodies may also lodge in accidentally inflicted wounds, for
+example, bullets, needles, splinters of wood, or fragments of clothing.
+The needles of hypodermic syringes sometimes break and a portion remains
+embedded in the tissues. As a result of explosions, particles of carbon,
+in the form of coal-dust or gunpowder, or portions of shale, may lodge
+in a wound.
+
+The embedded foreign body at first acts as an irritant, and induces a
+reaction in the tissues in which it lodges, in the form of hyperaemia,
+local leucocytosis, proliferation of fibroblasts, and the formation of
+granulation tissue. The subsequent changes depend upon whether or not
+the wound is infected with pyogenic bacteria. If it is so infected,
+suppuration ensues, a sinus forms, and persists until the foreign body
+is either cast out or removed.
+
+If the wound is aseptic, the fate of the foreign body varies with its
+character. A substance that is absorbable, such as catgut or fine silk,
+is surrounded and permeated by the phagocytes, which soften and
+disintegrate it, the debris being gradually absorbed in much the same
+manner as a fibrinous exudate. Minute bodies that are not capable of
+being absorbed, such as particles of carbon, or of pigment used in
+tattooing, are taken up by the phagocytes, and in course of time
+removed. Larger bodies, such as needles or bullets, which are not
+capable of being destroyed by the phagocytes, become encapsulated. In
+the granulation tissue by which they are surrounded large multinuclear
+giant-cells appear ("_foreign-body giant-cells_") and attach themselves
+to the foreign body, the fibroblasts proliferate and a capsule of scar
+tissue is eventually formed around the body. The tissues of the capsule
+may show evidence of iron pigmentation. Sometimes fluid accumulates
+around a foreign body within its capsule, constituting a cyst.
+
+Substances like paraffin, strands of silk used to bridge a gap in a
+tendon, or portions of calcined bone, instead of being encapsulated, are
+gradually permeated and eventually replaced by new connective tissue.
+
+Embedded bodies may remain in the tissues for an indefinite period
+without giving rise to inconvenience. At any time, however, they may
+cause trouble, either as a result of infective complications, or by
+inducing the formation of a mass of inflammatory tissue around them,
+which may simulate a gumma, a tuberculous focus, or a sarcoma. This
+latter condition may give rise to difficulties in diagnosis,
+particularly if there is no history forthcoming of the entrance of the
+foreign body. The ignorance of patients regarding the possible lodgment
+in the tissues of a foreign body--even of considerable size--is
+remarkable. In such cases the X-rays will reveal the presence of the
+foreign body if it is sufficiently opaque to cast a shadow. The heavy,
+lead-containing varieties of glass throw very definite shadows little
+inferior in sharpness and definition to those of metal; almost all the
+ordinary forms of commercial glass also may be shown up by the X-rays.
+
+Foreign bodies encapsulated in the peritoneal cavity are specially
+dangerous, as the proximity of the intestine furnishes a constant
+possibility of infection.
+
+The question of removal of the foreign body must be decided according to
+the conditions present in individual cases; in searching for a foreign
+body in the tissues, unless it has been accurately located, a general
+anaesthetic is to be preferred.
+
+
+BURNS AND SCALDS
+
+The distinction between a burn which results from the action of dry heat
+on the tissues of the body and a scald which results from the action of
+moist heat, has no clinical significance.
+
+In young and debilitated subjects hot poultices may produce injuries of
+the nature of burns. In old people with enfeebled circulation mere
+exposure to a strong fire may cause severe degrees of burning, the
+clothes covering the part being uninjured. This may also occur about the
+feet, legs, or knees of persons while intoxicated who have fallen asleep
+before the fire.
+
+The damage done to the tissues by strong caustics, such as fuming nitric
+acid, sulphuric acid, caustic potash, nitrate of silver, or arsenical
+paste, presents pathological and clinical features almost identical with
+those resulting from heat. Electricity and the Rontgen rays also produce
+lesions of the nature of burns.
+
+_Pathology of Burns._--Much discussion has taken place regarding the
+explanation of the rapidly fatal issue in extensive superficial burns.
+On post-mortem examination the lesions found in these cases are: (1)
+general hyperaemia of all the organs of the abdominal, thoracic, and
+cerebro-spinal cavities; (2) marked leucocytosis, with destruction of
+red corpuscles, setting free haemoglobin which lodges in the epithelial
+cells of the tubules of the kidneys; (3) minute thrombi and
+extravasations throughout the tissues of the body; (4) degeneration of
+the ganglion cells of the solar plexus; (5) oedema and degeneration of
+the lymphoid tissue throughout the body; (6) cloudy swelling of the
+liver and kidneys, and softening and enlargement of the spleen. Bardeen
+suggests that these morbid phenomena correspond so closely to those met
+with where the presence of a toxin is known to produce them, that in all
+probability death is similarly due to the action of some poison produced
+by the action of heat on the skin and on the proteins of the blood.
+
+#Clinical Features--Local Phenomena.#--The most generally accepted
+classification of burns is that of Dupuytren, which is based upon the
+depth of the lesion. Six degrees are thus, recognised: (1) hyperaemia or
+erythema; (2) vesication; (3) partial destruction of the true skin; (4)
+total destruction of the true skin; (5) charring of muscles; (6)
+charring of bones.
+
+It must be observed, however, that burns met with at the bedside always
+illustrate more than one of these degrees, the deeper forms always being
+associated with those less deep, and the clinical picture is made up of
+the combined characters of all. A burn is classified in terms of its
+most severe portion. It is also to be remarked that the extent and
+severity of a burn usually prove to be greater than at first sight
+appears.
+
+_Burns of the first degree_ are associated with erythema of the skin,
+due to hyperaemia of its blood vessels, and result from scorching by
+flame, from contact with solids or fluids below 212 F., or from
+exposure to the sun's rays. They are characterised clinically by acute
+pain, redness, transitory swelling from oedema, and subsequent
+desquamation of the surface layers of the epidermis. A special form of
+pigmentation of the skin is seen on the front of the legs of women from
+exposure to the heat of the fire.
+
+_Burns of Second Degree--Vesication of the Skin._--These are
+characterised by the occurrence of vesicles or blisters which are
+scattered over the hyperaemic area, and contain a clear yellowish or
+brownish fluid. On removing the raised epidermis, the congested and
+highly sensitive papillae of the skin are exposed. Unna has found that
+pyogenic bacteria are invariably present in these blisters. Burns of the
+second degree leave no scar but frequently a persistent discoloration.
+In rare instances the burned area becomes the seat of a peculiar
+overgrowth of fibrous tissue of the nature of keloid (p 401).
+
+_Burns of Third Degree--Partial Destruction of the Skin._--The epidermis
+and papillae are destroyed in patches, leaving hard, dry, and insensitive
+sloughs of a yellow or black colour. The pain in these burns is
+intense, but passes off during the first or second day, to return again,
+however, when, about the end of a week, the sloughs separate and expose
+the nerve filaments of the underlying skin. Granulations spring up to
+fill the gap, and are rapidly covered by epithelium, derived partly from
+the margins and partly from the remains of skin glands which have not
+been completely destroyed. These latter appear on the surface of the
+granulations as small bluish islets which gradually increase in size,
+become of a greyish-white colour, and ultimately blend with one another
+and with the edges. The resulting cicatrix may be slightly depressed,
+but otherwise exhibits little tendency to contract and cause deformity.
+
+_Burns of Fourth Degree--Total Destruction of the Skin._--These follow
+the more prolonged action of any form of intense heat. Large, black, dry
+eschars are formed, surrounded by a zone of intense congestion. Pain is
+less severe, and is referred to the parts that have been burned to a
+less degree. Infection is liable to occur and to lead to wide
+destruction of the surrounding skin. The amount of granulation tissue
+necessary to fill the gap is therefore great; and as the epithelial
+covering can only be derived from the margins--the skin glands being
+completely destroyed--the healing process is slow. The resulting scars
+are irregular, deep and puckered, and show a great tendency to contract.
+Keloid frequently develops in such cicatrices. When situated in the
+region of the face, neck, or flexures of joints, much deformity and
+impairment of function may result (Fig. 63).
+
+[Illustration: FIG. 63.--Cicatricial Contraction following Severe Burn.]
+
+In _burns of the fifth degree_ the lesion extends through the
+subcutaneous tissue and involves the muscles; while in those of the
+_sixth degree_ it passes still more deeply and implicates the bones.
+These burns are comparatively limited in area, as they are usually
+produced by prolonged contact with hot metal or caustics. Burns of the
+fifth and sixth degrees are met with in epileptics or intoxicated
+persons who fall into the fire. Large blood vessels, nerve-trunks,
+joints, or serous cavities may be implicated.
+
+#General Phenomena.#--It is customary to divide the clinical history of
+a severe burn into three periods; but it is to be observed that the
+features characteristic of the periods have been greatly modified since
+burns have been treated on the same lines as other wounds.
+
+_The first period_ lasts for from thirty-six to forty-eight hours,
+during which time the patient remains in a more or less profound state
+of _shock_, and there is a remarkable absence of pain. When shock is
+absent or little marked, however, the amount of suffering may be great.
+When the injury proves fatal during this period, death is due to shock,
+probably aggravated by the absorption of poisonous substances produced
+in the burned tissues. In fatal cases there is often evidence of
+cerebral congestion and oedema.
+
+The _second period_ begins when the shock passes off, and lasts till the
+sloughs separate. The outstanding feature of this period is _toxaemia_,
+manifested by fever, the temperature rising to 102, 103, or 104 F.,
+and congestive or inflammatory conditions of internal organs, giving
+rise to such clinical complications as bronchitis, broncho-pneumonia, or
+pleurisy--especially in burns of the thorax; or meningitis and
+cerebritis, when the neck or head is the seat of the burn. Intestinal
+catarrh associated with diarrhoea is not uncommon; and ulceration of the
+duodenum leading to perforation has been met with in a few cases. These
+phenomena are much more prominent when bacterial infection has taken
+place, and it seems probable that they are to be attributed chiefly to
+the infection, as they have become less frequent and less severe since
+burns have been treated like other breaches of the surface. Albuminuria
+is a fairly constant symptom in severe burns, and is associated with
+congestion of the kidneys. In burns implicating the face, neck, mouth,
+or pharynx, oedema of the glottis is a dangerous complication, entailing
+as it does the risk of suffocation.
+
+The _third period_ begins when the sloughs separate, usually between
+the seventh and fourteenth days, and lasts till the wound heals, its
+duration depending upon the size, depth, and asepticity of the raw area.
+The chief causes of death during this period are toxin absorption in any
+of its forms; waxy disease of the liver, kidneys, or intestine; less
+commonly erysipelas, tetanus, or other diseases due to infection by
+specific organisms. We have seen nothing to substantiate the belief that
+duodenal ulcers are liable to perforate during the third period.
+
+The _prognosis_ in burns depends on (1) the superficial extent, and, to
+a much less degree, the depth of the injury. When more than one-third of
+the entire surface of the body is involved, even in a mild degree, the
+prognosis is grave. (2) The situation of the burn is important. Burns
+over the serous cavities--abdomen, thorax, or skull--are, other things
+being equal, much more dangerous than burns of the limbs. The risk of
+oedema of the glottis in burns about the neck and mouth has already been
+referred to. (3) Children are more liable to succumb to shock during the
+early period, but withstand prolonged suppuration better than adults.
+(4) When the patient survives the shock, the presence or absence of
+infection is the all-important factor in prognosis.
+
+#Treatment.#--The _general treatment_ consists in combating the shock.
+When pain is severe, morphin must be injected.
+
+_Local Treatment._--The local treatment must be carried out on
+antiseptic lines, a general anaesthetic being administered, if necessary,
+to enable the purification to be carried out thoroughly. After carefully
+removing the clothing, the whole of the burned area is gently, but
+thoroughly, cleansed with peroxide of hydrogen or warm boracic lotion,
+followed by sterilised saline solution. As pyogenic bacteria are
+invariably found in the blisters of burns, these must be opened and the
+raised epithelium removed.
+
+The dressings subsequently applied should meet the following
+indications: the relief of pain; the prevention of sepsis; and the
+promotion of cicatrisation.
+
+An application which satisfactorily fulfils these requirements is
+_picric acid_. Pads of lint or gauze are lightly wrung out of a solution
+made up of picric acid, 1.5 drams; absolute alcohol, 3 ounces;
+distilled water, 40 ounces, and applied over the whole of the reddened
+area. These are covered with antiseptic wool, _without_ any waterproof
+covering, and retained in position by a many-tailed bandage. The
+dressing should be changed once or twice a week, under the guidance of
+the temperature chart, any portion of the original dressing which
+remains perfectly dry being left undisturbed. The value of a general
+anaesthetic in dressing extensive burns, especially in children, can
+scarcely be overestimated.
+
+Picric acid yields its best results in superficial burns, and it is
+useful as _a primary dressing_ in all. As soon as the sloughs separate
+and a granulating surface forms, the ordinary treatment for a healing
+sore is instituted. Any slough under which pus has collected should be
+cut away with scissors to permit of free drainage.
+
+An occlusive dressing of melted _paraffin_ has also been employed. A
+useful preparation consists of: Paraffin molle 25 per cent., paraffin
+durum 67 per cent., olive oil 5 per cent., oil of eucalyptus 2 per
+cent., and beta-naphthol 1/4 per cent. It has a melting point of 48 C.
+It is also known as _Ambrine_ and _Burnol_. After the burned area has
+been cleansed and thoroughly dried, it is sponged or painted with the
+melted paraffin, and before solidification takes place a layer of
+sterilised gauze is applied and covered with a second coating of
+paraffin. Further coats of paraffin are applied every other day to
+prevent the gauze sticking to the skin.
+
+An alternative method of treating extensive burns is by immersing the
+part, or even the whole body when the trunk is affected, in a bath of
+boracic lotion kept at the body temperature, the lotion being frequently
+renewed.
+
+If a burn is already infected when first seen, it is to be treated on
+the same principles as govern the treatment of other infected wounds.
+
+All moist or greasy applications, such as Carron oil, carbolic oil and
+ointments, and all substances like collodion and dry powders, which
+retain discharges, entirely fail to meet the indications for the
+rational treatment of burns, and should be abandoned.
+
+Skin-grafting is of great value in hastening healing after extensive
+burns, and in preventing cicatricial contraction. The _deformities_
+which are so liable to develop from contraction of the cicatrices are
+treated on general principles. In the region of the face, neck, and
+flexures of joints (Fig. 63), where they are most marked, the contracted
+bands may be divided and the parts stretched, the raw surface left being
+covered by Thiersch grafts or by flaps of skin raised from adjacent
+surfaces or from other parts of the body (Fig. 1).
+
+
+INJURIES PRODUCED BY ELECTRICITY
+
+#Injuries produced by Exposure to X-Rays and Radium.#--In the routine
+treatment of disease by radiations, injury is sometimes done to the
+tissues, even when the greatest care is exercised as to dosage and
+frequency of application. Robert Knox describes the following
+ill-effects.
+
+_Acute dermatitis_ varying in degree from a slight erythema to deep
+ulceration or even necrosis of skin. When ulcers form they are extremely
+painful and slow to heal. When hair-bearing areas are affected,
+epilation may occur without destroying the hair follicles and the hairs
+are reproduced, but if the reaction is excessive permanent alopecia may
+result.
+
+_Chronic dermatitis_, which results from persistence of the acute form,
+is most intractable and may assume malignant characters. X-ray warts are
+a late manifestation of chronic dermatitis and may become malignant.
+
+Among the _late manifestations_ are neuritis, telangiectasis, and a
+painful and intractable form of ulceration, any of which may come on
+months or even years after the cessation of exposure. _Sterility_ may be
+induced in X-ray workers who are imperfectly protected from the effects
+of the rays.
+
+#Electrical burns# usually occur in those who are engaged in industrial
+undertakings where powerful electrical currents are employed.
+
+The lesions--which vary from a slight superficial scorching to complete
+charring of parts--are most evident at the points of entrance and exit
+of the current, the intervening tissues apparently escaping injury.
+
+The more superficial degrees of electrical burns differ from those
+produced by heat in being almost painless, and in healing very slowly,
+although as a rule they remain dry and aseptic.
+
+The more severe forms are attended with a considerable degree of shock,
+which is not only more profound, but also lasts much longer than the
+shock in an ordinary burn of corresponding severity. The parts at the
+point of entrance of the current are charred to a greater or lesser
+depth. The eschar is at first dry and crisp, and is surrounded by a zone
+of pallor. For the first thirty-six to forty-eight hours there is
+comparatively little suffering, but at the end of that time the parts
+become exceedingly painful. In a majority of cases, in spite of careful
+purification, a slow form of moist gangrene sets in, and the slough
+spreads both in area and in depth, until the muscles and often the
+large blood vessels and nerves are exposed. A line of demarcation
+eventually forms, but the sloughs are exceedingly slow to separate,
+taking from three to five times as long as in an ordinary burn, and
+during the process of separation there is considerable risk of secondary
+haemorrhage from erosion of large vessels.
+
+_Treatment._--Electrical burns are treated on the same lines as ordinary
+burns, by thorough purification and the application of dry dressings,
+with a view to avoiding the onset of moist gangrene. After granulations
+have formed, skin-grafting is of value in hastening healing.
+
+#Lightning-stroke.#--In a large proportion of cases lightning-stroke
+proves instantly fatal. In non-fatal cases the patient suffers from a
+profound degree of shock, and there may or may not be any external
+evidence of injury. In the mildest cases red spots or wheals--closely
+resembling those of urticaria--may appear on the body, but they usually
+fade again in the course of twenty-four hours. Sometimes large patches
+of skin are scorched or stained, the discoloured area showing an
+arborescent appearance. In other cases the injured skin becomes dry and
+glazed, resembling parchment. Appearances are occasionally met with
+corresponding to those of a superficial burn produced by heat. The chief
+difference from ordinary burns is the extreme slowness with which
+healing takes place. Localised paralysis of groups of muscles, or even
+of a whole limb, may follow any degree of lightning-stroke. Treatment is
+mainly directed towards combating the shock, the surface-lesions being
+treated on the same lines as ordinary burns.
+
+
+
+
+CHAPTER XII
+
+METHODS OF WOUND TREATMENT
+
+
+Varieties of wounds--Modes of infection--Lister's work--Means taken to
+    prevent infection of wounds: _heat_; _chemical antiseptics_;
+    _disinfection of hands_; _preparation of skin of patient_;
+    _instruments_; _ligatures_; _dressings_--Means taken to combat
+    infection: _purification_; _open-wound method_.
+
+The surgeon is called upon to treat two distinct classes of wounds: (1)
+those resulting from injury or disease in which _the skin is already
+broken_, or in which a communication with a mucous surface exists; and
+(2) those that he himself makes _through intact skin_, no infected
+mucous surface being involved.
+
+Infection by bacteria must be assumed to have taken place in all wounds
+made in any other way than by the knife of the surgeon operating through
+unbroken skin. On this assumption the modern system of wound treatment
+is based. Pathogenic bacteria are so widely distributed, that in the
+ordinary circumstances of everyday life, no matter how trivial a wound
+may be, or how short a time it may remain exposed, the access of
+organisms to it is almost certain unless preventive measures are
+employed.
+
+It cannot be emphasised too strongly that rigid precautions are to be
+taken to exclude fresh infection, not only in dealing with wounds that
+are free of organisms, but equally in the management of wounds and other
+lesions that are already infected. Any laxity in our methods which
+admits of fresh organisms reaching an infected wound adds materially to
+the severity of the infective process and consequently to the patient's
+risk.
+
+There are many ways in which accidental infection may occur. Take, for
+example, the case of a person who receives a cut on the face by being
+knocked down in a carriage accident on the street. Organisms may be
+introduced to such a wound from the shaft or wheel by which he was
+struck, from the ground on which he lay, from any portion of his
+clothing that may have come in contact with the wound, or from his own
+skin. Or, again, the hands of those who render first aid, the water used
+to bathe the wound, the handkerchief or other extemporised dressing
+applied to it, may be the means of conveying bacterial infection. Should
+the wound open on a mucous surface, such as the mouth or nasal cavity,
+the organisms constantly present in such situations are liable to prove
+agents of infection.
+
+Even after the patient has come under professional care the risks of his
+wound becoming infected are not past, because the hands of the doctor,
+his instruments, dressings, or other appliances may all, unless
+purified, become the sources of infection.
+
+In the case of an operation carried out through unbroken skin, organisms
+may be introduced into the wound from the patient's own skin, from the
+hands of the surgeon or his assistants, through the medium of
+contaminated instruments, swabs, ligature or suture materials, or other
+things used in the course of the operation, or from the dressings
+applied to the wound.
+
+Further, bacteria may gain access to devitalised tissues by way of the
+blood-stream, being carried hither from some infected area elsewhere in
+the body.
+
+_The Antiseptic System of Surgery._--Those who only know the surgical
+conditions of to-day can scarcely realise the state of matters which
+existed before the introduction of the antiseptic system by Joseph
+Lister in 1867. In those days few wounds escaped the ravages of pyogenic
+and other bacteria, with the result that suppuration ensued after most
+operations, and such diseases as erysipelas, pyaemia, and "hospital
+gangrene" were of everyday occurrence. The mortality after compound
+fractures, amputations, and many other operations was appalling, and
+death from blood-poisoning frequently followed even the most trivial
+operations. An operation was looked upon as a last resource, and the
+inherent risk from blood-poisoning seemed to have set an impassable
+barrier to the further progress of surgery. To the genius of Lister we
+owe it that this barrier was removed. Having satisfied himself that the
+septic process was due to bacterial infection, he devised a means of
+preventing the access of organisms to wounds or of counteracting their
+effects. Carbolic acid was the first antiseptic agent he employed, and
+by its use in compound fractures he soon obtained results such as had
+never before been attained. The principle was applied to other
+conditions with like success, and so profoundly has it affected the
+whole aspect of surgical pathology, that many of the infective diseases
+with which surgeons formerly had to deal are now all but unknown. The
+broad principles upon which Lister founded his system remain unchanged,
+although the methods employed to put them into practice have been
+modified.
+
+#Means taken to Prevent Infection of Wounds.#--The avenues by which
+infective agents may gain access to surgical wounds are so numerous and
+so wide, that it requires the greatest care and the most watchful
+attention on the part of the surgeon to guard them all. It is only by
+constant practice and patient attention to technical details in the
+operating room and at the bedside, that the carrying out of surgical
+manipulations in such a way as to avoid bacterial infection will become
+an instinctive act and a second nature. It is only possible here to
+indicate the chief directions in which danger lies, and to describe the
+means most generally adopted to avoid it.
+
+To prevent infection, it is essential that everything which comes into
+contact with a wound should be sterilised or disinfected, and to ensure
+the best results it is necessary that the efficiency of our methods of
+sterilisation should be periodically tested. The two chief agencies at
+our disposal are heat and chemical antiseptics.
+
+#Sterilisation by Heat.#--The most reliable, and at the same time the
+most convenient and generally applicable, means of sterilisation is by
+heat. All bacteria and spores are completely destroyed by being
+subjected for fifteen minutes to _saturated circulating steam_ at a
+temperature of 130 to 145 C. (= 266 to 293 F.). The articles to be
+sterilised are enclosed in a perforated tin casket, which is placed in a
+specially constructed steriliser, such as that of Schimmelbusch. This
+apparatus is so arranged that the steam circulates under a pressure of
+from two to three atmospheres, and permeates everything contained in it.
+Objects so sterilised are dry when removed from the steriliser. This
+method is specially suitable for appliances which are not damaged by
+steam, such, for example, as gauze swabs, towels, aprons, gloves, and
+metal instruments; it is essential that the efficiency of the steriliser
+be tested from time to time by a self-registering thermometer or other
+means.
+
+The best substitute for circulating steam is _boiling_. The articles are
+placed in a "fish-kettle steriliser" and boiled for fifteen minutes in a
+1 per cent. solution of washing soda.
+
+To prevent contamination of objects that have been sterilised they must
+on no account be touched by any one whose hands have not been
+disinfected and protected by sterilised gloves.
+
+#Sterilisation by Chemical Agents.#--For the purification of the skin of
+the patient, the hands of the surgeon, and knives and other instruments
+that are damaged by heat, recourse must be had to chemical agents.
+These, however, are less reliable than heat, and are open to certain
+other objections.
+
+#Disinfection of the Hands.#--It is now generally recognised that one of
+the most likely sources of wound infection is the hands of the surgeon
+and his assistants. It is only by carefully studying to avoid all
+contact with infective matter that the hands can be kept surgically
+pure, and that this source of wound infection can be reduced to a
+minimum. The risk of infection from this source has further been greatly
+reduced by the systematic use of rubber gloves by house-surgeons,
+dressers, and nurses. The habitual use of gloves has also been adopted
+by the great majority of surgeons; the minority, who find they are
+handicapped by wearing gloves as a routine measure, are obliged to do so
+when operating in infective cases or dressing infected wounds, and in
+making rectal and vaginal examinations.
+
+The gloves may be sterilised by steam, and are then put on dry, or by
+boiling, in which case they are put on wet. The gauntlet of the glove
+should overlap and confine the end of the sleeve of the sterilised
+overall, and the gloved hands are rinsed in lotion before and at
+frequent intervals during the operation. The hands are sterilised before
+putting on the gloves, preferably by a method which dehydrates the skin.
+Cotton gloves may be worn by the surgeon when tying ligatures, or
+between operations, and by the anaesthetist during operations on the
+head, neck, and chest.
+
+The first step in the disinfection of the hands is the mechanical
+removal of gross surface dirt and loose epithelium by soap, a stream of
+running water as hot as can be borne, and a loofah or nail-brush, that
+has been previously sterilised by heat. The nails should be cut down
+till there is no sulcus between the nail edge and the pulp of the finger
+in which organisms may lodge. They are next washed for three minutes in
+methylated spirit to dehydrate the skin, and then for two or three
+minutes in 70 per cent. sublimate or biniodide alcohol (1 in 1000).
+Finally, the hands are rubbed with dry sterilised gauze.
+
+#Preparation of the Skin of the Patient.#--In the purification of the
+skin of the patient before operation, reliance is to be placed chiefly
+in the mechanical removal of dirt and grease by the same means as are
+taken for the cleansing of the surgeon's hands. Hair-covered parts
+should be shaved. The skin is then dehydrated by washing with methylated
+spirit, followed by 70 per cent. sublimate or biniodide alcohol (1 in
+1000). This is done some hours before the operation, and the part is
+then covered with pads of dry sterilised gauze or a sterilised towel.
+Immediately before the operation the skin is again purified in the same
+way.
+
+The _iodine method_ of disinfecting the skin introduced by Grossich is
+simple, and equally efficient. The day before operation the skin, after
+being washed with soap and water, is shaved, dehydrated by means of
+methylated spirit, and then painted with a 5 per cent. solution of
+iodine in rectified spirit. The painting with iodine is repeated just
+before the operation commences, and again after it is completed. The
+final application is omitted in the case of children. In emergency
+operations the skin is shaved dry and dehydrated with spirit, after
+which the iodine is applied as described above. The staining of the skin
+is an advantage, as it enables the operator to recognise the area that
+has been prepared.
+
+If any acne pustules or infected sinuses are present, they should be
+destroyed or purified by means of the thermo-cautery or pure carbolic
+acid, after the patient is anaesthetised.
+
+#Appliances used at Operation.#--_Instruments_ that are not damaged by
+heat must be boiled in a fish-kettle or other suitable steriliser for
+fifteen minutes in a 1 per cent. solution of cresol or washing soda.
+Just before the operation begins they are removed in the tray of the
+steriliser and placed on a sterilised towel within reach of the surgeon
+or his assistant. Knives and instruments that are liable to be damaged
+by heat should be purified by being soaked in pure cresol for a few
+minutes, or in 1 in 20 carbolic for at least an hour.
+
+_Pads of Gauze_ sterilised by compressed circulating steam have almost
+entirely superseded marine sponges for operative purposes. To avoid the
+risk of leaving swabs in the peritoneal cavity, large square pads of
+gauze, to one corner of which a piece of strong tape about a foot long
+is securely stitched, should be employed. They should be removed from
+the caskets in which they are sterilised by means of sterilised forceps,
+and handed direct to the surgeon. The assistant who attends to the swabs
+should wear sterilised gloves.
+
+_Ligatures and Sutures._--To avoid the risk of implanting infective
+matter in a wound by means of the materials used for ligatures and
+sutures, great care must be taken in their preparation.
+
+_Catgut._--The following methods of preparing catgut have proved
+satisfactory: (1) The gut is soaked in juniper oil for at least a month;
+the juniper oil is then removed by ether and alcohol, and the gut
+preserved in 1 in 1000 solution of corrosive sublimate in alcohol
+(Kocher). (2) The gut is placed in a brass receiver and boiled for
+three-quarters of an hour in a solution consisting of 85 per cent.
+absolute alcohol, 10 per cent. water, and 5 per cent. carbolic acid, and
+is then stored in 90 per cent. alcohol. (3) Cladius recommends that the
+catgut, just as it is bought from the dealers, be loosely rolled on a
+spool, and then immersed in a solution of--iodine, 1 part; iodide of
+potassium, 1 part; distilled water, 100 parts. At the end of eight days
+it is ready for use. Moschcowitz has found that the tensile strength of
+catgut so prepared is increased if it is kept dry in a sterile vessel,
+instead of being left indefinitely in the iodine solution. If
+Salkindsohn's formula is used--tincture of iodine, 1 part; proof spirit,
+15 parts--the gut can be kept permanently in the solution without
+becoming brittle. To avoid contamination from the hands, catgut should
+be removed from the bottle with aseptic forceps and passed direct to the
+surgeon. Any portion unused should be thrown away.
+
+_Silk_ is prepared by being soaked for twelve hours in ether, for other
+twelve in alcohol, and then boiled for ten minutes in 1 in 1000
+sublimate solution. It is then wound on spools with purified hands
+protected by sterilised gloves, and kept in absolute alcohol. Before an
+operation the silk is again boiled for ten minutes in the same solution,
+and is used directly from this (Kocher). Linen thread is sterilised in
+the same way as silk.
+
+Fishing-gut and silver wire, as well as the needles, should be boiled
+along with the instruments. Horse-hair and fishing-gut may be sterilised
+by prolonged immersion in 1 in 20 carbolic, or in the iodine solutions
+employed to sterilise catgut.
+
+The field of operation is surrounded by sterilised towels, clipped to
+the edges of the wound, and securely fixed in position so that no
+contamination may take place from the surroundings.
+
+The surgeon and his assistants, including the anaesthetist, wear
+overalls sterilised by steam. To avoid the risk of infection from dust,
+scurf, or drops of perspiration falling from the head, the surgeon and
+his assistants may wear sterilised cotton caps. To obviate the risk of
+infection taking place by drops of saliva projected from the mouth in
+talking or coughing in the vicinity of a wound, a simple mask may be
+worn.
+
+The risk of infection from the _air_ is now known to be very small, so
+long as there is no excess of floating dust. All sweeping, dusting, and
+disturbing of curtains, blinds, or furniture must therefore be avoided
+before or during an operation.
+
+It has been shown that the presence of spectators increases the number
+of organisms in the atmosphere. In teaching clinics, therefore, the risk
+from air infection is greater than in private practice.
+
+To facilitate primary union, all haemorrhage should be arrested, and the
+accumulation of fluid in the wound prevented. When much oozing is
+anticipated, a glass or rubber drainage-tube is inserted through a small
+opening specially made for the purpose. In aseptic wounds the tube may
+be removed in from twenty-four to forty-eight hours, and where it is
+important to avoid a scar, the opening should be closed with a Michel's
+clip; in infected wounds the tube must remain as long as the discharge
+continues.
+
+The fascia and skin should be brought into accurate apposition by
+sutures. If any cavity exists in the deeper part of the wound it should
+be obliterated by buried sutures, or by so adjusting the dressing as to
+bring its walls into apposition.
+
+If these precautions have been successful, the wound will heal under the
+original dressing, which need not be interfered with for from seven to
+ten days, according to the nature of the case.
+
+#Dressings.#--_Gauze_, sterilised by heat, is almost universally
+employed for the dressing of wounds. _Double cyanide gauze_ may be used
+in such regions as the neck, axilla, or groin, where complete
+sterilisation of the skin is difficult to attain, and where it is
+desirable to leave the dressing undisturbed for ten days or more.
+_Iodoform_ or _bismuth gauze_ is of special value for the packing of
+wounds treated by the open method.
+
+One variety or another of _wool_, rendered absorbent by the extraction
+of its fat, and sterilised by heat, forms a part of almost every
+surgical dressing, and various antiseptic agents may be added to it. Of
+these, corrosive sublimate is the most generally used. Wood-wool
+dressings are more highly and more uniformly absorbent than cotton
+wools. As evaporation takes place through wool dressings, the discharge
+becomes dried, and so forms an unfavourable medium for bacterial growth.
+
+Pads of _sphagnum moss_, sterilised by heat, are highly absorbent, and
+being economical are used when there is much discharge, and in cases
+where a leakage of urine has to be soaked up.
+
+#Means adopted to combat Infection.#--As has already been indicated, the
+same antiseptic precautions are to be taken in dealing with infected as
+with aseptic wounds.
+
+In _recent injuries_ such as result from railway or machinery accidents,
+with bruising and crushing of the tissues and grinding of gross dirt
+into the wounds, the scissors must be freely used to remove the tissues
+that have been devitalised or impregnated with foreign material.
+Hair-covered parts should be shaved and the surrounding skin painted
+with iodine. Crushed and contaminated portions of bone should be
+chiselled away. Opinions differ as to the benefit derived from washing
+such wounds with chemical antiseptics, which are liable to devitalise
+the tissues with which they come in contact, and so render them less
+able to resist the action of any organisms that may remain in them. All
+are agreed, however, that free washing with normal salt solution is
+useful in mechanically cleansing the injured parts. Peroxide of hydrogen
+sprayed over such wounds is also beneficial in virtue of its oxidising
+properties. Efficient drainage must be provided, and stitches should be
+used sparingly, if at all.
+
+The best way in which to treat such wounds is by the _open method_. This
+consists in packing the wound with iodoform or bismuth gauze, which is
+left in position as long as it adheres to the raw surface. The packing
+may be renewed at intervals until the wound is filled by granulations;
+or, in the course of a few days when it becomes evident that the
+infection has been overcome, _secondary_ sutures may be introduced and
+the edges drawn together, provision being made at the ends for further
+packing or for drainage-tubes.
+
+If earth or street dirt has entered the wound, the surface may with
+advantage be painted over with pure carbolic acid, as virulent
+organisms, such as those of tetanus or spreading gangrene, are liable to
+be present. Prophylactic injection of tetanus antitoxin may be
+indicated.
+
+
+
+
+CHAPTER XIII
+
+CONSTITUTIONAL EFFECTS OF INJURIES
+
+
+SYNCOPE--SHOCK--COLLAPSE--FAT EMBOLISM--TRAUMATIC ASPHYXIA--DELIRIUM
+    IN SURGICAL PATIENTS: _Delirium in general_; _Delirium tremens_;
+    _Traumatic delirium_.
+
+
+SYNCOPE, SHOCK, AND COLLAPSE
+
+Syncope, shock, and collapse are clinical conditions which, although
+depending on different causes, bear a superficial resemblance to one
+another.
+
+#Syncope or Fainting.#--Syncope is the result of a suddenly produced
+anaemia of the brain from temporary weakening or arrest of the heart's
+action. In surgical practice, this condition is usually observed in
+nervous persons who have been subjected to pain, as in the reduction of
+a dislocation or the incision of a whitlow; or in those who have rapidly
+lost a considerable quantity of blood. It may also follow the sudden
+withdrawal of fluid from a large cavity, as in tapping an abdomen for
+ascites, or withdrawing fluid from the pleural cavity. Syncope sometimes
+occurs also during the administration of a general anaesthetic,
+especially if there is a tendency to sickness and the patient is not
+completely under. During an operation the onset of syncope is often
+recognised by the cessation of oozing from the divided vessels before
+the general symptoms become manifest.
+
+_Clinical Features._--When a person is about to faint he feels giddy,
+has surging sounds in his ears, and haziness of vision; he yawns,
+becomes pale and sick, and a free flow of saliva takes place into the
+mouth. The pupils dilate; the pulse becomes small and almost
+imperceptible; the respirations shallow and hurried; consciousness
+gradually fades away, and he falls in a heap on the floor.
+
+Sometimes vomiting ensues before the patient completely loses
+consciousness, and the muscular exertion entailed may ward off the
+actual faint. This is frequently seen in threatened syncopal attacks
+during chloroform administration.
+
+Recovery begins in a few seconds, the patient sighing or gasping, or, it
+may be, vomiting; the strength of the pulse gradually increases, and
+consciousness slowly returns. In some cases, however, syncope is fatal.
+
+_Treatment._--The head should at once be lowered--in imitation of
+nature's method--to encourage the flow of blood to the brain, the
+patient, if necessary, being held up by the heels. All tight clothing,
+especially round the neck or chest, must be loosened. The heart may be
+stimulated reflexly by dashing cold water over the face or chest, or by
+rubbing the face vigorously with a rough towel. The application of
+volatile substances, such as ammonia or smelling-salts, to the nose; the
+administration by the mouth of sal-volatile, whisky or brandy, and the
+intra-muscular injection of ether, are the most speedily efficacious
+remedies. In severe cases the application of hot cloths over the heart,
+or of the faradic current over the line of the phrenic nerve, just above
+the clavicle, may be called for.
+
+#Surgical Shock.#--The condition known as surgical shock may be looked
+upon as a state of profound exhaustion of the mechanism that exists in
+the body for the transformation of energy. This mechanism consists of
+(1) the _brain_, which, through certain special centres, regulates all
+vital activity; (2) the _adrenal glands_, the secretion of
+which--adrenalin--acting as a stimulant of the sympathetic system, so
+controls the tone of the blood vessels as to maintain efficient
+oxidation of the tissues; and (3) _the liver_, which stores and delivers
+glycogen as it is required by the muscles, and in addition, deals with
+the by-products of metabolism.
+
+Crile and his co-workers have shown that in surgical shock histological
+changes occur in the cells of the brain, the adrenals, and the liver,
+and that these are identical, whatever be the cause that leads to the
+exhaustion of the energy-transforming mechanism. These changes vary in
+degree, and range from slight alterations in the structure of the
+protoplasm to complete disorganisation of the cell elements.
+
+The influences which contribute to bring about this form of exhaustion
+that we call shock are varied, and include such emotional states as
+fear, anxiety, or worry, physical injury and toxic infection, and the
+effects of these factors are augmented by anything that tends to lower
+the vitality, such as loss of blood, exposure, insufficient food, loss
+of sleep or antecedent illness.
+
+Any one or any combination of these influences may cause shock, but the
+most potent, and the one which most concerns the surgeon, is physical
+injury, _e.g._, a severe accident or an operation (_traumatic shock_).
+This is usually associated with some emotional disturbance, such as fear
+or anxiety (_emotional shock_), or with haemorrhage; and may be followed
+by septic infection (_toxic shock_).
+
+The exaggerated afferent impulses reaching the brain as a result of
+trauma, inhibit the action of the nuclei in the region of the fourth
+ventricle and cerebellum which maintain the muscular tone, with the
+result that the muscular tone is diminished and there is a marked fall
+in the arterial blood pressure. The capillaries dilate--the blood
+stagnating in them and giving off its oxygen and transuding its fluid
+elements into the tissues--with the result that an insufficient quantity
+of oxygenated blood reaches the heart to enable it to maintain an
+efficient circulation. As the sarco-lactic acid liberated in the muscles
+is not oxygenated a condition of acidosis ensues.
+
+The more highly the injured part is endowed with sensory nerves the more
+marked is the shock; a crush of the hand, for example, is attended with
+a more intense degree of shock than a correspondingly severe crush of
+the foot; and injuries of such specially innervated parts as the testis,
+the urethra, the face, or the spinal cord, are associated with severe
+degrees, as are also those of parts innervated from the sympathetic
+system, such as the abdominal or thoracic viscera. It is to be borne in
+mind that a state of general anaesthesia does not prevent injurious
+impulses reaching the brain and causing shock during an operation. If
+the main nerves of the part are "blocked" by injection of a local
+anaesthetic, however, the central nervous system is protected from these
+impulses.
+
+While the aged frequently manifest but few signs of shock, they have a
+correspondingly feeble power of recovery; and while many young children
+suffer little, even after severe operations, others with much less cause
+succumb to shock.
+
+When the injured person's mind is absorbed with other matters than his
+own condition,--as, for example, during the heat of a battle or in the
+excitement of a railway accident or a conflagration,--even severe
+injuries may be unattended by pain or shock at the time, although when
+the period of excitement is over, the severity of the shock is all the
+greater. The same thing is observed in persons injured while under the
+influence of alcohol.
+
+_Clinical Features._--The patient is in a state of prostration. He is
+roused from his condition of indifference with difficulty, but answers
+questions intelligently, if only in a whisper. The face is pale, beads
+of sweat stand out on the brow, the features are drawn, the eyes
+sunken, and the cheeks hollow. The lips and ears are pallid; the skin of
+the body of a greyish colour, cold, and clammy. The pulse is rapid,
+fluttering, and often all but imperceptible at the wrist; the
+respiration is irregular, shallow, and sighing; and the temperature may
+fall to 96 F. or even lower. The mouth is parched, and the patient
+complains of thirst. There is little sensibility to pain.
+
+Except in very severe cases, shock tends towards recovery within a few
+hours, the _reaction_, as it is called, being often ushered in by
+vomiting. The colour improves; the pulse becomes full and bounding; the
+respiration deeper and more regular; the temperature rises to 100 F. or
+higher; and the patient begins to take notice of his surroundings. The
+condition of neurasthenia which sometimes follows an operation may be
+associated with the degenerative changes in nerve cells described by
+Crile.
+
+In certain cases the symptoms of traumatic shock blend with those
+resulting from toxin absorption, and it is difficult to estimate the
+relative importance of the two factors in the causation of the
+condition. The conditions formerly known as "delayed shock" and
+"prostration with excitement" are now generally recognised to be due to
+toxaemia.
+
+_Question of Operating during Shock._--Most authorities agree that
+operations should only be undertaken during profound shock when they are
+imperatively demanded for the arrest of haemorrhage, the prevention of
+infection of serous cavities, or for the relief of pain which is
+producing or intensifying the condition.
+
+_Prevention of Operation Shock._--In the preparation of a patient for
+operation, drastic purgation and prolonged fasting must be avoided, and
+about half an hour before a severe operation a pint of saline solution
+should be slowly introduced into the rectum; this is repeated, if
+necessary, during the operation, and at its conclusion. The
+operating-room must be warm--not less than 70 F.--and the patient
+should be wrapped in cotton wool and blankets, and surrounded by
+hot-bottles. All lotions used must be warm (100 F.); and the operation
+should be completed as speedily and as bloodlessly as possible. The
+element of fear may to some extent be eliminated by the preliminary
+administration of such drugs as scopolamin or morphin, and with a view
+to preventing the passage of exciting afferent impulses, Crile advocates
+"blocking" of the nerves by the injection of a 1 per cent. solution of
+novocaine into their substance on the proximal side of the field of
+operation. To prevent after-pain in abdominal wounds he recommends
+injecting the edges with quinine and urea hydrochlorate before suturing,
+the resulting anaesthesia lasting for twenty-four to forty-eight hours.
+To these preventive measures the term _anoci-association_ has been
+applied. In selecting an anaesthetic, it may be borne in mind that
+chloroform lowers the blood pressure more than ether does, and that with
+spinal anaesthesia there is no lowering of the blood pressure.
+
+_Treatment._--A patient suffering from shock should be placed in the
+recumbent position, with the foot of the bed raised to facilitate the
+return circulation in the large veins, and so to increase the flow of
+blood to the brain. His bed should be placed near a large fire, and the
+patient himself surrounded by cotton wool and blankets and hot-bottles.
+If he has lost much blood, the limbs should be wrapped in cotton wool
+and firmly bandaged from below upwards, to conserve as much of the
+circulating blood as possible in the trunk and head. If the shock is
+moderate in degree, as soon as the patient has been put to bed, about a
+pint of saline solution should be introduced into the rectum, and 10 to
+15 minims of adrenalin chloride (1 in 1000) may with advantage be added
+to the fluid. The injection should be repeated every two hours until the
+circulation is sufficiently restored. In severe cases, especially when
+associated with haemorrhage, transfusion of whole blood from a compatible
+donor, is the most efficient means (_Op. Surg._, p. 37). Cardiac
+stimulants such as strychnin, digitalin, or strophanthin are
+contra-indicated in shock, as they merely exhaust the already impaired
+vaso-motor centre.
+
+Artificial respiration may be useful in tiding a patient over the
+critical period of shock, especially at the end of a severe operation.
+
+Failing this, the introduction of saline solution at a temperature of
+about 105 F. into a vein or into the subcutaneous tissue is useful
+where much blood has been lost (p. 276). Two or three pints may be
+injected into a vein, or smaller quantities under the skin.
+
+Thirst is best met by giving small quantities of warm water by the
+mouth, or by the introduction of saline solution into the rectum. Ice
+only relieves thirst for a short time, and as it is liable to induce
+flatulence should be avoided, especially in abdominal cases. Dryness of
+the tongue may be relieved by swabbing the mouth with a mixture of
+glycerine and lemon juice.
+
+If severe pain calls for the use of morphin, 1/120th grain of atropin
+should be added, or heroin alone may be given in doses of 1/24th to
+1/12th grain.
+
+#Collapse# is a clinical condition which comes on more insidiously than
+shock, and which does not attain its maximum degree of severity for
+several hours. It is met with in the course of severe illnesses,
+especially such as are associated with the loss of large quantities of
+fluid from the body--for example, by severe diarrhoea, notably in Asiatic
+cholera; by persistent vomiting; or by profuse sweating, as in some
+cases of heat-stroke. Severe degrees of collapse follow sudden and
+profuse loss of blood.
+
+Collapse often follows upon shock--for example, in intestinal
+perforations, or after abdominal operations complicated by peritonitis,
+especially if there is vomiting, as in cases of obstruction high up in
+the intestine. The symptoms of collapse are aggravated if toxin
+absorption is superadded to the loss of fluid.
+
+The _clinical features_ of this condition are practically the same as
+those of shock; and it is treated on the same lines.
+
+FAT EMBOLISM.--After various injuries and operations, but
+especially such as implicate the marrow of long bones--for example,
+comminuted fractures, osteotomies, resections of joints, or the forcible
+correction of deformities--fluid fat may enter the circulation in
+variable quantity. In the vast majority of cases no ill effects follow,
+but when the quantity is large or when the absorption is long continued
+certain symptoms ensue, either immediately, or more frequently not for
+two or three days. These are mostly referable to the lungs and brain.
+
+In the lung the fat collects in the minute blood vessels and produces
+venous congestion and oedema, and sometimes pneumonia. Dyspnoea, with
+cyanosis, a persistent cough and frothy or blood-stained sputum, a
+feeble pulse and low temperature, are the chief symptoms.
+
+When the fat lodges in the capillaries of the brain, the pulse becomes
+small, rapid, and irregular, delirium followed by coma ensues, and the
+condition is usually rapidly fatal.
+
+Fat is usually to be detected in the urine, even in mild cases.
+
+The _treatment_ consists in tiding the patient over the acute stage of
+his illness, until the fat is eliminated from the blood vessels.
+
+TRAUMATIC ASPHYXIA OR TRAUMATIC CYANOSIS.--This term has been
+applied to a condition which results when the thorax is so forcibly
+compressed that respiration is mechanically arrested for several
+minutes. It has occurred from being crushed in a struggling crowd, or
+under a fall of masonry, and in machinery accidents. When the patient is
+released, the face and the neck as low down as the level of the
+clavicles present an intense coloration, varying from deep purple to
+blue-black. The affected area is sharply defined, and on close
+inspection the appearance is found to be due to the presence of
+countless minute reddish-blue or black spots, with small areas or
+streaks of normal skin between them. The punctate nature of the
+coloration is best recognised towards the periphery of the affected
+area--at the junction of the brow with the hairy scalp, and where the
+dark patch meets the normal skin of the chest (Beach and Cobb). Pressure
+over the skin does not cause the colour to disappear as in ordinary
+cyanosis. It has been shown by Wright of Boston, that the coloration is
+due to stasis from mechanical over-distension of the veins and
+capillaries; actual extravasation into the tissues is exceptional. The
+sharply defined distribution of the coloration is attributed to the
+absence of functionating valves in the veins of the head and neck, so
+that when the increased intra-thoracic pressure is transmitted to these
+veins they become engorged. Under the conjunctivae there are
+extravasations of bright red blood; and sublingual haematoma has been
+observed (Beatson).
+
+The discoloration begins to fade within a few hours, and after the
+second or third day it disappears, without showing any of the chromatic
+changes which characterise a bruise. The sub-conjunctival ecchymosis,
+however, persists for several weeks and disappears like other
+extravasations. Apart from combating the shock, or dealing with
+concomitant injuries, no treatment is called for.
+
+
+DELIRIUM IN SURGICAL PATIENTS
+
+Delirium is a temporary disturbance of mind which occurs in the course
+of certain diseases, and sometimes after injuries or operations. It may
+be associated with any of the acute pyogenic infections; with
+erysipelas, especially when it affects the head or face; or with chronic
+infective diseases of the urinary organs. In the various forms of
+meningitis also, and in some cases of injury to the head, it is common;
+and it is sometimes met with after severe haemorrhage, and in cases of
+poisoning by such drugs as iodoform, cocain, or alcohol. Delirium may
+also, of course, be a symptom of insanity.
+
+Often there is merely incoherent muttering regarding past incidents or
+occupations, or about absent friends; or the condition may assume the
+form of excitement, of dementia, or of melancholia; and the symptoms are
+usually worst at night.
+
+#Delirium Tremens# is seen in persons addicted to alcohol, who, as the
+result of accident or operation, are suddenly compelled to lie in bed.
+Although oftenest met with in habitual drunkards or chronic tipplers, it
+is by no means uncommon in moderate drinkers, and has even been seen in
+children.
+
+_Clinical Features._--The delirium, which has been aptly described as
+being of a "busy" character, usually manifests itself within a few days
+of the patient being laid up. For two or three days he refuses food, is
+depressed, suspicious, sleepless and restless, demanding to be allowed
+up. Then he begins to mutter incoherently, to pull off the bedclothes,
+and to attempt to get out of bed. There is general muscular tremor, most
+marked in the tongue, the lips, and the hands. The patient imagines that
+he sees all sorts of horrible beings around him, and is sometimes
+greatly distressed because of rats, mice, beetles, or snakes, which he
+fancies are crawling over him. The pulse is soft, rapid, and
+compressible; the temperature is only moderately raised (100-101 F.),
+and as a rule there is profuse sweating. The digestion is markedly
+impaired, and there is often vomiting. Patients in this condition are
+peculiarly insensitive to pain, and may even walk about with a fractured
+leg without apparent discomfort.
+
+In most cases the symptoms begin to pass off in three or four days; the
+patient sleeps, the hallucinations and tremors cease, and he gradually
+recovers. In other cases the temperature rises, the pulse becomes rapid,
+and death results from exhaustion.
+
+The main indication in _treatment_ is to secure sleep, and this is done
+by the administration of bromides, chloral, or paraldehyde, or of one or
+other of the drugs of which sulphonal, trional, and veronal are
+examples. Heroin in doses of from 1/24th to 1/12th grain is often of
+service. Morphin must be used with great caution. In some cases hyoscin
+(1/200 grain) injected hypodermically is found efficacious when all
+other means have failed, but this drug must be used with great
+discrimination. The patient must be encouraged to take plenty of easily
+digested fluid food, supplemented, if necessary, by nutrient enemata and
+saline infusions.
+
+In the early stage a brisk mercurial purge is often of value. Alcohol
+should be withheld, unless failing of the pulse strongly indicates its
+use, and then it should be given along with the food.
+
+A delirious patient must be constantly watched by a trained attendant or
+other competent person, lest he get out of bed and do harm to himself or
+others. Mechanical restraint is often necessary, but must be avoided if
+possible, as it is apt to increase the excitement and exhaust the
+patient. On account of the extreme restlessness, there is often great
+difficulty in carrying out the proper treatment of the primary surgical
+condition, and considerable modifications in splints and other
+appliances are often rendered necessary.
+
+A form of delirium, sometimes spoken of as #Traumatic Delirium#, may
+follow on severe injuries or operations in persons of neurotic
+temperament, or in those whose nervous system is exhausted by overwork.
+It is met with apart from alcoholic intemperance. This form of delirium
+seems to be specially prone to ensue on operations on the face, the
+thyreoid gland, or the genito-urinary organs. The symptoms appear in
+from two to five days after the operation, and take the form of
+restlessness, sleeplessness, low incoherent muttering, and picking at
+the bedclothes. It is not necessarily attended by fever or by muscular
+tremors. The patient may show hysterical symptoms. This condition is
+probably to be regarded as a form of insanity, as it is liable to merge
+into mania or melancholia.
+
+The _treatment_ is carried out on the same lines as that of delirium
+tremens.
+
+
+
+
+CHAPTER XIV
+
+THE BLOOD VESSELS
+
+
+Anatomy--INJURIES OF ARTERIES: _Varieties_--INJURIES OF
+    VEINS: _Air Embolism_--Repair of blood vessels and natural
+    arrest of haemorrhage--HAEMORRHAGE: _Varieties_;
+    _Prevention_; _Arrest_--Constitutional effects of
+    haemorrhage--Haemophilia--DISEASES OF BLOOD VESSELS:
+    Thrombosis; Embolism--Arteritis: _Varieties_;
+    Arterio-sclerosis--Thrombo-phlebitis--Phlebitis:
+    _Varieties_--VARIX--ANGIOMATA--Naevus: _Varieties_;
+    _Electrolysis_--Cirsoid aneurysm--ANEURYSM: _Varieties_;
+    _Methods of treatment_--ANEURYSMS OF INDIVIDUAL ARTERIES.
+
+#Surgical Anatomy.#--An _artery_ has three coats: an internal coat--the
+_tunica intima_--made up of a single layer of endothelial cells lining
+the lumen; outside of this a layer of delicate connective tissue; and
+still farther out a dense tissue composed of longitudinally arranged
+elastic fibres--the internal elastic lamina. The tunica intima is easily
+ruptured. The middle coat, or _tunica media_, consists of non-striped
+muscular fibres, arranged for the most part concentrically round the
+vessel. In this coat also there is a considerable proportion of elastic
+tissue, especially in the larger vessels. The thickness of the vessel
+wall depends chiefly on the development of the muscular coat. The
+external coat, or _tunica externa_, is composed of fibrous tissue,
+containing, especially in vessels of medium calibre, some yellow elastic
+fibres in its deeper layers.
+
+In most parts of the body the arteries lie in a sheath of connective
+tissue, from which fine fibrous processes pass to the tunica externa.
+The connection, however, is not a close one, and the artery when divided
+transversely is capable of retracting for a considerable distance within
+its sheath. In some of the larger arteries the sheath assumes the form
+of a definite membrane.
+
+The arteries are nourished by small vessels--the _vasa vasorum_--which
+ramify chiefly in the outer coat. They are also well supplied with
+nerves, which regulate the size of the lumen by inducing contraction or
+relaxation of the muscular coat.
+
+The _veins_ are constructed on the same general plan as the arteries,
+the individual coats, however, being thinner. The inner coat is less
+easily ruptured, and the middle coat contains a smaller proportion of
+muscular tissue. In one important point veins differ structurally from
+arteries--namely, in being provided with valves which prevent reflux of
+the blood. These valves are composed of semilunar folds of the tunica
+intima strengthened by an addition of connective tissue. Each valve
+usually consists of two semilunar flaps attached to opposite sides of
+the vessel wall, each flap having a small sinus on its cardiac side.
+The distension of these sinuses with blood closes the valve and
+prevents regurgitation. Valves are absent from the superior and inferior
+venae cavae, the portal vein and its tributaries, the hepatic, renal,
+uterine, and spermatic veins, and from the veins in the lower part of
+the rectum. They are ill-developed or absent also in the iliac and
+common femoral veins--a fact which has an important bearing on the
+production of varix in the veins of the lower extremity.
+
+The wall of _capillaries_ consists of a single layer of endothelial
+cells.
+
+
+HAEMORRHAGE
+
+Various terms are employed in relation to haemorrhage, according to its
+seat, its origin, the time at which it occurs, and other circumstances.
+
+The term _external haemorrhage_ is employed when the blood escapes on the
+surface; when the bleeding takes place into the tissues or into a cavity
+it is spoken of as _internal_. The blood may infiltrate the connective
+tissue, constituting an _extravasation_ of blood; or it may collect in a
+space or cavity and form a _haematoma_.
+
+The coughing up of blood from the lungs is known as _haemoptysis_;
+vomiting of blood from the stomach, as _haematemesis_; the passage of
+black-coloured stools due to the presence of blood altered by digestion,
+as _melaena_; and the passage of bloody urine, as _haematuria_.
+
+Haemorrhage is known as arterial, venous, or capillary, according to the
+nature of the vessel from which it takes place.
+
+In _arterial_ haemorrhage the blood is bright red in colour, and escapes
+from the cardiac end of the divided vessel in pulsating jets
+synchronously with the systole of the heart. In vascular parts--for
+example the face--both ends of a divided artery bleed freely. The blood
+flowing from an artery may be dark in colour if the respiration is
+impeded. When the heart's action is weak and the blood tension low the
+flow may appear to be continuous and not in jets. The blood from a
+divided artery at the bottom of a deep wound, escapes on the surface in
+a steady flow.
+
+_Venous_ bleeding is not pulsatile, but occurs in a continuous stream,
+which, although both ends of the vessel may bleed, is more copious from
+the distal end. The blood is dark red under ordinary conditions, but may
+be purplish, or even black, if the respiration is interfered with. When
+one of the large veins in the neck is wounded, the effects of
+respiration produce a rise and fall in the stream which may resemble
+arterial pulsation.
+
+In _capillary_ haemorrhage, red blood escapes from numerous points on the
+surface of the wound in a steady ooze. This form of bleeding is serious
+in those who are the subjects of haemophilia.
+
+
+INJURIES OF ARTERIES
+
+The following description of the injuries of arteries refers to the
+larger, named trunks. The injuries of smaller, unnamed vessels are
+included in the consideration of wounds and contusions.
+
+#Contusion.#--An artery may be contused by a blow or crush, or by the
+oblique impact of a bullet. The bruising of the vessel wall, especially
+if it is diseased, may result in the formation of a thrombus which
+occludes the lumen temporarily or even permanently, and in rare cases
+may lead to gangrene of the limb beyond.
+
+#Subcutaneous Rupture.#--An artery may be ruptured subcutaneously by a
+blow or crush, or by a displaced fragment of bone. This injury has been
+produced also during attempts to reduce dislocations, especially those
+of old standing at the shoulder. It is most liable to occur when the
+vessels are diseased. The rupture may be incomplete or complete.
+
+_Incomplete Subcutaneous Rupture._--In the majority of cases the rupture
+is incomplete--the inner and middle coats being torn, while the outer
+remains intact. The middle coat contracts and retracts, and the
+internal, because of its elasticity, curls up in the interior of the
+vessel, forming a valvular obstruction to the blood-flow. In most cases
+this results in the formation of a thrombus which occludes the vessel.
+In some cases the blood-pressure gradually distends the injured segment
+of the vessel wall and leads to the formation of an aneurysm.
+
+The pulsation in the vessels beyond the seat of rupture is arrested--for
+a time at least--owing to the occlusion of the vessel, and the limb
+becomes cold and powerless. The pulsation seldom returns within five or
+six weeks of the injury, if indeed it is not permanently arrested, but,
+as a rule, a collateral circulation is rapidly established, sufficient
+to nourish the parts beyond. If the pulsation returns within a week of
+the injury, the presumption is that the occlusion was due to pressure
+from without--for example, by haemorrhage into the sheath or the pressure
+of a fragment of bone.
+
+_Complete Subcutaneous Rupture._--When the rupture is complete, all the
+coats of the vessel are torn and the blood escapes into the surrounding
+tissues. If the original injury is attended with much shock, the
+bleeding may not take place until the period of reaction. Rupture of the
+popliteal artery in association with fracture of the femur, or of the
+axillary or brachial artery with fracture of the humerus or dislocation
+of the shoulder, are familiar examples of this injury.
+
+Like incomplete rupture, this lesion is accompanied by loss of pulsation
+and power, and by coldness of the limb beyond; a tense and excessively
+painful swelling rapidly appears in the region of the injury, and, where
+the cellular tissue is loose, may attain a considerable size. The
+pressure of the effused blood occludes the veins and leads to congestion
+and oedema of the limb beyond. The interference with the circulation, and
+the damage to the tissues, may be so great that gangrene ensues.
+
+_Treatment._--When an artery has been contused or ruptured, the limb
+must be placed in the most favourable condition for restoration of the
+circulation. The skin is disinfected and the limb wrapped in cotton wool
+to conserve its heat, and elevated to such an extent as to promote the
+venous return without at the same time interfering with the inflow of
+blood. A careful watch must be kept on the state of nutrition of the
+limb, lest gangrene occurs.
+
+If no complications supervene, the swelling subsides, and recovery may
+be complete in six or eight weeks. If the extravasation is great and the
+skin threatens to give way, or if the vitality of the limb is seriously
+endangered, it is advisable to expose the injured vessel, and, after
+clearing away the clots, to attempt to suture the rent in the artery,
+or, if torn across, to join the ends after paring the bruised edges. If
+this is impracticable, a ligature is applied above and below the
+rupture. If gangrene ensues, amputation must be performed.
+
+These descriptions apply to the larger arteries of the extremities. A
+good illustration of subcutaneous rupture of the arteries of the head is
+afforded by the tearing of the middle meningeal artery caused by the
+application of blunt violence to the skull; and of the arteries of the
+trunk--caused by the tearing of the renal artery in rupture of the
+kidney.
+
+#Open Wounds of Arteries--Laceration.#--Laceration of large arteries is
+a common complication of machinery and railway accidents. The violence
+being usually of a tearing, twisting, or crushing nature, such injuries
+are seldom associated with much haemorrhage, as torn or crushed vessels
+quickly become occluded by contraction and retraction of their coats and
+by the formation of a clot. A whole limb even may be avulsed from the
+body with comparatively little loss of blood. The risk in such cases is
+secondary haemorrhage resulting from pyogenic infection.
+
+The _treatment_ is that applicable to all wounds, with, in addition, the
+ligation of the lacerated vessels.
+
+#Punctured wounds# of blood vessels may result from stabs, or they may
+be accidentally inflicted in the course of an operation.
+
+The division of the coats of the vessel being incomplete, the natural
+haemostasis that results from curling up of the intima and contraction of
+the media, fails to take place, and bleeding goes on into the
+surrounding tissues, and externally. If the sheath of the vessel is not
+widely damaged, the gradually increasing tension of the extravasated
+blood retained within it may ultimately arrest the haemorrhage. A clot
+then forms between the lips of the wound in the vessel wall and projects
+for a short distance into the lumen, without, however, materially
+interfering with the flow through the vessel. The organisation of this
+clot results in the healing of the wound in the vessel wall.
+
+In other cases the blood escapes beyond the sheath and collects in the
+surrounding tissues, and a traumatic aneurysm results. Secondary
+haemorrhage may occur if the wound becomes infected.
+
+The _treatment_ consists in enlarging the external wound to permit of
+the damaged vessel being ligated above and below the puncture. In some
+cases it may be possible to suture the opening in the vessel wall. When
+circumstances prevent these measures being taken, the bleeding may be
+arrested by making firm pressure over the wound with a pad; but this
+procedure is liable to be followed by the formation of an aneurysm.
+
+_Minute puncture of arteries_ such as frequently occur in the hypodermic
+administration of drugs and in the use of exploring needles, are not
+attended with any escape of blood, chiefly because of the elastic recoil
+of the arterial wall; a tiny thrombus of platelets and thrombus forms at
+the point where the intima is punctured.
+
+#Incised Wounds.#--We here refer only to such incised wounds as partly
+divide the vessel wall.
+
+Longitudinal wounds show little tendency to gape, and are therefore not
+attended with much bleeding. They usually heal rapidly, but, like
+punctured wounds, are liable to be followed by the formation of an
+aneurysm.
+
+When, however, the incision in the vessel wall is oblique or transverse,
+the retraction of the muscular coat causes the opening to gape, with the
+result that there is haemorrhage, which, even in comparatively small
+arteries, may be so profuse as to prove dangerous. When the associated
+wound in the soft parts is valvular the haemorrhage is arrested and an
+aneurysm may develop.
+
+When a large arterial trunk, such as the external iliac, the femoral,
+the common carotid, the brachial, or the popliteal, has been partly
+divided, for example, in the course of an operation, the opening should
+be closed with sutures--_arteriorrhaphy_. The circulation being
+controlled by a tourniquet, or the artery itself occluded by a clamp,
+fine silk or catgut stitches are passed through the outer and middle
+coats after the method of Lembert, a fine, round needle being employed.
+The sheath of the vessel or an adjacent fascia should be stitched
+over the line of suture in the vessel wall. If infection be excluded,
+there is little risk of thrombosis or secondary haemorrhage; and even if
+thrombosis should develop at the point of suture, the artery is
+obstructed gradually, and the establishment of a collateral circulation
+takes place better than after ligation. In the case of smaller trunks,
+or when suture is impracticable, the artery should be tied above and
+below the opening, and divided between the ligatures.
+
+#Gunshot Wounds of Blood Vessels.#--In the majority of cases injuries of
+large vessels are associated with an external wound; the profusion of
+the bleeding indicates the size of the damaged vessel, and the colour of
+the blood and the nature of the flow denote whether an artery or a vein
+is implicated.
+
+When an artery is wounded a firm _haematoma_ may form, with an expansile
+pulsation and a palpable thrill--whether such a haematoma remains
+circumscribed or becomes diffuse depends upon the density or laxity of
+the tissues around it. In course of time a _traumatic arterial aneurysm_
+may develop from such a haematoma.
+
+When an artery and its companion vein are injured simultaneously an
+_arterio-venous aneurysm_ (p. 310) may develop. This frequently takes
+place without the formation of a haematoma as the arterial blood finds
+its way into the vein and so does not escape into the tissues. Even if a
+haematoma forms it seldom assumes a great size. In time a swelling is
+recognised, with a palpable thrill and a systolic bruit, loudest at the
+level of the communication and accompanied by a continuous venous hum.
+
+If leakage occurs into the tissues, the extravasated blood may occlude
+the vein by pressure, and the symptoms of arterial aneurysm replace
+those of the arterio-venous form, the systolic bruit persisting, while
+the venous hum disappears.
+
+_Gangrene_ may ensue if the blood supply is seriously interfered with,
+or the signs of _ischaemia_ may develop; the muscles lose their
+elasticity, become hard and paralysed, and anaesthesia of the "glove" or
+"stocking" type, with other alterations of sensation ensue. Apart from
+ischaemia, _reflex paralysis_ of motion and sensation of a transient kind
+may follow injury of a large vessel.
+
+_Treatment_ is carried out on the same lines as for similar injuries due
+to other causes.
+
+
+INJURIES OF VEINS
+
+Veins are subject to the same forms of injury as arteries, and the
+results are alike in both, such variations as occur being dependent
+partly on the difference in their anatomical structure, and partly on
+the conditions of the circulation through them.
+
+#Subcutaneous rupture# of veins occur most frequently in association
+with fractures and in the reduction of dislocations. The veins most
+commonly ruptured are the popliteal, the axillary, the femoral, and the
+subclavian. On account of the smaller amount of elastic and muscular
+tissue in the wall of a vein, the contraction and retraction of its
+walls are less than in an artery, and so bleeding may continue for a
+longer period. On the other hand, owing to the lower blood-pressure the
+outflow goes on more slowly, and the gradually increasing pressure
+produced by the extravasated blood is usually sufficient to arrest the
+haemorrhage before it becomes serious. As an aid in diagnosing the source
+of the bleeding, it should be remembered that the rupture of a vein does
+not affect the pulsation in the limb beyond. The risks are practically
+the same as when an artery is ruptured, excepting that of aneurysm, and
+the treatment is carried out on the same lines, but it is seldom
+necessary to operate for the purpose of applying a ligature to the
+injured vein.
+
+#Wounds# of veins--punctured and incised--frequently occur in the course
+of operations; for example, in the removal of tumours or diseased glands
+from the neck, the axilla, or the groin. They are also met with as a
+result of accidental stabs and of suicidal or homicidal injuries. The
+haemorrhage from a large vein so damaged is usually profuse, but it is
+more readily controlled by external pressure than that from an artery.
+When a vein is merely punctured, the bleeding may be arrested by
+pressure with a pad of gauze, or by a lateral ligature--that is, picking
+up the margins of the rent in the wall and securing them with a
+ligature without occluding the lumen. In the large veins, such as the
+internal jugular, the femoral, or the axillary, it is usually possible
+to suture the opening in the wall. This does not necessarily result in
+thrombosis in the vessel, or in obliteration of its lumen.
+
+When an _artery and vein are simultaneously wounded_, the features
+peculiar to each are present in greater or less degree. In the limbs
+gangrene may ensue, especially if the wound is infected. Punctured and
+gun-shot wounds implicating both artery and vein are liable to be
+followed by the development of arterio-venous aneurysm.
+
+#Entrance of Air into Veins--Air Embolism.#--This serious, though
+fortunately rare, accident is apt to occur in the course of operations
+in the region of the thorax, neck, or axilla, if a large vein is opened
+and fails to collapse on account of the rigidity of its walls, its
+incorporation in a dense fascia, or from traction being made upon it. If
+the wound in a vein is thus held open, the negative pressure during
+inspiration sucks air into the right side of the heart. This is
+accompanied by a hissing or gurgling sound, and with the next expiration
+some frothy blood escapes from the wound. The patient instantly becomes
+pale, the pupils dilate, respiration becomes laboured, and although the
+heart may continue to beat forcibly, the peripheral pulse is weak, and
+may even be imperceptible. On auscultating the heart, a churning sound
+may be heard. Death may result in a few minutes; or the heart may slowly
+regain its power and recovery take place.
+
+_Prevention._--In operations in the "dangerous area"--as the region of
+the root of the neck is called in this connection--care must be taken
+not to cut or divide any vein before it has been secured by forceps, and
+to apply ligatures securely and at once. Deep wounds in this region
+should be kept filled with normal salt solution. Immediately a cut is
+recognised in a vein, a finger should be placed over the vessel on the
+cardiac side of the wound, and kept there until the opening is secured.
+
+_Treatment._--Little can be done after the air has actually entered the
+vein beyond endeavouring to maintain the heart's action by hypodermic
+injections of ether or strychnin and the application of mustard or hot
+cloths over the chest. The head at the same time should be lowered to
+prevent syncope. Attempts to withdraw the air by suction, and the
+employment of artificial respiration, have proved futile, and are, by
+some, considered dangerous. In a desperate case massage of the heart
+might be tried.
+
+
+THE NATURAL ARREST OF HAEMORRHAGE AND THE REPAIR OF BLOOD
+VESSELS
+
+#Primary Haemorrhage.#--The term primary haemorrhage is applied to the
+bleeding which follows immediately on the wounding of a blood vessel.
+The natural process by which such haemorrhage is arrested varies with the
+character of the wound in the vessel and may be modified by accidental
+circumstances.
+
+(a) _Repair of completely divided Artery._--When an artery is
+_completely_ divided, the circular fibres of the muscular coat contract,
+so that the lumen of the cut ends is diminished, and at the same time
+each segment retracts within its sheath in virtue of the recoil of the
+elastic elements in its walls, the tunica intima curls up in the
+interior of the vessel, and the tunica externa collapses over the cut
+ends. The blood that escapes from the injured vessel fills the
+interstices of the tissues, and, coagulating, forms a clot which
+temporarily arrests the bleeding. That part of the clot which lies
+between the divided ends of the vessel and in the cellular tissue
+outside, is known as the _external clot_, while the portion which
+projects into the lumen of the vessel is known as the _internal clot_,
+and it usually extends as far as the nearest collateral branch. These
+processes constitute what is known as the _temporary arrest of
+haemorrhage_, which, it will be observed, is effected by the contraction
+and retraction of the divided artery and by clotting.
+
+The _permanent arrest_ takes place by the transformation of the clot
+into scar tissue. The internal clot plays the most important part in the
+process; it becomes invaded by leucocytes and proliferating endothelial
+and connective-tissue cells, and new blood vessels permeate the mass,
+which is thus converted into granulation tissue. This is ultimately
+replaced by fibrous tissue, which permanently occludes the end of the
+vessel. Concurrently and by the same process the external clot is
+converted into scar tissue.
+
+If a divided artery is _ligated at its cut end_, the tension of the
+ligature is usually sufficient to rupture the inner and middle coats,
+which curl up within the lumen, the outer coat alone being held in the
+grasp of the ligature. An internal clot forms and, becoming organised,
+permanently occludes the vessel as above described. The ligature and the
+small portion of vessel beyond it are subsequently absorbed.
+
+In course of time the collateral branches of the vessel above and below
+the level of section enlarge and their inter-communication becomes more
+free, so that even when large trunks have been divided the vascular
+supply of the parts beyond may be completely restored. This is known as
+the development of the _collateral circulation_.
+
+_Imperfect Collateral Circulation._--While the development of the
+collateral circulation after the ligation or obstruction from other
+cause of a main arterial trunk may be sufficient to prevent gangrene of
+the limb, it may be insufficient for its adequate nourishment; it may be
+cold, bluish in colour, and there may be necrosis of the skin over bony
+points; this is notably the case in the lower extremity after ligation
+of the femoral or popliteal artery, when patches of skin may die over
+the prominence of the heel, the balls of the toes, the projecting base
+of the fifth metatarsal and the external malleolus.
+
+If, during the period of reaction, the blood-pressure rises
+considerably, the occluding clot at the divided end of the vessel may be
+washed away or the ligature displaced, permitting of fresh bleeding
+taking place--_reactionary_ or _intermediary haemorrhage_ (p. 272).
+
+In the event of the wound becoming infected with pyogenic organisms, the
+occluding blood-clot or the young fibrous tissue may become
+disintegrated in the suppurative process, and the bleeding start
+afresh--_secondary haemorrhage_ (p. 273).
+
+(b) If an artery is only _partly cut across_, the divided fibres of
+the tunica muscularis contract and those of the tunica externa retract,
+with the result that a more or less circular hole is formed in the wall
+of the vessel, from which free bleeding takes place, as the conditions
+are unfavourable for the formation of an occluding clot. Even if a clot
+does form, when the blood-pressure rises it is readily displaced,
+leading to reactionary haemorrhage. Should the wound become infected,
+secondary haemorrhage is specially liable to occur. A further risk
+attends this form of injury, in that the intra-vascular tension may in
+time lead to gradual stretching of the scar tissue which closes the gap
+in the vessel wall, with the result that a localised dilatation or
+diverticulum forms, constituting a _traumatic aneurysm_.
+
+(c) When the injury merely takes the form of a _puncture_ or _small
+incision_ a blood-clot forms between the edges, becomes organised, and
+is converted into cicatricial tissue which seals the aperture. Such
+wounds may also be followed by reactionary or secondary haemorrhage, or
+later by the formation of a traumatic aneurysm.
+
+_Conditions which influence the Natural Arrest of Haemorrhage._--The
+natural arrest of bleeding is favoured by tearing or crushing of the
+vessel walls, owing to the contraction and retraction of the coats and
+the tendency of blood to coagulate when in contact with damaged tissue.
+Hence the primary haemorrhage following lacerated wounds is seldom
+copious. The occurrence of syncope or of profound shock also helps to
+stop bleeding by reducing the force of the heart's action.
+
+On the other hand, there are conditions which retard the natural arrest.
+When, for example, a vessel is only partly divided, the contraction and
+retraction of the muscular coat, instead of diminishing the calibre of
+the artery, causes the wound in the vessel to gape; by completing the
+division of the vessel under these circumstances the bleeding can often
+be arrested. In certain situations, also, the arteries are so intimately
+connected with their sheaths, that when cut across they were unable to
+retract and contract--for example, in the scalp, in the penis, and in
+bones--and copious bleeding may take place from comparatively small
+vessels. This inability of the vessels to contract and retract is met
+with also in inflamed and oedematous parts and in scar tissue. Arteries
+divided in the substance of a muscle also sometimes bleed unduly. Any
+increase in the force of the heart's action, such as may result from
+exertion, excitement, or over-stimulation, also interferes with the
+natural arrest. Lastly, in bleeders, there are conditions which
+interfere with the natural arrest of haemorrhage.
+
+#Repair of a Vessel ligated in its Continuity.#--When a ligature is
+applied to an artery it should be pulled sufficiently tight to occlude
+the lumen without causing rupture of its coats. It often happens,
+however, that the compression causes rupture of the inner and middle
+coats, so that only the outer coat remains in the grasp of the ligature.
+While this weakens the wall of the vessel, it has the advantage of
+hastening coagulation, by bringing the blood into contact with damaged
+tissue. Whether the inner and middle coats are ruptured or not, blood
+coagulates both above and below the ligature, the proximal clot being
+longer and broader than that on the distal side. In small arteries these
+clots extend as far as the nearest collateral branch, but in the larger
+trunks their length varies. The permanent occlusion of those portions of
+the vessel occupied by clot is brought about by the formation of
+granulation tissue, and its replacement by cicatricial tissue, so that
+the occluded segment of the vessel is represented by a fibrous cord. In
+this process the coagulum only plays a passive role by forming a
+scaffolding on which the granulation tissue is built up. The ligature
+surrounding the vessel, and the elements of the clot, are ultimately
+absorbed.
+
+#Repair of Veins.#--The process of repair in veins is the same as that
+in arteries, but the thrombosed area may become canalised and the
+circulation through the vessel be re-established.
+
+
+HAEMORRHAGE IN SURGICAL OPERATIONS
+
+The management of the haemorrhage which accompanies an operation includes
+(a) preventive measures, and (b) the arrest of the bleeding.
+
+#Prevention of Haemorrhage.#--Whenever possible, haemorrhage should be
+controlled by _digital compression_ of the main artery supplying the
+limb rather than by a tourniquet. If efficiently applied compression
+reduces the immediate loss of blood to a minimum, and the bleeding from
+small vessels that follows the removal of the tourniquet is avoided.
+Further, the pressure of a tourniquet has been shown to be a material
+factor in producing shock.
+
+In selecting a point at which to apply digital compression, it is
+essential that the vessel should be lying over a bone which will furnish
+the necessary resistance. The common carotid, for example, is pressed
+backward and medially against the transverse process (carotid tubercle)
+of the sixth cervical vertebra; the temporal against the temporal
+process (zygoma) in front of the ear; and the facial against the
+mandible at the anterior edge of the masseter.
+
+In the upper extremity, the subclavian is pressed against the first rib
+by making pressure downwards and backwards in the hollow above the
+clavicle; the axillary and brachial by pressing against the shaft of the
+humerus.
+
+In the lower extremity, the femoral is controlled by pressing in a
+direction backward and slightly upward against the brim of the pelvis,
+midway between the symphysis pubis and the anterior superior iliac
+spine.
+
+The abdominal aorta may be compressed against the bodies of the lumbar
+vertebrae opposite the umbilicus, if the spine is arched well forwards
+over a pillow or sand-bag, or by the method suggested by Macewen, in
+which the patient's spine is arched forwards by allowing the lower
+extremities and pelvis to hang over the end of the table, while the
+assistant, standing on a stool, applies his closed fist over the
+abdominal aorta and compresses it against the vertebral column.
+Momburg recommends an elastic cord wound round the body between the
+iliac crest and the lower border of the ribs, but this procedure has
+caused serious damage to the intestine.
+
+When digital compression is not available, the most convenient and
+certain means of preventing haemorrhage--say in an amputation--is by the
+use of some form of _tourniquet_, such as the elastic tube of Esmarch or
+of Foulis, or an elastic bandage, or the screw tourniquet of Petit.
+Before applying any of these it is advisable to empty the limb of blood.
+This is best done after the manner suggested by Lister: the limb is held
+vertical for three or four minutes; the veins are thus emptied by
+gravitation, and they collapse, and as a physiological result of this
+the arteries reflexly contract, so that the quantity of blood entering
+the limb is reduced to a minimum. With the limb still elevated the
+tourniquet is firmly applied, a part being selected where the vessel can
+be pressed directly against a bone, and where there is no risk of
+exerting injurious pressure on the nerve-trunks. The tourniquet should
+be applied over several layers of gauze or lint to protect the skin, and
+the first turn of the tourniquet must be rapidly and tightly applied to
+arrest completely the arterial flow, otherwise the veins only are
+obstructed and the limb becomes congested. In the lower extremity the
+best place to apply a tourniquet is the middle third of the thigh; in
+the upper extremity, in the middle of the arm. A tourniquet should never
+be applied tighter or left on longer than is absolutely necessary.
+
+The screw tourniquet of Petit is to be preferred when it is desired to
+intermit the flow through the main artery as in operations for aneurysm.
+
+When a tourniquet cannot conveniently be applied, or when its presence
+interferes with the carrying out of the operation--as, for example, in
+amputations at the hip or shoulder--the haemorrhage may be controlled by
+preliminary ligation of the main artery above the seat of operation--for
+instance, the external iliac or the subclavian. For such contingencies
+also the steel skewers used by Spence and Wyeth, or a special clamp or
+forceps, such as that suggested by Lynn Thomas, may be employed. In the
+case of vessels which it is undesirable to occlude permanently, such as
+the common carotid, the temporary application of a ligature or clamp is
+useful.
+
+#Arrest of Haemorrhage.#--_Ligature._--This is the best means of securing
+the larger vessels. The divided vessel having been caught with forceps
+as near to its cut end as possible, a ligature of catgut or silk is tied
+round it. When there is difficulty in applying a ligature securely, for
+example in a dense tissue like the scalp or periosteum, or in a friable
+tissue like the thyreoid gland or the mesentery, a stitch should be
+passed so as to surround the bleeding vessel a short distance from its
+end, in this way ensuring a better hold and preventing the ligature from
+slipping.
+
+If the haemorrhage is from a partly divided vessel, this should be
+completely cut across to enable its walls to contract and retract, and
+to facilitate the application of forceps and ligatures.
+
+_Torsion._--This method is seldom employed except for comparatively
+small vessels, but it is applicable to even the largest arteries. In
+employing torsion, the end of the vessel is caught with forceps, and the
+terminal portion twisted round several times. The object is to tear the
+inner and middle coats so that they curl up inside the lumen, while the
+outer fibrous coat is twisted into a cord which occludes the end of the
+vessel.
+
+_Forci-pressure._--Bleeding from the smallest arteries and from
+arterioles can usually be arrested by firmly squeezing them for a few
+minutes with artery forceps. It is usually found that on the removal of
+the forceps at the end of an operation no further haemorrhage takes
+place. By the use of specially strong clamps, such as the angiotribes of
+Doyen, large trunks may be occluded by pressure.
+
+_Cautery._--The actual cautery or Paquelin's thermo-cautery is seldom
+employed to arrest haemorrhage, but is frequently useful in preventing
+it, as, for example, in the removal of piles, or in opening the bowel in
+colostomy. It is used at a dull-red heat, which sears the divided ends
+of the vessel and so occludes the lumen. A bright-red or a white heat
+cuts the vessel across without occluding it. The separation of the
+slough produced by the charring of the tissues is sometimes attended
+with secondary bleeding.
+
+_Haemostatics_ or _Styptics_.--The local application of haemostatics is
+seldom to be recommended. In the treatment of epistaxis or bleeding from
+the nose, of haemorrhage from the socket of a tooth, and sometimes from
+ulcerating or granulating surfaces, however, they may be useful. All
+clots must be removed and the drug applied directly to the bleeding
+surface. Adrenalin and turpentine are the most useful drugs for this
+purpose.
+
+Haemorrhage from bone, for example the skull, may be arrested by means of
+Horsley's aseptic plastic wax. To stop persistent oozing from soft
+tissues, Horsley successfully applied a portion of living vascular
+tissue, such as a fragment of muscle, which readily adheres to the
+oozing surface and yields elements that cause coagulation of the blood
+by thrombo-kinetic processes. When examined after two or three days the
+muscle has been found to be closely adherent and undergoing
+organisation.
+
+#Arrest of Accidental Haemorrhage.#--The most efficient means of
+temporarily controlling haemorrhage is by pressure applied with the
+finger, or with a pad of gauze, directly over the bleeding point. While
+this is maintained an assistant makes digital pressure, or applies a
+tourniquet, over the main vessel of the limb on the proximal side of the
+bleeding point. A useful _emergency tourniquet_ may be improvised by
+folding a large handkerchief _en cravatte_, with a cork or piece of wood
+in the fold to act as a pad. The handkerchief is applied round the
+limb, with the pad over the main artery, and the ends knotted on the
+lateral aspect of the limb. With a strong piece of wood the handkerchief
+is wound up like a Spanish windlass, until sufficient pressure is
+exerted to arrest the bleeding.
+
+When haemorrhage is taking place from a number of small vessels, its
+arrest may be effected by elevation of the bleeding part, particularly
+if it is a limb. By this means the force of the circulation is
+diminished and the formation of coagula favoured. Similarly, in wounds
+of the hand or forearm, or of the foot or leg, bleeding may be arrested
+by placing a pad in the flexure and acutely flexing the limb at the
+elbow or knee respectively.
+
+#Reactionary Haemorrhage.#--Reactionary or intermediary haemorrhage
+is really a recurrence of primary bleeding. As the name indicates, it
+occurs during the period of reaction--that is, within the first twelve
+hours after an operation or injury. It may be due to the increase in the
+blood-pressure that accompanies reaction displacing clots which have
+formed in the vessels, or causing vessels to bleed which did not bleed
+during the operation; to the slipping of a ligature; or to the giving
+way of a grossly damaged portion of the vessel wall. In the scrotum, the
+relaxation of the dartos during the first few hours after operation
+occasionally leads to reactionary haemorrhage.
+
+As a rule, reactionary haemorrhage takes place from small vessels as a
+result of the displacement of occluding clots, and in many cases the
+haemorrhage stops when the bandages and soaked dressings are removed. If
+not, it is usually sufficient to remove the clots and apply firm
+pressure, and in the case of a limb to elevate it. Should the haemorrhage
+recur, the wound must be reopened, and ligatures applied to the bleeding
+vessels. Douching the wound with hot sterilised water (about 110 F.),
+and plugging it tightly with gauze, are often successful in arresting
+capillary oozing. When the bleeding is more copious, it is usually due
+to a ligature having slipped from a large vessel such as the external
+jugular vein after operations in the neck, and the wound must be opened
+up and the vessel again secured. The internal administration of heroin
+or morphin, by keeping the patient quiet, may prove useful in preventing
+the recurrence of haemorrhage.
+
+#Secondary Haemorrhage.#--The term secondary haemorrhage refers to
+bleeding that is delayed in its onset and is due to pyogenic infection
+of the tissues around an artery. The septic process causes softening and
+erosion of the wall of the artery so that it gives way under the
+pressure of the contained blood. The leakage may occur in drops, or as a
+rush of blood, according to the extent of the erosion, the size of the
+artery concerned, and the relations of the erosion to the surrounding
+tissues. When met with as a complication of a wound there is an
+interval--usually a week to ten days--between the receipt of the wound
+and the first haemorrhage, this time being required for the extension of
+the septic process to the wall of the artery and the consequent erosion
+of its coats. When secondary haemorrhage occurs apart from a wound, there
+is a similar septic process attacking the wall of the artery from the
+outside; for example in sloughing sore-throat, the separation of a
+slough may implicate the wall of an artery and be followed by serious
+and it may be fatal haemorrhage. The mechanical pressure of a fragment of
+bone or of a rubber drainage tube upon the vessel may aid the septic
+process in causing erosion of the artery. In pre-Listerian days, the
+silk ligature around the artery likewise favoured the changes that lead
+to secondary haemorrhage, and the interesting observation was often made,
+that when the collateral circulation was well established, the leakage
+occurred on the _distal_ side of the ligature. While it may happen that
+the initial haemorrhage is rapidly fatal, as for example when the
+external carotid or one of its branches suddenly gives way, it is quite
+common to have one, two or more _warning haemorrhages_ before the leakage
+on a large scale, which is rapidly fatal.
+
+The _appearances of the wound_ in cases complicated by secondary
+haemorrhage are only characteristic in so far that while obviously
+infected, there is an absence of all reaction; instead of frankly
+suppurating, there is little or no discharge and the surrounding
+cellular tissue and the limb beyond are oedematous and pit on pressure.
+
+The _general symptoms_ of septic poisoning in cases of secondary
+haemorrhage vary widely in severity: they may be so slight that the
+general health is scarcely affected and the convalescence from an
+operation, for example, may be apparently normal except that the wound
+does not heal satisfactorily. For example, a patient may be recovering
+from an operation such as the removal of an epithelioma of the mouth,
+pharynx or larynx and the associated lymph glands in the neck, and be
+able to be up and going about his room, when, suddenly, without warning
+and without obvious cause, a rush of blood occurs from the mouth or the
+incompletely healed wound in the neck, causing death within a few
+minutes.
+
+On the other hand, the toxaemia may be of a profound type associated with
+marked pallor and progressive failure of strength, which, of itself,
+even when the danger from haemorrhage has been overcome, may have a fatal
+termination. The _prognosis_ therefore in cases of secondary haemorrhage
+can never be other than uncertain and unfavourable; the danger from loss
+of blood _per se_ is less when the artery concerned is amenable to
+control by surgical measures.
+
+_Treatment._--The treatment of secondary haemorrhage includes the use of
+local measures to arrest the bleeding, the employment of general
+measures to counteract the accompanying toxaemia, and when the loss of
+blood has been considerable, the treatment of the bloodless state.
+
+_Local Measures to arrest the Haemorrhage._--The occurrence of even
+slight haemorrhages from a septic wound in the vicinity of a large blood
+vessel is to be taken seriously; it is usually necessary to _open up the
+wound_, clear out the clots and infected tissues with a sharp spoon,
+disinfect the walls of the cavity with eusol or hydrogen peroxide, and
+_pack_ it carefully but not too tightly with gauze impregnated with some
+antiseptic, such as "bipp," so that, if the bleeding does not recur, it
+may be left undisturbed for several days. The packing should if possible
+be brought into actual contact with the leaking point in the vessel, and
+so arranged as to make pressure on the artery above the erosion. The
+dressings and bandage are then applied, with the limb in the attitude
+that will diminish the force of the stream through the main artery, for
+example, flexion at the elbow in haemorrhage from the deep palmar arch.
+Other measures for combating the local sepsis, such as the irrigation
+method of Carrel, may be considered.
+
+If the wound involves one of the extremities, it may be useful; and it
+imparts confidence to the nurse, and, it may be, to the patient, if a
+Petit's tourniquet is loosely applied above the wound, which the nurse
+is instructed to tighten up in the event of bleeding taking place.
+
+_Ligation of the Artery._--If the haemorrhage recurs in spite of packing
+the wound, or if it is serious from the outset and likely to be critical
+if repeated, ligation of the artery itself or of the trunk from which it
+springs, at a selected spot higher up, should be considered. This is
+most often indicated in wounds of the extremities.
+
+As examples of proximal ligation for secondary haemorrhage may be cited
+ligation of the hypogastric artery for haemorrhage in the buttock, of the
+common iliac for haemorrhage in the thigh, of the brachial in the upper
+arm for haemorrhage from the deep palmar arch, and of the posterior
+tibial behind the medial malleolus for haemorrhage from the sole of the
+foot.
+
+_Amputation_ is the last resource, and should be decided upon if the
+haemorrhage recurs after proximal ligation, or if this has been followed
+by gangrene of the limb; it should also be considered if the nature of
+the wound and the virulence of the sepsis would of themselves justify
+removal of the limb. Every surgeon can recall cases in which a timely
+amputation has been the means of saving life.
+
+The _counteraction of the toxaemia_ and the _treatment of the bloodless
+state_, are carried out on the usual lines.
+
+#Haemorrhage of Toxic Origin.#--Mention must also be made of haemorrhages
+which depend upon infective or toxic conditions and in which no gross
+lesion of the vessels can be discovered. The bleeding occurs as an
+oozing, which may be comparatively slight and unimportant, or by its
+persistence may become serious. It takes place into the superficial
+layers of the skin, from mucous membranes, and into the substance of
+such organs as the pancreas. Haemorrhage from the stomach and intestine,
+attended with a brown or black discoloration of the vomit and of the
+stools, is one of the best known examples: it is not uncommonly met with
+in infective conditions originating in the appendix, intestine,
+gall-bladder, and other abdominal organs. Haemorrhage from the mucous
+membrane of the stomach after abdominal operations--apparently also due
+to toxic causes and not to the operation--gives rise to the so-called
+_post-operative haematemesis_.
+
+#Constitutional Effects of Haemorrhage.#--The severity of the symptoms
+resulting from haemorrhage depends as much on the rapidity with which the
+bleeding takes place as on the amount of blood lost. The sudden loss of
+a large quantity, whether from an open wound or into a serous
+cavity--for example, after rupture of the liver or spleen--is attended
+with marked pallor of the surface of the body and coldness of the skin,
+especially of the face, feet, and hands. The skin is moist with a cold,
+clammy sweat, and beads of perspiration stand out on the forehead. The
+pulse becomes feeble, soft, and rapid, and the patient is dull and
+listless, and complains of extreme thirst. The temperature is usually
+sub-normal; and the respiration rapid, shallow, and sighing in
+character. Abnormal visual sensations, in the form of flashes of light
+or spots before the eyes; and rushing, buzzing, or ringing sounds in the
+ears, are often complained of.
+
+In extreme cases, phenomena which have been aptly described as those of
+"air-hunger" ensue. On account of the small quantity of blood
+circulating through the body, and the diminished haemoglobin content of
+the blood, the tissues are imperfectly oxygenated, and the patient
+becomes extremely restless, gasping for breath, constantly throwing
+about his arms and baring his chest in the vain attempt to breath more
+freely. Faintness and giddiness are marked features. The diminished
+supply of oxygen to the brain and to the muscles produces muscular
+twitchings, and sometimes convulsions. Finally the pupils dilate, the
+sphincters relax, and death ensues.
+
+Young children stand the loss of blood badly, but they quickly recover,
+as the regeneration of blood takes place rapidly. In old people also,
+and especially when they are fat, the loss of blood is badly borne, and
+the ill effects last longer. Women, on the whole, stand loss of blood
+better than men, and in them the blood is more rapidly re-formed. A few
+hours after a severe haemorrhage there is usually a leucocytosis of from
+15,000 to 30,000.
+
+#Treatment of the Bloodless State.#--The patient should be placed in a
+warm, well-ventilated room, and the foot of the bed elevated. Cardiac
+stimulants, such as strychnin or alcohol, must be judiciously
+administered, over-stimulation being avoided. The inhalation of oxygen
+has been found useful in relieving the urgent symptoms of dyspnoea.
+
+The blood may be emptied from the limbs into the vessels of the trunk,
+where it is more needed, by holding them vertically in the air for a few
+minutes, and then applying a firm elastic bandage over a layer of cotton
+wool, from the periphery towards the trunk.
+
+_Introduction of Fluids into the Circulation._--The most valuable
+measure for maintaining the circulation, however, is by transfusion of
+blood (_Op. Surg._, p. 37). If this is not immediately available the
+introduction of from one to three pints of physiological salt
+solution (a teaspoonful of common salt to a pint of water) into a vein,
+or a 6 per cent. solution of gum acacia, is a useful expedient. The
+solution is sterilised by boiling, and cooled to a temperature of about
+105 F. The addition of 5 to 10 minims of adrenalin solution (1 in 1000)
+is advantageous in raising the blood-pressure (_Op. Surg._, p. 565).
+
+When the intra-venous method is not available, one or two pints of
+saline solution with adrenalin should be slowly introduced into the
+rectum, by means of a long rubber tube and a filler. Satisfactory,
+although less rapidly obtained results follow the introduction of saline
+solution into the cellular tissue--for example, under the mamma, into
+the axilla, or under the skin of the back.
+
+If the patient can retain fluids taken by the mouth--such as hot coffee,
+barley water, or soda water--these should be freely given, unless the
+injury necessitates operative treatment under a general anaesthetic.
+
+Transfusion of blood is most valuable as _a preliminary to operation_ in
+patients who are bloodless as a result of haemorrhage from gastric and
+duodenal ulcers, and in bleeders.
+
+
+HAEMOPHILIA
+
+The term haemophilia is applied to an inherited disease which renders the
+patient liable to serious haemorrhage from even the most trivial
+injuries; and the subjects of it are popularly known as "bleeders."
+
+The cause of the disease and its true nature are as yet unknown. There
+is no proof of any structural defect in the blood vessels, and beyond
+the fact that there is a diminution in the number of blood-plates, it
+has not been demonstrated that there is any alteration in the
+composition of the blood.
+
+The affection is in a marked degree hereditary, all the branches of an
+affected family being liable to suffer. Its mode of transmission to
+individuals, moreover, is characteristic: the male members of the stock
+alone suffer from the affection in its typical form, while the tendency
+is transmitted through the female line. Thus the daughters of a father
+who is a bleeder, whilst they do not themselves suffer from the disease,
+transmit the tendency to their male offspring. The sons, on the other
+hand, neither suffer themselves nor transmit the disease to their
+children (Fig. 64). The female members of a haemophilic stock are often
+very prolific, and there is usually a predominance of daughters in their
+families.
+
+
+FIG 64.--Genealogical Tree of a Haemophilic Family.
+
+Great-Great-Grandmother                Great-Great-Grandfather
+Mrs D. (Lancashire) F                  M (History not known
+                   .|                  |  as to bleeding)
+                   .|                  |
+                   .+----------+-------+
+                   ............|
+                              .|
+                           ....|
+                           .+---------+--------+
+         Great-Grandmother .|         |        |
+           (Married three  .F        MB       MB
+                times)     .|
+                           .|
+                           .|
+      By First Husband     .|                  By Second           By Third
+              ..............|                  Husband             Husband
+   +-----------+------------+----------+-------+-------+-----------+------+
+   |          .|            |          |       +-------+-----------+------+
+   M          .F            F          F       |       |           +------+
+   |          .|            |          |       MB      F Died in      No
+Died       Grandmother      |          |               | Childbed    Family
+ aet.         .|            |     +-----------+   +----+---
+ 70           .|        +------+  |had family |   |
+              .|        |      |  |but history|   |
+              .|        MB    MB  |not known  |   MB
+              .|
+              .|
+              .|.............................
++-----+----------+------------+------------+------------+-------------+
+|     |          |            |            |.           |             |
+|     |          |            |            |.           |             |
+M     M          M            MB           F.           F             F
+      |                                    |.           |             |
+      |                                  Mother   +--+--+---+--+--+   |
+    +----+                                 |.     |  |  |   |  |  |   |
+    |    |                                 |.     M  M  MB  F  F  F   |
+    M    F                                 |.                         |
+     Not Married                           |.             +---+---+---+---+
+                                           |.             |   |   |   |   |
+                                           |.             MB  M   MB  M   M
+                              .............|.
+                         +-----+-----+-----+-----+-----+
+                         |    .|    .|     |     |     |
+                         |    .|*   .|*    |     |     |
+                         M    MB    MB     F     F     F
+
+
+F = Females.  M = Males (not bleeders).  MB = Males (bleeders)
+
+ ** the patients observed by the authors. The dotted line shows the
+    transmission of the disease to our patients through four
+    generations.
+
+
+The disease is met with in boys who are otherwise healthy, and usually
+manifests itself during the first few years of life. In rare instances
+profuse haemorrhage takes place when the umbilical cord separates. As a
+rule the first evidence is the occurrence of long-continued and
+uncontrollable bleeding from a comparatively slight injury, such as the
+scratch of a pin, the extraction of a tooth, or after the operation of
+circumcision. The blood oozes slowly from the capillaries; at first it
+appears normal, but after flowing for some days, or it may be weeks, it
+becomes pale, thin, and watery, and shows less and less tendency to
+coagulate.
+
+Female members of haemophilia families sometimes show a tendency to
+excessive haemorrhage, but they seldom manifest the characteristic
+features met with in the male members.
+
+Sometimes the haemorrhage takes place apparently spontaneously from the
+gums, the nasal or the intestinal mucous membrane. In other cases the
+bleeding occurs into the cellular tissue under the skin or mucous
+membrane, producing large areas of ecchymosis and discoloration. One of
+the commonest manifestations of the disease is the occurrence of
+haemorrhage into the cavities of the large joints, especially the knee,
+elbow, or hip. The patient suffers repeatedly from such haemorrhages, the
+determining injury being often so slight as to have passed unobserved.
+
+There is evidence that the tendency to bleed is greater at certain times
+than at others--in some cases showing almost a cyclical
+character--although nothing is known as to the cause of the variation.
+
+After a severe haemorrhage into the cellular tissue or into a joint, the
+patient becomes pale and anaemic, the temperature may rise to 102 or
+103 F., the pulse become small and rapid, and haemic murmurs are
+sometimes developed over the heart and large arteries. The swelling is
+tense, fluctuating, and hot, and there is considerable pain and
+tenderness.
+
+In exceptional cases, blisters form over the seat of the effusion, or
+the skin may even slough, and the clinical features may therefore come
+to simulate closely those of an acute suppurative condition. When the
+skin sloughs, an ulcer is formed with altered blood-clot in its floor
+like that seen in scurvy, and there is a remarkable absence of any
+attempt at healing.
+
+The acute symptoms gradually subside, and the blood is slowly absorbed,
+the discoloration of the skin passing through the same series of changes
+as occur after an ordinary bruise. The patients seldom manifest the
+symptoms of the bloodless state, and the blood is rapidly regenerated.
+
+The _diagnosis_ is easy if the patient or his friends are aware of the
+family tendency to haemorrhage and inform the doctor of it, but they are
+often sensitive and reticent regarding the fact, and it may only be
+elicited after close investigation. From the history it is usually easy
+to exclude scurvy and purpura. Repeated haemorrhages into a joint may
+result in appearances which closely simulate those of tuberculous
+disease. Recent haemorrhages into the cellular tissue often present
+clinical features closely resembling those of acute cellulitis or
+osteomyelitis. A careful examination, however, may reveal ecchymoses on
+other parts of the body which give a clue to the nature of the
+condition, and may prevent the disastrous consequences that may follow
+incision.
+
+These patients usually succumb sooner or later to haemorrhage, although
+they often survive several severe attacks. After middle life the
+tendency to bleed appears to diminish.
+
+_Treatment._--As a rule the ordinary means of arresting haemorrhage are
+of little avail. From among the numerous means suggested, the following
+may be mentioned: The application to the bleeding point of gauze soaked
+in a 1 in 1000 solution of adrenalin; prolonged inhalation of oxygen;
+freezing the part with a spray of ethyl-chloride; one or more
+subcutaneous injections of gelatin--5 ounces of a 2.5 per cent.
+solution of white gelatin in normal salt solution being injected at a
+temperature of about 100 F.; the injection of pituitary extract. The
+application of a pad of gauze soaked in the blood of a normal person
+sometimes arrests the bleeding.
+
+To prevent bleeding in haemophilics, intra-venous or subcutaneous
+injections of fresh blood serum, taken from the human subject, the
+sheep, the dog, or the horse, have proved useful. If fresh serum is not
+available, anti-diphtheritic or anti-tetanic serum or trade
+preparations, such as hemoplastin, may be employed. We have removed the
+appendix and amputated through the thigh in haemophilic subjects without
+excessive loss of blood after a course of fresh sheep's serum given by
+the mouth over a period of several weeks.
+
+The chloride and lactate of calcium, and extract of thymus gland have
+been employed to increase the coagulability of the blood. The patient
+should drink large quantities of milk, which also increases the
+coagulability of the blood. Monro has observed remarkable results from
+the hypodermic injection of emetin hydrochloride in 1/2-grain doses.
+
+
+THROMBOSIS AND EMBOLISM
+
+The processes known as thrombosis and embolism are so intimately
+associated with the diseases of blood vessels that it is convenient to
+define these terms in the first instance.
+
+#Thrombosis.#--The term _thrombus_ is applied to a clot of blood formed
+in the interior of the heart or of a blood vessel, and the process by
+which such a clot forms is known as _thrombosis_. It would appear that
+slowing or stagnation of the blood-stream, and interference with the
+integrity of the lining membrane of the vessel wall, are the most
+important factors determining the formation of the clot. Alterations in
+the blood itself, such as occur, for example, in certain toxaemias, also
+favour coagulation. When the thrombus is formed slowly, it consists of
+white blood cells with a small proportion of fibrin, and, being
+deposited in successive layers, has a distinctly laminated appearance on
+section. It is known as a _white thrombus_ or laminated clot, and is
+often met with in the sac of an aneurysm (Fig. 72). When rapidly formed
+in a vessel in which the blood is almost stagnant--as, for example, in a
+pouched varicose vein--the blood coagulates _en masse_, and the clot
+consists of all the elements of the blood, constituting a _red thrombus_
+(Fig. 66). Sometimes the thrombus is _mixed_--a red thrombus being
+deposited on a white one, it may be in alternate layers.
+
+When aseptic, a thrombus may become detached and be carried off in the
+blood-stream as an embolus; it may become organised; or it may
+degenerate and undergo calcification. Occasionally a small thrombus
+situated behind a valve in a varicose vein or in the terminal end of a
+dilated vein--for example in a pile--undergoes calcification, and is
+then spoken of as a _phlebolith_; it gives a shadow with the X-rays.
+
+When infected with pyogenic bacteria, the thrombus becomes converted
+into pus and a localised abscess forms; or portions of the thrombus may
+be carried as emboli in the circulation to distant parts, where they
+give rise to secondary foci of suppuration--pyaemic abscesses.
+
+#Embolism.#--The term _embolus_ is applied to any body carried along in
+the circulation and ultimately becoming impacted in a blood vessel. This
+occurrence is known as _embolism_. The commonest forms of embolus are
+portions of thrombi or of fibrinous formations on the valves of the
+heart, the latter being usually infected with micro-organisms.
+
+Embolism plays an important part in determining one form of gangrene, as
+has already been described. Infective emboli are the direct cause of the
+secondary abscesses that occur in pyaemia; and they are sometimes
+responsible for the formation of aneurysm.
+
+Portions of malignant tumours also may form emboli, and their impaction
+in the vessels may lead to the development of secondary growths in
+distant parts of the body.
+
+Fat and air embolism have already been referred to.
+
+
+ARTERITIS
+
+_Pyogenic._--Non-suppurative inflammation of the coats of an artery may
+so soften the wall of the vessel as to lead to aneurysmal dilatation. It
+is not uncommon in children, and explains the occurrence of aneurysm in
+young subjects.
+
+When suppuration occurs, the vessel wall becomes disintegrated and gives
+way, leading to secondary haemorrhage. If the vessel ruptures into an
+abscess cavity, dangerous bleeding may occur when the abscess bursts or
+is opened.
+
+_Syphilitic._--The inflammation associated with syphilis results in
+thickening of the tunica intima, whereby the lumen of the vessel becomes
+narrowed, or even obliterated--_endarteritis obliterans_. The middle
+coat usually escapes, but the tunica externa is generally thickened.
+These changes cause serious interference with the nutrition of the parts
+supplied by the affected arteries. In large trunks, by diminishing the
+elasticity of the vessel wall, they are liable to lead to the formation
+of aneurysm.
+
+Changes in the arterial walls closely resembling those of syphilitic
+arteritis are sometimes met with in _tuberculous_ lesions.
+
+#Arterio-sclerosis# or #Chronic Arteritis#.--These terms are applied to
+certain changes which result in narrowing of the lumen and loss of
+elasticity in the arteries. The condition may affect the whole vascular
+system or may be confined to particular areas. In the smaller arteries
+there is more or less uniform thickening of the tunica intima from
+proliferation of the endothelium and increase in the connective tissue
+in the elastic lamina--a form of obliterative endarteritis. The
+narrowing of the vessels may be sufficient to determine gangrene in the
+extremities. In course of time, particularly in the larger arteries,
+this new tissue undergoes degeneration, at first of a fatty nature, but
+progressing in the direction of calcification, and this is followed by
+the deposit of lime salts in the young connective tissue and the
+formation of calcareous plates or rings over a considerable area of the
+vessel wall. To this stage in the process the term _atheroma_ is
+applied. The endothelium over these plates often disappears, leaving
+them exposed to the blood-stream.
+
+Changes of a similar kind sometimes occur in the middle coat, the lime
+salts being deposited among the muscle fibres in concentric rings.
+
+The primary cause of arterio-sclerosis is not definitely known, but its
+almost constant occurrence, to a greater or less degree, in the aged
+suggests that it is of the nature of a senile degeneration. It is
+favoured by anything which throws excessive strain on the vessel walls,
+such as heavy muscular work; by chronic alcoholism and syphilis; or by
+such general diseases as tend to raise the blood-pressure--for example,
+chronic Bright's disease or gout. It occurs with greater frequency and
+with greater severity in men than in women.
+
+Atheromatous degeneration is most common in the large arterial trunks,
+and the changes are most marked at the arch of the aorta, opposite the
+flexures of joints, at the mouths of large branches, and at parts where
+the vessel lies in contact with bone. The presence of diseased patches
+in the wall of an artery diminishes its elasticity and favours
+aneurysmal dilatation. Such a vessel also is liable to be ruptured by
+external violence and so give rise to traumatic aneurysm. Thrombosis is
+liable to occur when calcareous plates are exposed in the lumen of the
+vessel by destruction of the endothelium, and this predisposes to
+embolism. Arterio-sclerosis also interferes with the natural arrest of
+haemorrhage, and by rendering the vessels brittle, makes it difficult to
+secure them by ligature. In advanced cases the accessible arteries--such
+as the radial, the temporal or the femoral--may be felt as firm,
+tortuous cords, which are sometimes so hard that they have been aptly
+compared to "pipe-stems." The pulse is smaller and less compressible
+than normal, and the vessel moves bodily with each pulsation. It must be
+borne in mind, however, that the condition of the radial artery may fail
+to afford a clue to that of the larger arteries. Calcified arteries are
+readily identified in skiagrams (Fig. 65).
+
+[Illustration: FIG. 65.--Radiogram showing Calcareous Degeneration
+(Atheroma) of Arteries.]
+
+We have met with a chronic form of arterial degeneration in elderly
+women, affecting especially the great vessels at the root of the neck,
+in which the artery is remarkably attenuated and dilated, and so friable
+that the wall readily tears when seized with an artery-forceps,
+rendering ligation of the vessel in the ordinary way well-nigh
+impossible. Matas suggests infolding the wall of the vessel with
+interrupted sutures that do not pierce the intima, and wrapping it
+round with a strip of peritoneum or omentum.
+
+The most serious form of arterial _thrombosis_ is that met with _in the
+abdominal aorta_, which is attended with violent pains in the lower
+limbs, rapidly followed by paralysis and arrest of the circulation.
+
+
+THROMBO-PHLEBITIS AND THROMBOSIS IN VEINS
+
+#Thrombosis# is more common in veins than in arteries, because slowing
+of the blood-stream and irritation of the endothelium of the vessel wall
+are, owing to the conditions of the venous circulation, more readily
+induced in veins.
+
+Venous thrombosis may occur from purely mechanical causes--as, for
+example, when the wall of a vein is incised, or the vessel included in a
+ligature, or when it is bruised or crushed by a fragment of a broken
+bone or by a bandage too tightly applied. Under these conditions
+thrombosis is essentially a reparative process, and has already been
+considered in relation to the repair of blood vessels.
+
+In other cases thrombosis is associated with certain constitutional
+diseases--gout, for example; the endothelium of the veins undergoing
+changes--possibly the result of irritation by abnormal constituents in
+the blood--which favour the formation of thrombi.
+
+Under these various conditions the formation of a thrombus is not
+necessarily associated with the action of bacteria, although in any
+of them this additional factor may be present.
+
+The most common cause of venous thrombosis, however, is inflammation of
+the wall of the vein--phlebitis.
+
+#Phlebitis.#--Various forms of phlebitis are met with, but for practical
+purposes they may be divided into two groups--one in which there is a
+tendency to the formation of a thrombus; the other in which the
+infective element predominates.
+
+In surgical patients, the _thrombotic form_ is almost invariably met
+with in the lower extremity, and usually occurs in those who are
+debilitated and anaemic, and who are confined to bed for prolonged
+periods--for example, during the treatment of fractures of the leg or
+pelvis, or after such operations as herniotomy, prostatectomy, or
+appendectomy.
+
+_Clinical Features._--The most typical example of this form of phlebitis
+is that so frequently met with in the great saphena vein, especially
+when it is varicose. The onset of the attack is indicated by a sudden
+pain in the lower limb--sometimes below, sometimes above the knee. This
+initial pain may be associated with shivering or even with a rigor, and
+the temperature usually rises one or two degrees. There is swelling and
+tenderness along the line of the affected vein, and the skin over it is
+a dull-red or purple colour. The swollen vein may be felt as a firm
+cord, with bead-like enlargements in the position of the valves. The
+patient experiences a feeling of stiffness and tightness throughout the
+limb. There is often oedema of the leg and foot, especially when the limb
+is in the dependent position. The acute symptoms pass off in a few days,
+but the swelling and tenderness of the vein and the oedema of the limb
+may last for many weeks.
+
+When the deep veins--iliac, femoral, popliteal--are involved, there is
+great swelling of the whole limb, which is of a firm almost "wooden"
+consistence, and of a pale-white colour; the oedema may be so great that
+it is impossible to feel the affected vein until the swelling has
+subsided. This is most often seen in puerperal women, and is known as
+_phlegmasia alba dolens_.
+
+_Treatment._--The patient must be placed at absolute rest, with the foot
+of the bed raised on blocks 10 or 12 inches high, and the limb
+immobilised by sand-bags or splints. It is necessary to avoid handling
+the parts, lest the clot be displaced and embolism occur. To avoid
+frequent movement of the limb, the necessary dressings should be kept in
+position by means of a many-tailed rather than a roller bandage.
+
+To relieve the pain, warm fomentations or lead and opium lotion should
+be applied. Later, ichthyol-glycerin, or glycerin and belladonna, may be
+substituted.
+
+When, at the end of three weeks, the danger of embolism is past,
+douching and gentle massage may be employed to disperse the oedema; and
+when the patient gets up he should wear a supporting elastic bandage.
+
+The _infective_ form usually begins as a peri-phlebitis arising in
+connection with some focus of infection in the adjacent tissues. The
+elements of the vessel wall are destroyed by suppuration, and the
+thrombus in its lumen becomes infected with pyogenic bacteria and
+undergoes softening.
+
+_Occlusion of the inferior vena cava_ as a result of infective
+thrombosis is a well-known condition, the thrombosis extending into the
+main trunk from some of its tributaries, either from the femoral or
+iliac veins below or from the hepatic veins above.
+
+Portions of the softened thrombus are liable to become detached and to
+enter the circulating blood, in which they are carried as emboli. These
+may lodge in distant parts, and give rise to secondary foci of
+suppuration--pyaemic abscesses.
+
+_Clinical Features._--Infective phlebitis is most frequently met with in
+the transverse sinus as a sequel to chronic suppuration in the mastoid
+antrum and middle ear. It also occurs in relation to the peripheral
+veins, but in these it can seldom be recognised as a separate entity,
+being merged in the general infective process from which it takes
+origin. Its occurrence may be inferred, if in the course of a
+suppurative lesion there is a sudden rise of temperature, with pain,
+redness, and swelling along the line of a venous trunk, and a rapidly
+developed oedema of the limb, with pitting of the skin on pressure. In
+rare cases a localised abscess forms in the vein and points towards the
+surface.
+
+_Treatment._--Attention must be directed towards the condition with
+which the phlebitis is associated. Ligation of the vein on the cardiac
+side of the thrombus with a view to preventing embolism is seldom
+feasible in the peripheral veins, although, as will be pointed out
+later, the jugular vein is ligated with this object in cases of
+phlebitis of the transverse sinus.
+
+
+VARIX--VARICOSE VEINS
+
+The term varix is applied to a condition in which veins are so altered
+in structure that they remain permanently dilated, and are at the same
+time lengthened and tortuous. Two types are met with: one in which
+dilatation of a large superficial vein and its tributaries is the most
+obvious feature; the other, in which bunches of distended and tortuous
+vessels develop at one or more points in the course of a vein, a
+condition to which Virchow applied the term _angioma racemosum venosum_.
+The two types may occur in combination.
+
+Any vein in the body may become varicose, but the condition is rare
+except in the veins of the lower extremity, in the veins of the
+spermatic cord (varicocele), and in the veins of the anal canal
+(haemorrhoids).
+
+We are here concerned with varix as it occurs in the veins of the lower
+extremity.
+
+_Etiology._--Considerable difference of opinion exists as to the
+essential cause of varix. The weight of evidence is in favour of the
+view that, when dilatation is the predominant element, it results from a
+congenital deficiency in the number, size, and strength of the valves of
+the affected veins, and in an inherent weakness in the vessel walls.
+The _angioma racemosum venosum_ is probably also due to a congenital
+alteration in the structure of the vessels, and is allied to tumours of
+blood vessels. The view that varix is congenital in origin, as was first
+suggested by Virchow, is supported by the fact that in a large
+proportion of cases the condition is hereditary; not only may several
+members of the same family in succeeding generations suffer from varix,
+but it is often found that the same vein, or segment of a vein, is
+involved in all of them. The frequent occurrence of varix in youth is
+also an indication of its congenital origin.
+
+In the majority of cases it is only when some exciting factor comes into
+operation that the clinical phenomena associated with varix appear. The
+most common exciting cause is increased pressure within the veins, and
+this may be produced in a variety of ways. In certain diseases of the
+heart, lungs, and liver, for example, the venous pressure may be so
+raised as to cause a localised dilatation of such veins as are
+congenitally weak. The direct pressure of a tumour, or of the gravid
+uterus on the large venous trunks in the pelvis, may so obstruct the
+flow as to distend the veins of the lower extremity. It is a common
+experience in women that the signs of varix date from an antecedent
+pregnancy. The importance of the wearing of tight garters as a factor in
+the production of varicose veins has been exaggerated, although it must
+be admitted that this practice is calculated to aggravate the condition
+when it is once established. It has been proved experimentally that the
+backward pressure in the veins may be greatly increased by straining, a
+fact which helps to explain the frequency with which varicosity occurs
+in the lower limbs of athletes and of those whose occupation involves
+repeated and violent muscular efforts. There is reason to believe,
+moreover, that a sudden strain may, by rupturing the valves and so
+rendering them incompetent, induce varicosity independently of any
+congenital defect. Prolonged standing or walking, by allowing gravity to
+act on the column of blood in the veins of the lower limbs, is also an
+important determining factor in the production of varix.
+
+Thrombosis of the deep veins--in the leg, for example--may induce marked
+dilatation of the superficial veins, by throwing an increased amount of
+work upon them. This is to be looked upon rather as a compensatory
+hypertrophy of the superficial vessels than as a true varix.
+
+_Morbid Anatomy._--In the lower extremity the varicosity most commonly
+affects the vessels of the great saphena system; less frequently those
+of the small saphena system. Sometimes both systems are involved, and
+large communicating branches may develop between the two.
+
+The essential lesion is the absence or deficiency of valves, so that
+they are incompetent and fail to support the column of blood which bears
+back upon them. Normally the valves in the femoral and iliac veins and
+in the inferior vena cava are imperfectly developed, so that in the
+erect posture the great saphena receives a large share of the backward
+pressure of the column of venous blood.
+
+The whole length of the vein may be affected, but as a rule the disease
+is confined to one or more segments, which are not only dilated, but are
+also increased in length, so that they become convoluted. The adjacent
+loops of the convoluted vein are often bound together by fibrous tissue.
+All the coats are thickened, chiefly by an increased development of
+connective tissue, and in some cases changes similar to those of
+arterio-sclerosis occur. The walls of varicose veins are often
+exceedingly brittle. In some cases the thickening is uniform, and in
+others it is irregular, so that here and there thin-walled sacs or
+pouches project from the side of the vein. These pouches vary in size
+from a bean to a hen's egg, the larger forms being called _venous
+cysts_, and being most commonly met with in the region of the saphenous
+opening and of the opening in the popliteal fascia. Such pouches, being
+exposed to injury, are frequently the seat of thrombosis (Fig. 66).
+
+[Illustration: FIG. 66.--Thrombosis in Tortuous and Pouched Great
+Saphena Vein, in longitudinal section.]
+
+_Clinical Features._--Varix is most frequently met with between puberty
+and the age of thirty, and the sexes appear to suffer about equally.
+
+The amount of discomfort bears no direct proportion to the extent of
+the varicosity. It depends rather upon the degree of pressure in the
+veins, as is shown by the fact that it is relieved by elevation of the
+limb. When the whole length of the main trunk of the great saphena is
+implicated, the pressure in the vein is high and the patient suffers a
+good deal of pain and discomfort. When, on the contrary, the upper part
+of the saphena and its valves are intact, and only the more distal veins
+are involved, the pressure is not so high and there is comparatively
+little suffering. The usual complaint is of a sense of weight and
+fulness in the limb after standing or walking, sometimes accompanied by
+actual pain, from which relief is at once obtained by raising the limb.
+Cramp-like pains in the muscles are often associated with varix of the
+deep veins.
+
+The dilated and tortuous vein can be readily seen and felt when the
+patient is examined in the upright posture. In advanced cases, bead-like
+swellings are sometimes to be detected over the position of the valves,
+and, on running the fingers along the course of the vessel, a firm
+ridge, due to periphlebitis, may be detected on each side of the vein.
+When the limb is oedematous, the outline of the veins is obscured, but
+they can be identified on palpation as gutter-like tracks. When large
+veins are implicated, a distinct impulse on coughing may be seen to pass
+down as far as the knee; and if the vessel is sharply percussed a fluid
+wave may be detected passing both up and down the vein.
+
+If the patient is placed on a couch and the limb elevated, the veins are
+emptied, and if pressure is then made over the region of the saphenous
+opening and the patient allowed to stand up, so long as the great
+saphena system alone is involved, the veins fill again very slowly from
+below. If the small saphena system also is involved, and if
+communicating branches are dilated, the veins fill up from below more
+rapidly. When the pressure over the saphenous opening is removed, the
+blood rapidly rushes into the varicose vessels from above; this is known
+as Trendelenburg's test.
+
+The most marked dilatation usually occurs on the medial side of the
+limb, between the middle of the thigh and the middle of the calf, the
+arrangement of the veins showing great variety (Fig. 67).
+
+There are usually one or more bunches of enlarged and tortuous veins in
+the region of the knee. Frequently a large branch establishes a
+communication between the systems of the great and small saphenous veins
+in the region of the popliteal space, or across the front of the upper
+part of the tibia. The superficial position of this last branch and its
+proximity to the bone render it liable to injury.
+
+[Illustration: FIG. 67.--Extensive Varix of Internal Saphena System on
+Left Leg, of many years' standing.]
+
+The small veins of the skin of the ankle and foot often show as fine
+blue streaks arranged in a stellate or arborescent manner, especially in
+women who have borne children.
+
+_Complications._--When the varix is of long standing, the skin in the
+lower part of the leg sometimes assumes a mahogany-brown or bluish hue,
+as a result of the _deposit of blood pigment_ in the tissues, and this
+is frequently a precursor of ulceration.
+
+_Chronic dermatitis_ (_varicose eczema_) is often met with in the lower
+part of the leg, and is due to interference with the nutrition of the
+skin. The incompetence of the valves allows the pressure in the varicose
+veins to equal that in the arterioles, so that the capillary circulation
+is impeded. From the same cause the blood in the deep veins is enabled
+to enter the superficial veins, where the backward pressure is so great
+that the blood flows down again, and so a vicious circle is established.
+The blood therefore loses more and more of its oxygen, and so fails to
+nourish the tissues.
+
+The _ulcer_ of the leg associated with varicose veins has already been
+described.
+
+_Haemorrhage_ may take place from a varicose vein as a result of a wound
+or of ulceration of its wall. Increased intra-venous pressure produced
+by severe muscular strain may determine rupture of a vein exposed in the
+floor of an ulcer. If the limb is dependent, the incompetency of the
+valves permits of rapid and copious bleeding, which may prove fatal,
+particularly if the patient is intoxicated when the rupture takes place
+and no means are taken to arrest the haemorrhage. The bleeding may be
+arrested at once by elevating the limb, or by applying pressure directly
+over the bleeding point.
+
+_Phlebitis and thrombosis_ are common sequelae of varix, and may prove
+dangerous, either by spreading into the large venous trunks or by giving
+rise to emboli. The larger the varix the greater is the tendency for a
+thrombus to spread upwards and to involve the deep veins. Thrombi
+usually originate in venous cysts or pouches, and at acute bends on the
+vessel, especially when these are situated in the vicinity of the knee,
+and are subjected to repeated injuries--for example in riding.
+Phleboliths sometimes form in such pouches, and may be recognised in a
+radiogram. In a certain proportion of cases, especially in elderly
+people, the occurrence of thrombosis leads to cure of the condition by
+the thrombus becoming organised and obliterating the vein.
+
+_Treatment._--At best the treatment of varicose veins is only
+palliative, as it is obviously impossible to restore to the vessels
+their normal structure. The patient must avoid wearing anything, such as
+a garter, which constricts the limb, and any obvious cause of direct
+pressure on the pelvic veins, such as a tumour, persistent
+constipation, or an ill-fitting truss, should be removed. Cardiac,
+renal, or pulmonary causes of venous congestion must also be treated,
+and the functions of the liver regulated. Severe forms of muscular
+exertion and prolonged standing or walking are to be avoided, and the
+patient may with benefit rest the limb in an elevated position for a few
+hours each day. To support the distended vessels, a closely woven silk
+or worsted stocking, or a light and porous form of elastic bandage,
+applied as a puttee, should be worn. These appliances should be put on
+before the patient leaves his bed in the morning, and should only be
+removed after he lies down at night. In this way the vessels are never
+allowed to become dilated. Elastic stockings, and bandages made entirely
+of india-rubber, are to be avoided. In early and mild cases these
+measures are usually sufficient to relieve the patient's discomfort.
+
+_Operative Treatment._--In aggravated cases, when the patient is
+suffering pain, when his occupation is interfered with by repeated
+attacks of phlebitis, or when there are large pouches on the veins,
+operative treatment is called for. The younger the patient the clearer
+is the indication to operate. It may be necessary to operate to enable a
+patient to enter one of the public services, even although no symptoms
+are present. The presence of an ulcer does not contra-indicate
+operation; the ulcer should be excised, and the raw surface covered with
+skin grafts, before dealing with the veins.
+
+The _operation of Trendelenburg_ is especially appropriate to cases in
+which the trunk of the great saphena vein in the thigh is alone
+involved. It consists in exposing three or four inches of the vein in
+its upper part, applying a ligature at the upper and lower ends of the
+exposed portion, and, after tying all tributary branches, resecting this
+portion of the vein.
+
+The procedure of C. H. Mayo is adapted to cases in which it is desirable
+to remove longer segments of the veins. It consists in the employment of
+special instruments known as "ring-enucleators" or "vein-strippers," by
+means of which long portions of the vein are removed through
+comparatively small incisions.
+
+An alternative procedure consists in avulsing segments of the vein by
+means of Babcock's stylet, which consists of a flexible steel rod, 30
+inches in length, with acorn-shaped terminals. The instrument is passed
+along the lumen of the segment to be dealt with, and a ligature applied
+around the vein above the bulbous end of the stylet enables nearly the
+whole length of the great saphena vein to be dragged out in one piece.
+These methods are not suitable when the veins are brittle, when there
+are pouches or calcareous deposits in their walls, or where there has
+been periphlebitis binding the coils together.
+
+Mitchell of Belfast advises exposing the varices at numerous points by
+half-inch incisions, and, after clamping the vein between two pairs of
+forceps, cutting it across and twisting out the segments of the vein
+between adjacent incisions. The edges of the incisions are sutured; and
+the limb is firmly bandaged from below upwards, and kept in an elevated
+position. We have employed this method with satisfactory results.
+
+The treatment of the complications of varix has already been considered.
+
+
+ANGIOMA[4]
+
+[4] In the description of angiomas we have followed the teaching of the
+late John Duncan.
+
+Tumours of blood vessels may be divided, according to the nature of the
+vessels of which they are composed, into the capillary, the venous, and
+the arterial angiomas.
+
+
+CAPILLARY ANGIOMA
+
+The most common form of capillary angioma is the naevus or congenital
+telangiectasis.
+
+#Naevus.#--A naevus is a collection of dilated capillaries, the afferent
+arterioles and the efferent venules of which often share in the
+dilatation. Little is known regarding the _etiology_ of naevi beyond the
+fact that they are of congenital origin. They often escape notice until
+the child is some days old, but attention is usually drawn to them
+within a fortnight of birth. For practical purposes the most useful
+classification of naevi is into the cutaneous, the subcutaneous, and the
+mixed forms.
+
+_The cutaneous naevus_, "mother's mark," or "port-wine stain," consists
+of an aggregation of dilated capillaries in the substance of the skin.
+On stretching the skin the vessels can be seen to form a fine network,
+or to run in leashes parallel to one another. A dilated arteriole or a
+vein winding about among the capillaries may sometimes be detected.
+These naevi occur on any part of the body, but they are most frequently
+met with on the face. They may be multiple, and vary greatly in size,
+some being no bigger than a pin-head, while others cover large areas of
+the body. In colour they present every tint from purple to brilliant
+red; in the majority there is a considerable dash of blue, especially in
+cold weather.
+
+Unlike the other forms of naevi, the cutaneous variety shows little
+tendency to disappear, and it is especially persistent when associated
+with overgrowth of the epidermis and of the hairs--_naevoid mole_.
+
+The _treatment_ of the cutaneous naevus is unsatisfactory, owing to the
+difficulty of removing the naevus without leaving a scar which is even
+more disfiguring. Very small naevi may be destroyed by a fine pointed
+Paquelin thermo-cautery, or by escharotics, such as nitric acid. For
+larger naevi, radium and solidified carbon dioxide ("CO_2 snow") may be
+used. The extensive port-wine stains so often met with on the face are
+best left alone.
+
+The _subcutaneous naevus_ is comparatively rare. It constitutes a
+well-defined, localised tumour, which may possess a distinct capsule,
+especially when it has ceased to grow or is retrogressing. On section,
+it presents the appearance of a finely reticulated sponge.
+
+Although it may be noticed at, or within a few days of, birth, a
+subcutaneous naevus is often overlooked, especially when on a covered
+part of the body, and may not be discovered till the patient is some
+years old. It forms a rounded, lobulated swelling, seldom of large size
+and yielding a sensation like that of a sponge; the skin over it is
+normal, or may exhibit a bluish tinge, especially in cold weather. In
+some cases the tumour is diminished by pressing the blood out of it, but
+slowly fills again when the pressure is relaxed, and it swells up when
+the child struggles or cries. From a cold abscess it is diagnosed by the
+history and progress of the swelling and by the absence of fluctuation.
+When situated over one of the hernial openings, it closely simulates a
+hernia; and when it occurs in the middle line of the face, head, or
+back, it may be mistaken for such other congenital conditions as
+meningocele or spina bifida. When other means fail, the use of an
+exploring needle clears up the diagnosis.
+
+_Mixed Naevus._--As its name indicates, the mixed naevus partakes of the
+characters of the other two varieties; that is, it is a subcutaneous
+naevus with involvement of the skin.
+
+It is frequently met with on the face and head, but may occur on any
+part of the body. It also affects parts covered by mucous membrane, such
+as the cheek, tongue, and soft palate. The swelling is rounded or
+lobulated, and projects beyond the level of its surroundings. Sometimes
+the skin is invaded by the naevoid tissue over the whole extent of the
+tumour, sometimes only over a limited area. Frequently the margin only
+is of a bright-red colour, while the skin in the centre resembles a
+cicatrix. The swelling is reduced by steady pressure, and increases in
+size and becomes tense when the child cries.
+
+[Illustration: FIG. 68.--Mixed Naevus of Nose which was subsequently
+cured by Electrolysis.]
+
+_Prognosis._--The rate of growth of the subcutaneous and mixed forms of
+naevi varies greatly. They sometimes increase rapidly, especially during
+the first few months of life; after this they usually grow at the same
+rate as the child, or more slowly. There is a decided tendency to
+disappearance of these varieties, fully 50 per cent. undergoing natural
+cure by a process of obliteration, similar to the obliteration of
+vessels in cicatricial tissue. This usually begins about the period of
+the first dentition, sometimes at the second dentition, and sometimes at
+puberty. On the other hand, an increased activity of growth may be shown
+at these periods. The onset of natural cure is recognised by the tumour
+becoming firmer and less compressible, and, in the mixed variety, by the
+colour becoming less bright. Injury, infection, or ulceration of the
+overlying skin may initiate the curative process.
+
+Towards adult life the spaces in a subcutaneous naevus may become greatly
+enlarged, leading to the formation of a cavernous angioma.
+
+_Treatment._--In view of the frequency with which subcutaneous and mixed
+naevi disappear spontaneously, interference is only called for when the
+growth of the tumour is out of proportion to that of the child, or when,
+from its situation--for example in the vicinity of the eye--any marked
+increase in its size would render it less amenable to treatment.
+
+The methods of treatment most generally applicable are the use of radium
+and carbon dioxide snow, igni-puncture, electrolysis, and excision.
+
+For naevi situated on exposed parts, where it is desirable to avoid a
+scar, the use of _radium_ is to be preferred. The tube of radium is
+applied at intervals to different parts of the naevus, the duration and
+frequency of the applications varying with the strength of the
+emanations and the reaction produced. The object aimed at is to induce
+obliteration of the naevoid tissue by cicatricial contraction without
+destroying the overlying skin. _Carbon-dioxide snow_ may be employed in
+the same manner, but the results are inferior to those obtained by
+radium.
+
+_Igni-puncture_ consists in making a number of punctures at different
+parts of the naevus with a fine-pointed thermo-cautery, with the object
+of starting at each point a process of cicatrisation which extends
+throughout the naevoid tissue and so obliterates the vessels.
+
+_Electrolysis_ acts by decomposing the blood and tissues into their
+constituent elements--oxygen and acids appearing at the positive,
+hydrogen and bases at the negative electrode. These substances and gases
+being given off in a nascent condition, at once enter into new
+combinations with anything in the vicinity with which they have a
+chemical affinity. In the naevus the practical result of this reaction is
+that at the positive pole nitric acid, and at the negative pole caustic
+potash, both in a state of minute subdivision, make their appearance.
+The effect on the tissues around the positive pole, therefore, is
+equivalent to that of an acid cauterisation, and on those round the
+negative pole, to an alkaline cauterisation.
+
+As the process is painful, a general anaesthetic is necessary. The
+current used should be from 20 to 80 milliamperes, gradually increasing
+from zero, without shock; three to six large Bunsen cells give a
+sufficient current, and no galvanometer is required. Steel needles,
+insulated with vulcanite to within an eighth of an inch of their points,
+are the best. Both poles are introduced into the naevus, the positive
+being kept fixed at one spot, while the negative is moved about so as to
+produce a number of different tracks of cauterisation. On no account
+must either pole be allowed to come in contact with the skin, lest a
+slough be formed. The duration of the sitting is determined by the
+effect produced, as indicated by the hardening of the tumour, the
+average duration being from fifteen to twenty minutes. If pallor of the
+skin appears, it indicates that the needles are too near the surface, or
+that the blood supply to the integument is being cut off, and is an
+indication to stop. To cauterise the track and so prevent bleeding, the
+needles should be slowly withdrawn while the current is flowing. When
+the skin is reached the current is turned off. The punctures are covered
+with collodion. Six or eight weeks should be allowed to elapse before
+repeating the procedure. From two to eight or ten sittings may be
+necessary, according to the size and character of the naevus.
+
+_Excision_ is to be preferred for naevi of moderate size situated on
+covered parts of the body, where a scar is of no importance. Its chief
+advantages over electrolysis are that a single operation is sufficient,
+and that the cure is speedy and certain. The operation is attended with
+much less haemorrhage than might be expected.
+
+#Cavernous Angioma.#--This form of angioma consists of a series of large
+blood spaces which are usually derived from the dilatation of the
+capillaries of a subcutaneous naevus. The spaces come to communicate
+freely with one another by the disappearance of adjacent capillary
+walls. While the most common situation is in the subcutaneous tissue, a
+cavernous angioma is sometimes met with in internal organs. It may
+appear at any age from early youth to middle life, and is of slow growth
+and may become stationary. The swelling is rounded or oval, there is no
+pulsation or bruit, and the tumour is but slightly compressible. The
+treatment consists in dissecting it out.
+
+#Aneurysm by Anastomosis# is the name applied to a vascular tumour in
+which the arteries, veins, and capillaries are all involved. It is met
+with chiefly on the upper part of the trunk, the neck, and the scalp. It
+tends gradually to increase in size, and may, after many years, attain
+an enormous size. The tumour is ill-defined, and varies in consistence.
+It is pulsatile, and a systolic bruit or a "thrilling" murmur may be
+heard over it. The chief risk is haemorrhage from injury or ulceration.
+
+[Illustration: FIG. 69.--Cirsoid Aneurysm of Forehead in a boy aet. 10.
+
+(Mr. J. W. Dowden's case.)]
+
+The _treatment_ is conducted on the same lines as for naevus. When
+electrolysis is employed, it should be directed towards the afferent
+vessels; and if it fails to arrest the flow through these, it is useless
+to persist with it. In some cases ligation of the afferent vessels has
+been successful.
+
+#Arterial Angioma# or #Cirsoid Aneurysm#.--This is composed of the
+enlarged branches of an arterial trunk. It originates in the smaller
+branches of an artery--usually the temporal--and may spread to the main
+trunk, and may even involve branches of other trunks with which the
+affected artery anastomoses.
+
+The condition is probably congenital in origin, though its appearance is
+frequently preceded by an injury. It almost invariably occurs in the
+scalp, and is usually met with in adolescent young adults.
+
+The affected vessels slowly increase in size, and become tortuous, with
+narrowings and dilatations here and there. Grooves and gutters are
+frequently found in the bone underlying the dilated vessels.
+
+There is a constant loud bruit in the tumour, which greatly troubles the
+patient and may interfere with sleep. There is no tendency either to
+natural cure or to rupture, but severe and even fatal haemorrhage may
+follow a wound of the dilated vessels.
+
+[Illustration: FIG. 70.--Cirsoid Aneurysm of Orbit and Face, which
+developed after a blow on the Orbit with a cricket ball.
+
+(From a photograph lent by Sir Montagu Cotterill.)]
+
+The condition may be treated by excision or by electrolysis. In excision
+the haemorrhage is controlled by an elastic tourniquet applied
+horizontally round the head, or by ligation of the feeding trunks. In
+large tumours the bleeding is formidable. In many cases electrolysis is
+to be preferred, and is performed in the same way as for naevus. The
+positive pole is placed in the centre of the tumour, while the negative
+is introduced into the main affluents one after another.
+
+
+ANEURYSM
+
+An aneurysm is a sac communicating with an artery, and containing fluid
+or coagulated blood.
+
+Two types are met with--the pathological and the traumatic. It is
+convenient to describe in this section also certain conditions in which
+there is an abnormal communication between an artery and a
+vein--arterio-venous aneurysm.
+
+
+PATHOLOGICAL ANEURYSM
+
+In this class are included such dilatations as result from weakening of
+the arterial coats, combined, in most cases, with a loss of elasticity
+in the walls and increase in the arterial tension due to
+arterio-sclerosis. In some cases the vessel wall is softened by
+arteritis--especially the embolic form--so that it yields before the
+pressure of the blood.
+
+Repeated and sudden raising of the arterial tension, as a result, for
+example, of violent muscular efforts or of excessive indulgence in
+alcohol, plays an important part in the causation of aneurysm. These
+factors probably explain the comparative frequency of aneurysm in those
+who follow such arduous occupations as soldiers, sailors,
+dock-labourers, and navvies. In these classes the condition usually
+manifests itself between the ages of thirty and fifty--that is, when the
+vessels are beginning to degenerate, although the heart is still
+vigorous and the men are hard at work. The comparative immunity of women
+may also be explained by the less severe muscular strain involved by
+their occupations and recreations.
+
+Syphilis plays an important part in the production of aneurysm, probably
+by predisposing the patient to arterio-sclerosis and atheroma, and
+inducing an increase in the vascular tension in the peripheral vessels,
+from loss of elasticity of the vessel wall and narrowing of the lumen as
+a result of syphilitic arteritis. It is a striking fact that aneurysm is
+seldom met with in women who have not suffered from syphilis.
+
+#Varieties--Fusiform Aneurysm.#--When the _whole circumference_ of an
+artery has been weakened, the tension of the blood causes the walls to
+dilate uniformly, so that a fusiform or tubular aneurysm results. All
+the coats of the vessel are stretched and form the sac of the aneurysm,
+and the affected portion is not only dilated but is also increased in
+length. This form is chiefly met with in the arch of the aorta, but may
+occur in any of the main arterial trunks. As the sac of the aneurysm
+includes all three coats, and as the inner and outer coats are usually
+thickened by the deposit in them of connective tissue, this variety
+increases in size slowly and seldom gives rise to urgent symptoms.
+
+As a rule a fusiform aneurysm contains fluid blood, but when the intima
+is roughened by disease, especially in the form of calcareous plates,
+shreds of clot may adhere to it.
+
+It has little tendency to natural cure, although this is occasionally
+effected by the emerging artery becoming occluded by a clot; it has also
+little tendency to rupture.
+
+#Sacculated Aneurysm.#--When a _limited area_ of the vessel wall is
+weakened--for example by atheroma or by other form of arteritis--this
+portion yields before the pressure of the blood, and a sacculated
+aneurysm results. The internal and middle coats being already damaged,
+or, it may be, destroyed, by the primary disease, the stress falls on
+the external coat, which in the majority of cases constitutes the sac.
+To withstand the pressure the external coat becomes thickened, and as
+the aneurysm increases in size it forms adhesions to surrounding
+tissues, so that fasciae, tendons, nerves, and other structures may be
+found matted together in its wall. The wall is further strengthened by
+the deposit on its inner aspect of blood-clot, which may eventually
+become organised.
+
+The contents of the sac consist of fluid blood and a varying amount of
+clot which is deposited in concentric layers on the inner aspect of the
+sac, where it forms a pale, striated, firm mass, which constitutes a
+laminated clot. Near the blood-current the clot is soft, red, and
+friable (Fig. 72). The laminated clot not only strengthens the sac,
+enabling it to resist the blood-pressure and so prevent rupture, but, if
+it increases sufficiently to fill the cavity, may bring about cure. The
+principle upon which all methods of treatment are based is to imitate
+nature in producing such a clot.
+
+Sacculated aneurysm, as compared with the fusiform variety, tends to
+rupture and also to cure by the formation of laminated clot; natural
+cure is sometimes all but complete when extension and rupture occur and
+cause death.
+
+An aneurysm is said to be _diffused_ when the sac ruptures and the blood
+escapes into the cellular tissue.
+
+#Clinical Features of Aneurysm.#--Surgically, the sacculated is by far
+the most important variety. The outstanding feature is the existence in
+the line of an artery of a globular swelling, which pulsates. The
+pulsation is of an expansile character, which is detected by observing
+that when both hands are placed over the swelling they are separated
+with each beat of the heart. If the main artery be compressed on the
+cardiac side of the swelling, the pulsation is arrested and the tumour
+becomes smaller and less tense, and it may be still further reduced in
+size by gentle pressure being made over it so as to empty it of fluid
+blood. On allowing the blood again to flow through the artery, the
+pulsation returns at once, but several beats are required before the sac
+regains its former size. In most cases a distinct thrill is felt on
+placing the hand over the swelling, and a blowing, systolic murmur may
+be heard with the stethoscope. It is to be borne in mind that
+occasionally, when the interchange of blood between an aneurysm and the
+artery from which it arises is small, pulsation and bruit may be slight
+or even absent. This is also the case when the sac contains a
+considerable quantity of clot. When it becomes filled with
+clot--_consolidated aneurysm_--these signs disappear, and the clinical
+features are those of a solid tumour lying in contact with an artery,
+and transmitting its pulsation.
+
+A comparison of the pulse in the artery beyond the seat of the aneurysm
+with that in the corresponding artery on the healthy side, shows that on
+the affected side the wave is smaller in volume, and delayed in time. A
+pulse tracing shows that the normal impulse and dicrotic waves are lost,
+and that the force and rapidity of the tidal wave are diminished.
+
+[Illustration: FIG. 71.--Radiogram of Aneurysm of Aorta, showing
+laminated clot and erosion of bodies of vertebrae. The intervertebral
+discs are intact.]
+
+An aneurysm exerts pressure on the surrounding structures, which are
+usually thickened and adherent to it and to one another. Adjacent veins
+may be so compressed that congestion and oedema of the parts beyond are
+produced. Pain, disturbances of sensation, and muscular paralyses may
+result from pressure on nerves. Such bones as the sternum and vertebrae
+undergo erosion and are absorbed by the gradually increasing pressure of
+the aneurysm. Cartilage, on the other hand, being elastic, yields before
+the pressure, so that the intervertebral discs or the costal cartilages
+may escape while the adjacent bones are destroyed (Fig. 71). The skin
+over the tumour becomes thinned and stretched, until finally a slough
+forms, and when it separates haemorrhage takes place.
+
+[Illustration: FIG. 72.--Sacculated Aneurysm of Abdominal Aorta nearly
+filled with laminated clot. Note greater density of clot towards
+periphery.]
+
+In the progress of an aneurysm towards rupture, timely clotting may
+avert death for the moment, but while extension in one direction has
+been arrested there is apt to be extension in another, with imminence of
+rupture, or it may be again postponed.
+
+#Differential Diagnosis.#--The diagnosis is to be made from other
+pulsatile swellings. Pulsation is sometimes transmitted from a large
+artery to a tumour, a mass of enlarged lymph glands, or an inflammatory
+swelling which lies in its vicinity, but the pulsation is not
+expansile--a most important point in differential diagnosis. Such
+swellings may, by appropriate manipulation, be moved from the artery and
+the pulsation ceases, and compression of the artery on the cardiac side
+of the swelling, although it arrests the pulsation, does not produce any
+diminution in the size or tension of the swelling, and when the pressure
+is removed the pulsation is restored immediately.
+
+Fluid swellings overlying an artery, such as cysts, abscesses, or
+enlarged bursae, may closely simulate aneurysm. An apparent expansion may
+accompany the pulsation, but careful examination usually enables this to
+be distinguished from the true expansion of an aneurysm. Compression of
+the artery makes no difference in the size or tension of the swelling.
+
+Vascular tumours, such as sarcoma and goitre, may yield an expansile
+pulsation and a soft, whifling bruit, but they differ from an aneurysm
+in that they are not diminished in size by compression of the main
+artery, nor can they be emptied by pressure.
+
+The exaggerated pulsation sometimes observed in the abdominal aorta, the
+"pulsating aorta" seen in women, should not be mistaken for aneurysm.
+
+#Prognosis.#--When _natural cure_ occurs it is usually brought about by
+the formation of laminated clot, which gradually increases in amount
+till it fills the sac. Sometimes a portion of the clot in the sac is
+separated and becomes impacted as an embolus in the artery beyond,
+leading to thrombosis which first occludes the artery and then extends
+into the sac.
+
+The progress of natural cure is indicated by the aneurysm becoming
+smaller, firmer, less expansile, and less compressible; the murmur and
+thrill diminish and the pressure effects become less marked. When the
+cure is complete the expansile pulsation is lost, and there remains a
+firm swelling attached to the vessel (_consolidated aneurysm_). While
+these changes are taking place the collateral arteries become enlarged,
+and an anastomotic circulation is established.
+
+An aneurysm may prove _fatal_ by exerting pressure on important
+structures, by causing syncope, by rupture, or from the occurrence of
+suppuration. _Pressure_ symptoms are usually most serious from aneurysms
+situated in the neck, thorax, or skull. Sudden fatal _syncope_ is not
+infrequent in cases of aneurysm of the thoracic aorta.
+
+_Rupture_ may take place through the skin, on a mucous or serous
+surface, or into the cellular tissue. The first haemorrhage is often
+slight and stops naturally, but it soon recurs, and is so profuse,
+especially when the blood escapes externally, that it rapidly proves
+fatal. When the bleeding takes place into the cellular tissue, the
+aneurysm is said to become _diffused_, and the extravasated blood
+spreads widely through the tissues, exerting great pressure on the
+surrounding structures.
+
+The _clinical features_ associated with rupture are sudden and severe
+pain in the part, and the patient becomes pale, cold, and faint. If a
+comparatively small escape of blood takes place into the tissues, the
+sudden alteration in the size, shape, and tension of the aneurysm,
+together with loss of pulsation, may be the only local signs. When the
+bleeding is profuse, however, the parts beyond the aneurysm become
+greatly swollen, livid, and cold, and the pulse beyond is completely
+lost. The arrest of the blood supply may result in gangrene. Sometimes
+the pressure of the extravasated blood causes the skin to slough and,
+later, give way, and fatal haemorrhage results.
+
+The _treatment_ is carried out on the same lines as for a ruptured
+artery (p. 261), it being remembered, however, that the artery is
+diseased and does not lend itself to reconstructive procedures.
+
+_Suppuration_ may occur in the vicinity of an aneurysm, and the aneurysm
+may burst into the abscess which forms, so that when the latter points
+the pus is mixed with broken-down blood-clot, and finally free
+haemorrhage takes place. It has more than once happened that a surgeon
+has incised such an abscess without having recognised its association
+with aneurysm, with tragic results.
+
+#Treatment.#--In treating an aneurysm, the indications are to imitate
+Nature's method of cure by means of laminated clot.
+
+_Constitutional treatment_ consists in taking measures to reduce the
+arterial tension and to diminish the force of the heart's action. The
+patient must be kept in bed. A dry and non-stimulating diet is
+indicated, the quantity being gradually reduced till it is just
+sufficient to maintain nutrition. Saline purges are employed to reduce
+the vascular tension. The benefit derived from potassium iodide
+administered in full doses, as first recommended by George W. Balfour,
+probably depends on its depressing action on the heart and its
+therapeutic benefit in syphilis. Pain or restlessness may call for the
+use of opiates, of which heroin is the most efficient.
+
+_Local Treatment._--When constitutional treatment fails, local measures
+must be adopted, and many methods are available.
+
+#Endo-aneurysmorrhaphy.#--The operation devised by Rudolf Matas in 1888
+aims at closing the opening between the sac and its feeding artery, and
+in addition, folding the wall of the sac in such a way as to leave no
+vacant space. If there is marked disease of the vessel, Matas' operation
+is not possible and recourse is then had to ligation of the artery just
+above the sac.
+
+_Extirpation of the Sac--The Old Operation._--The procedure which goes
+by this name consists in exposing the aneurysm, incising the sac,
+clearing out the clots, and ligating the artery above and below the sac.
+This method is suitable to sacculated aneurysm of the limbs, so long as
+they are circumscribed and free from complications. It has been
+successfully practised also in aneurysm of the subclavian, carotid, and
+external iliac arteries. It is not applicable to cases in which there is
+such a degree of atheroma as would interfere with the successful
+ligation of the artery. The continuity of the artery may be restored by
+grafting into the gap left after excision of the sac a segment of the
+great saphena vein.
+
+_Ligation of the Artery._--The object of tying the artery is to diminish
+or to arrest the flow of blood through the aneurysm so that the blood
+coagulates both in the sac and in the feeding artery. The ligature may
+be applied on the cardiac side of the aneurysm--proximal ligation, or to
+the artery beyond--distal ligation.
+
+_Proximal Ligation._--The ligature may be applied immediately above the
+sac (Anel, 1710) or at a distance above (John Hunter, 1785). The
+_Hunterian operation_ ensures that the ligature is applied to a part of
+the artery that is presumably healthy and where relations are
+undisturbed by the proximity of the sac; the best example is the
+ligation of the superficial femoral artery in Scarpa's triangle or in
+Hunter's canal for popliteal aneurysm; it is on record that Syme
+performed this operation with cure of the aneurysm on thirty-nine
+occasions.
+
+It is to be noted that the Hunterian ligature does not aim at
+_arresting_ the flow of blood through the sac, but is designed so to
+diminish its volume and force as to favour the deposition within the sac
+of laminated clot. The development of the collateral circulation which
+follows upon ligation of the artery at a distance above the sac may be
+attended with just that amount of return stream which favours the
+deposit of laminated clot, and consequently the cure of the aneurysm;
+the return stream may, however, be so forcible as to prevent coagulation
+of the blood in the sac, or only to allow of the formation of a red
+thrombus which may in its turn be dispersed so that pulsation in the sac
+recurs. This does not necessarily imply failure to cure, as the
+recurrent pulsation may only be temporary; the formation of laminated
+clot may ultimately take place and lead to consolidation of the
+aneurysm.
+
+The least desirable result of the Hunterian ligature is met with in
+cases where, owing to widespread arterial disease, the collateral
+circulation does not develop and gangrene of the limb supervenes.
+
+_Anel's ligature_ is only practised as part of the operation which deals
+with the sac directly.
+
+_Distal Ligation._--The tying of the artery beyond the sac, or of its
+two branches where it bifurcates (Brasdor, 1760, and Wardrop, 1825), may
+arrest or only diminish the flow of blood through the sac. It is less
+successful than the proximal ligature, and is therefore restricted to
+aneurysms so situated as not to be amenable to other methods; for
+example, in aneurysm of the common carotid near its origin, the artery
+may be ligated near its bifurcation, or in aneurysm of the innominate
+artery, the carotid and subclavian arteries are tied at the seat of
+election.
+
+_Compression._--Digital compression of the feeding artery has been given
+up except as a preparation for operations on the sac with a view to
+favouring the development of a collateral circulation.
+
+_Macewen's acupuncture or "needling"_ consists in passing one or more
+fine, highly tempered steel needles through the tissues overlying the
+aneurysm, and through its outer wall. The needles are made to touch the
+opposite wall of the sac, and the pulsation of the aneurysm imparts a
+movement to them which causes them to scarify the inner surface of the
+sac. White thrombus forms on the rough surface produced, and leads to
+further coagulation. The needles may be left in position for some hours,
+being shifted from time to time, the projecting ends being surrounded
+with sterile gauze.
+
+The _Moore-Corradi method_ consists in introducing through the wall of
+the aneurysm a hollow insulated needle, through the lumen of which from
+10 to 20 feet of highly drawn silver or other wire is passed into the
+sac, where it coils up into an open meshwork (Fig. 73). The positive
+pole of a galvanic battery is attached to the wire, and the negative
+pole placed over the patient's back. A current, varying in strength from
+20 to 70 milliamperes, is allowed to flow for about an hour. The hollow
+needle is then withdrawn, but the wire is left _in situ_. The results
+are somewhat similar to those obtained by needling, but the clot formed
+on the large coil of wire is more extensive.
+
+[Illustration: FIG. 73.--Radiogram of Innominate Aneurysm after
+treatment by the Moore-Corradi method. Two feet of finely drawn silver
+wire were introduced. The patient, a woman, aet. 47, lived for ten months
+after operation, free from pain (cf. Fig. 75).]
+
+Colt's method of wiring has been mainly used in the treatment of
+abdominal aneurysm; gilt wire in the form of a wisp is introduced
+through the cannula and expands into an umbrella shape.
+
+_Subcutaneous Injections of Gelatin._--Three or four ounces of a 2 per
+cent. solution of white gelatin in sterilised water, at a temperature of
+about 100 F., are injected into the subcutaneous tissue of the abdomen
+every two, three, or four days. In the course of a fortnight or three
+weeks improvement may begin. The clot which forms is liable to soften
+and be absorbed, but a repetition of the injection has in several cases
+established a permanent cure.
+
+_Amputation of the limb_ is indicated in cases complicated by
+suppuration, by secondary haemorrhage after excision or ligation, or by
+gangrene. Amputation at the shoulder was performed by Fergusson in a
+case of subclavian aneurysm, as a means of arresting the blood-flow
+through the sac.
+
+
+TRAUMATIC ANEURYSM
+
+The essential feature of a traumatic aneurysm is that it is produced by
+some form of injury which divides all the coats of the artery. The walls
+of the injured vessel are presumably healthy, but they form no part of
+the sac of the aneurysm. The sac consists of the condensed and thickened
+tissues around the artery.
+
+The injury to the artery may be a subcutaneous one such as a tear by a
+fragment of bone: much more commonly it is a punctured wound from a stab
+or from a bullet.
+
+The aneurysm usually forms soon after the injury is inflicted; the blood
+slowly escapes into the surrounding tissues, gradually displacing and
+condensing them, until they form a sac enclosing the effused blood.
+
+Less frequently a traumatic aneurysm forms some considerable time after
+the injury, from gradual stretching of the fibrous cicatrix by which the
+wound in the wall of the artery has been closed. The gradual stretching
+of this cicatrix results in condensation of the surrounding structures
+which form the sac, on the inner aspect of which laminated clot is
+deposited.
+
+A traumatic aneurysm is almost always sacculated, and, so long as it
+remains circumscribed, has the same characters as a pathological
+sacculated aneurysm, with the addition that there is a scar in the
+overlying skin. A traumatic aneurysm is liable to become diffuse--a
+change which, although attended with considerable risk of gangrene, has
+sometimes been the means of bringing about a cure.
+
+The treatment is governed by the same principles as apply to the
+pathological varieties, but as the walls of the artery are not diseased,
+operative measures dealing with the sac and the adjacent segment of the
+affected artery are to be preferred.
+
+
+ARTERIO-VENOUS ANEURYSM
+
+An abnormal communication between an artery and a vein constitutes an
+arterio-venous aneurysm. Two varieties are recognised--one in which the
+communication is direct--_aneurysmal varix_; the other in which the
+vein communicates with the artery through the medium of a sac--_varicose
+aneurysm_.
+
+Either variety may result from pathological causes, but in the majority
+of cases they are traumatic in origin, being due to such injuries as
+stabs, punctured wounds, and gun-shot injuries which involve both artery
+and vein. In former times the most common situation was at the bend of
+the elbow, the brachial artery being accidentally punctured in
+blood-letting from the median basilic vein. Arterio-venous aneurysm is a
+frequent result of injuries by modern high-velocity bullets--for
+example, in the neck or groin.
+
+In _aneurysmal varix_ the higher blood pressure in the artery forces
+arterial blood into the vein, which near the point of communication with
+the artery tends to become dilated, and to form a thick-walled sac,
+beyond which the vessel and its tributaries are distended and tortuous.
+The clinical features resemble those associated with varicose veins, but
+the entrance of arterial blood into the dilated veins causes them to
+pulsate, and produces in them a vibratory thrill and a loud murmur. In
+those at the groin, the distension of the veins may be so great that
+they look like sinuses running through the muscles, a feature that must
+be taken into account in any operation.
+
+As the condition tends to remain stationary, the support of an elastic
+bandage is all that is required; but when the condition progresses and
+causes serious inconvenience, it may be necessary to cut down and expose
+the communication between the artery and vein, and, after separating the
+vessels, to close the opening in each by suture; this may be difficult
+or impossible if the parts are matted from former suppuration. If it is
+impossible thus to obliterate the communication, the artery should be
+ligated above and below the point of communication; although the risk of
+gangrene is considerable unless means are taken to develop the
+collateral circulation beforehand (Makins).
+
+_Varicose aneurysm_ usually develops in relation to a traumatic
+aneurysm, the sac becoming adherent to an adjacent vein, and ultimately
+opening into it. In this way a communication between the artery and the
+vein is established, and the clinical features are those of a
+combination of aneurysm and aneurysmal varix.
+
+As there is little tendency to spontaneous cure, and as the aneurysm is
+liable to increase in size and finally to rupture, operative treatment
+is usually called for. This is carried out on the same lines as for
+aneurysmal varix, and at the same time incising the sac, turning out the
+clots, and ligating any branches which open into the sac. If it can be
+avoided, the vein should not be ligated.
+
+
+ANEURYSMS OF INDIVIDUAL ARTERIES
+
+#Thoracic Aneurysm.#--All varieties of aneurysm occur in the aorta, the
+fusiform being the most common, although a sacculated aneurysm
+frequently springs from a fusiform dilatation.
+
+The _clinical features_ depend chiefly on the direction in which the
+aneurysm enlarges, and are not always well marked even when the sac is
+of considerable size. They consist in a pulsatile swelling--sometimes in
+the supra-sternal notch, but usually towards the right side of the
+sternum--with an increased area of dulness on percussion. With the
+X-rays a dark shadow is seen corresponding to the sac. Pain is usually a
+prominent symptom, and is largely referable to the pressure of the
+aneurysm on the vertebrae or the sternum, causing erosion of these bones.
+Pressure on the thoracic veins and on the air-passage causes cyanosis
+and dyspnoea. When the oesophagus is pressed upon, the patient may have
+difficulty in swallowing. The left recurrent nerve may be stretched or
+pressed upon as it hooks round the arch of the aorta, and hoarseness of
+the voice and a characteristic "brassy" cough may result from paralysis
+of the muscles of the larynx which it supplies. The vagus, the phrenic,
+and the spinal nerves may also be pressed upon. When the aneurysm is on
+the transverse part of the arch, the trachea is pulled down with each
+beat of the heart--a clinical phenomena known as the "tracheal tug."
+Aneurysm of the descending aorta may, after eroding the bodies of the
+vertebrae (Fig. 71) and posterior portions of the ribs, form a swelling
+in the back to the left of the spine.
+
+Inasmuch as obliteration of the sac and the feeding artery is out of the
+question, surgical treatment is confined to causing coagulation of the
+blood in an extension or pouching of the sac, which, making its way
+through the parietes of the chest, threatens to rupture externally. This
+may be achieved by Macewen's needles or by the introduction of wire into
+the sac. We have had cases under observation in which the treatment
+referred to has been followed by such an amount of improvement that the
+patient has been able to resume a laborious occupation for one or more
+years. Christopher Heath found that improvement followed ligation of the
+left common carotid in aneurysm of the transverse part of the aortic
+arch.
+
+[Illustration: FIG. 74.--Thoracic Aneurysm, threatening to rupture
+externally, but prevented from doing so by Macewen's needling. The
+needles were left in for forty-eight hours.]
+
+#Abdominal Aneurysm.#--Aneurysm is much less frequent in the abdominal
+than in the thoracic aorta. While any of the large branches in the
+abdomen may be affected, the most common seats are in the aorta itself,
+just above the origin of the coeliac artery and at the bifurcation.
+
+The _clinical features_ vary with the site of the aneurysm and with its
+rapidity and direction of growth. A smooth, rounded swelling, which
+exhibits expansile pulsation, forms, usually towards the left of the
+middle line. It may extend upwards under cover of the ribs, downwards
+towards the pelvis, or backward towards the loin. On palpation a
+systolic thrill may be detected, but the presence of a murmur is neither
+constant nor characteristic. Pain is usually present; it may be
+neuralgic in character, or may simulate renal colic. When the aneurysm
+presses on the vertebrae and erodes them, the symptoms simulate those of
+spinal caries, particularly if, as sometimes happens, symptoms of
+compression paraplegia ensue. In its growth the swelling may press upon
+and displace the adjacent viscera, and so interfere with their
+functions.
+
+The _diagnosis_ has to be made from solid or cystic tumours overlying
+the artery; from a "pulsating aorta"; and from spinal caries; much help
+is obtained by the use of the X-rays.
+
+The condition usually proves fatal, either by the aneurysm bursting into
+the peritoneal cavity, or by slow leakage into the retro-peritoneal
+tissue.
+
+The Moore-Corradi method has been successfully employed, access to the
+sac having been obtained by opening the abdomen. Ligation of the aorta
+has so far been unsuccessful, but in one case operated upon by Keen the
+patient survived forty-eight days.
+
+#Innominate aneurysm# may be of the fusiform or of the sacculated
+variety, and is frequently associated with pouching of the aorta. It
+usually grows upwards and laterally, projecting above the sternum and
+right clavicle, which may be eroded or displaced (Fig. 75). Symptoms of
+pressure on the structures in the neck, similar to those produced by
+aortic aneurysm, occur. The pulses in the right upper extremity and in
+the right carotid and its branches are diminished and delayed. Pressure
+on the right brachial plexus causes shooting pain down the arm and
+muscular paresis on that side. Vaso-motor disturbances and contraction
+of the pupil on the right side may result from pressure on the
+sympathetic. Death may take place from rupture, or from pressure on the
+air-passage.
+
+[Illustration: FIG. 75.--Innominate Aneurysm in a woman, aet. 47, eight
+months after treatment by Moore-Corradi method (cf. Fig. 73).]
+
+The available methods of treatment are ligation of the right common
+carotid and third part of the right subclavian (Wardrop's operation), of
+which a number of successful cases have been recorded. Those most
+suitable for ligation are cases in which the aneurysm is circumscribed
+and globular (Sheen). If ligation is found to be impracticable, the
+Moore-Corradi method or Macewen's needling may be tried.
+
+#Carotid Aneurysms.#--Aneurysm of the _common carotid_ is more frequent
+on the right than on the left side, and is usually situated either at
+the root of the neck or near the bifurcation. It is the aneurysm most
+frequently met with in women. From its position the swelling is liable
+to press on the vagus, recurrent and sympathetic nerves, on the
+air-passage, and on the oesophagus, giving rise to symptoms referable to
+such pressure. There may be cerebral symptoms from interference with the
+blood supply of the brain.
+
+Aneurysm near the origin has to be diagnosed from subclavian,
+innominate, and aortic aneurysm, and from other swellings--solid or
+fluid--met with in the neck. It is often difficult to determine with
+precision the trunk from which an aneurysm at the root of the neck
+originates, and not infrequently more than one vessel shares in the
+dilatation. A careful consideration of the position in which the
+swelling first appeared, of the direction in which it has progressed, of
+its pressure effects, and of the condition of the pulses beyond, may
+help in distinguishing between aortic, innominate, carotid, and
+subclavian aneurysms. Skiagraphy is also of assistance in recognising
+the vessel involved.
+
+Tumours of the thyreoid, enlarged lymph glands, and fatty and
+sarcomatous tumours can usually be distinguished from aneurysm by the
+history of the swelling and by physical examination. Cystic tumours and
+abscesses in the neck are sometimes more difficult to differentiate on
+account of the apparently expansile character of the pulsation
+transmitted to them. The fact that compression of the vessel does not
+affect the size and tension of these fluid swellings is useful in
+distinguishing them from aneurysm.
+
+_Treatment._--Digital compression of the vessel against the transverse
+process of the sixth cervical vertebra--the "carotid tubercle"--has been
+successfully employed in the treatment of aneurysm near the bifurcation.
+Proximal ligation in the case of high aneurysms, or distal ligation in
+those situated at the root of the neck, is more certain. Extirpation of
+the sac is probably the best method of treatment, especially in those of
+traumatic origin. These operations are attended with considerable risk
+of hemiplegia from interference with the blood supply of the brain.
+
+The _external carotid_ and the cervical portion of the _internal
+carotid_ are seldom the primary seat of aneurysm, although they are
+liable to be implicated by the upward spread of an aneurysm at the
+bifurcation of the common trunk. In addition to the ordinary signs of
+aneurysm, the clinical manifestations are chiefly referable to pressure
+on the pharynx and larynx, and on the hypoglossal nerve. Aneurysm of the
+internal carotid is of special importance on account of the way in which
+it bulges into the pharynx in the region of the tonsil, in some cases
+closely simulating a tonsillar abscess. Cases are on record in which
+such an aneurysm has been mistaken for an abscess and incised, with
+disastrous results.
+
+_Aneurysmal varix_ may occur in the neck as a result of stabs or bullet
+wounds. The communication is usually between the common carotid artery
+and the internal jugular vein. The resulting interference with the
+cerebral circulation causes headache, giddiness, and other brain
+symptoms, and a persistent loud murmur is usually a source of annoyance
+to the patient and may be sufficient indication for operative treatment.
+
+#Intracranial aneurysm# involves the internal carotid and its branches,
+or the basilar artery, and appears to be more frequently associated with
+syphilis and with valvular disease of the heart than are external
+aneurysms. It gives rise to symptoms similar to those of other
+intracranial tumours, and there is sometimes a loud murmur. It usually
+proves fatal by rupture, and intracranial haemorrhage. The treatment is
+to ligate the common carotid or the vertebral artery in the neck,
+according to the seat of the aneurysm.
+
+#Orbital Aneurysm.#--The term pulsating exophthalmos is employed to
+embrace a number of pathological conditions, including aneurysm, in
+which the chief symptoms are pulsation in the orbit and protrusion of
+the eyeball. There may be, in addition, congestion and oedema of the
+eyelids, and a distinct thrill and murmur, which can be controlled by
+compression of the common carotid in the neck. Varying degrees of ocular
+paralysis and of interference with vision may also be present.
+
+These symptoms are due, in the majority of cases, to an aneurysmal varix
+of the internal carotid artery and cavernous sinus, which is often
+traumatic in origin, being produced either by fracture of the base of
+the skull or by a punctured wound of the orbit. In other cases they are
+due to aneurysm of the ophthalmic artery, to thrombosis of the cavernous
+sinus, and, in rare instances, to cirsoid aneurysm.
+
+If compression of the common carotid is found to arrest the pulsation,
+ligation of this vessel is indicated.
+
+#Subclavian Aneurysm.#--Subclavian aneurysm is usually met with in men
+who follow occupations involving constant use of the shoulder--for
+example, dock-porters and coal-heavers. It is more common on the right
+side.
+
+The aneurysm usually springs from the third part of the artery, and
+appears as a tense, rounded, pulsatile swelling just above the clavicle
+and to the outer side of the sterno-mastoid muscle. It occasionally
+extends towards the thorax, where it may become adherent to the pleura.
+The radial pulse on the same side is small and delayed. Congestion and
+oedema of the arm, with pain, numbness, and muscular weakness, may result
+from pressure on the veins and nerves as they pass under the clavicle;
+and pressure on the phrenic nerve may induce hiccough. The aneurysm is
+of slow growth, and occasionally undergoes spontaneous cure.
+
+The conditions most likely to be mistaken for it are a soft, rapidly
+growing sarcoma, and a normal artery raised on a cervical rib.
+
+On account of the relations of the artery and of its branches, treatment
+is attended with greater difficulty and danger in subclavian than in
+almost any other form of external aneurysm. The available operative
+measures are proximal ligation of the innominate, and distal ligation.
+In some cases it has been found necessary to combine distal ligation
+with amputation at the shoulder-joint, to prevent the collateral
+circulation maintaining the flow through the aneurysm. Matas' operation
+has been successfully performed by Hogarth Pringle.
+
+#Axillary Aneurysm.#--This is usually met with in the right arm of
+labouring men and sailors, and not infrequently follows an injury in the
+region of the shoulder. The vessel may be damaged by the head of a
+dislocated humerus or in attempts to reduce the dislocation, by the
+fragments of a fractured bone, or by a stab or cut. Sometimes the vein
+also is injured and an arterio-venous aneurysm established.
+
+Owing to the laxity of the tissues, it increases rapidly, and it may
+soon attain a large size, filling up the axilla, and displacing the
+clavicle upwards. This renders compression of the third part of the
+subclavian difficult or impossible. It may extend beneath the clavicle
+into the neck, or, extending inwards may form adhesions to the chest
+wall, and, after eroding the ribs, to the pleura.
+
+The usual symptoms of aneurysm are present, and the pressure effects on
+the veins and nerves are similar to those produced by an aneurysm of the
+subclavian. Intra-thoracic complications, such as pleurisy or pneumonia,
+are not infrequent when there are adhesions to the chest wall and
+pleura. Rupture may take place externally, into the shoulder-joint, or
+into the pleura.
+
+Extirpation of the sac is the operation of choice, but, if this is
+impracticable, ligation of the third part of the subclavian may be had
+recourse to.
+
+#Brachial aneurysm# usually occurs at the bend of the elbow, is of
+traumatic origin, and is best treated by excision of the sac.
+
+_Aneurysmal varix_, which was frequently met with in this situation in
+the days of the barber-surgeons,--usually as a result of the artery
+having been accidentally wounded while performing venesection of the
+median basilic vein,--may be treated, according to the amount of
+discomfort it causes, by a supporting bandage, or by ligation of the
+artery above and below the point of communication.
+
+Aneurysms of the vessels of the #forearm and hand# call for no special
+mention; they are almost invariably traumatic, and are treated by
+excision of the sac.
+
+#Inguinal Aneurysm# (_Aneurysm of the Iliac and Femoral
+Arteries_).--Aneurysms appearing in the region of Poupart's ligament may
+have their origin in the external or common iliac arteries or in the
+upper part of the femoral. On account of the tension of the fascia lata,
+they tend to spread upwards towards the abdomen, and, to a less extent,
+downwards into the thigh. Sometimes a constriction occurs across the
+sac at the level of Poupart's ligament.
+
+The pressure exerted on the nerves and veins of the lower extremity
+causes pain, congestion, and oedema of the limb. Rupture may take place
+externally, or into the cellular tissue of the iliac fossa.
+
+These aneurysms have to be diagnosed from pulsating sarcoma growing from
+the pelvic bones, and from an abscess or a mass of enlarged lymph glands
+overlying the artery and transmitting its pulsation.
+
+The method of treatment that has met with most success is ligation of
+the common or external iliac, reached either by reflecting the
+peritoneum from off the iliac fossa (extra-peritoneal operation), or by
+going through the peritoneal cavity (trans-peritoneal operation).
+
+#Gluteal Aneurysm.#--An aneurysm in the buttock may arise from the
+superior or from the inferior gluteal artery, but by the time it forms a
+salient swelling it is seldom possible to recognise by external
+examination in which vessel it takes origin. The special symptoms to
+which it gives rise are pain down the limb from pressure on the sciatic
+nerve, and interference with the movements at the hip.
+
+Ligation of the hypogastric (internal iliac) by the trans-peritoneal
+route is the most satisfactory method of treatment. Extirpation of the
+sac is difficult and dangerous, especially when the aneurysm has spread
+into the pelvis.
+
+#Femoral Aneurysm.#--Aneurysm of the femoral artery beyond the origin of
+the profunda branch is usually traumatic in origin, and is more common
+in Scarpa's triangle than in Hunter's canal. Any of the methods already
+described is available for their treatment--the choice lying between
+Matas' operation and ligation of the external iliac.
+
+Aneurysm of the _profunda femoris_ is distinguished from that of the
+main trunk by the fact that the pulses beyond are, in the former,
+unaffected, and by the normal artery being felt pulsating over or
+alongside the sac.
+
+In _aneurysmal varix_, a not infrequent result of a bullet wound or a
+stab, the communication with the vein may involve the main trunk of the
+femoral artery. Should operative interference become necessary as a
+result of progressive increase in size of the tumour, or progressive
+distension of the veins of the limb, an attempt should be made to
+separate the vessels concerned and to close the opening in each by
+suture. If this is impracticable, the artery is tied above and below the
+communication; gangrene of the limb may supervene, and we have observed
+a case in which the gangrene extended up to the junction of the middle
+and lower thirds of the thigh, and in which recovery followed upon
+amputation of the thigh.
+
+#Popliteal Aneurysm.#--This is the most common surgical aneurysm, and is
+not infrequently met with in both limbs. It is generally due to disease
+of the artery, and repeated slight strains, which are so liable to occur
+at the knee, play an important part in its formation. In former times it
+was common in post-boys, from the repeated flexion and extension of the
+knee in riding.
+
+The aneurysm is usually of the sacculated variety, and may spring from
+the front or from the back of the vessel. It may exert pressure on the
+bones and ligaments of the joint, and it has been known to rupture into
+the articulation. The pain, stiffness, and effusion into the joint which
+accompany these changes often lead to an erroneous diagnosis of joint
+disease. The sac may press upon the popliteal artery or vein and their
+branches, causing congestion and oedema of the leg, and lead to gangrene.
+Pressure on the tibial and common peroneal nerves gives rise to severe
+pain, muscular cramp, and weakness of the leg.
+
+The differential diagnosis is to be made from abscess, bursal cyst,
+enlarged glands, and sarcoma, especially pulsating sarcoma of one of the
+bones entering into the knee joint.
+
+The choice of operation lies between ligation of the femoral artery in
+Hunter's canal, and Matas' operation of aneurysmo-arteriorrhaphy. The
+success which attends the Hunterian operation is evidenced by the fact
+that Syme performed it thirty-seven times without a single failure. If
+it fails, the old operation should be considered, but it is a more
+serious operation, and one which is more liable to be followed by
+gangrene of the limb. Experience shows that ligation of the vein, or
+even the removal of a portion of it, is not necessarily followed by
+gangrene. The risk of gangrene is diminished by a course of digital
+compression of the femoral artery, before operating on the aneurysm.
+
+_Aneurysmal varix_ is sometimes met with in the region of the popliteal
+space. It is characterised by the usual symptoms, and is treated by
+palliative measures, or by ligation of the artery above and below the
+point of communication.
+
+_Aneurysm_ in the #leg and foot# is rare. It is almost always traumatic,
+and is treated by excision of the sac.
+
+
+
+
+CHAPTER XV
+
+THE LYMPH VESSELS AND GLANDS
+
+
+Anatomy and Physiology--INJURIES OF LYMPH VESSELS--_Wounds of
+    thoracic duct_--DISEASES OF LYMPH VESSELS--Lymphangitis:
+    _Varieties_--Lymphangiectasis--Filarial
+    disease--Lymphangioma--DISEASES OF LYMPH
+    GLANDS--Lymphadenitis: _Septic_; _Tuberculous_;
+    _Syphilitic_--Lymphadenoma--Leucocythaemia--TUMOURS.
+
+#Surgical Anatomy and Physiology.#--Lymph is essentially blood plasma,
+which has passed through the walls of capillaries. After bathing
+and nourishing the tissues, it is collected by lymph vessels, which
+return it to the blood stream by way of the thoracic duct. These lymph
+vessels take origin in the lymph spaces of the tissues and in the
+walls of serous cavities, and they usually run alongside blood
+vessels--_perivascular lymph vessels_. They have a structure similar to
+that of veins, but are more abundantly provided with valves. Along the
+course of the lymph trunks are the _lymph glands_, which possess a
+definite capsule and are composed of a reticulated connective tissue,
+the spaces of which are packed with leucocytes. The glands act as
+filters, arresting not only inert substances, such as blood pigment
+circulating in the lymph, but also living elements, such as cancer cells
+or bacteria. As it passes through a gland the lymph is brought into
+intimate contact with the leucocytes, and in bacterial infections there
+is always a struggle between the organisms and the leucocytes, so that
+the glands may be looked upon as an important line of defence, retarding
+or preventing the passage of bacteria and their products into the
+general circulation. The infective agent, moreover, in order to reach
+the blood stream, must usually overcome the resistance of several
+glands.
+
+Lymph glands are, for the most part, arranged in groups or chains, such
+as those in the axilla, neck, and groin. In any given situation they
+vary in number and size in different individuals, and fresh glands may
+be formed on comparatively slight stimulus, and disappear when the
+stimulus is withdrawn. The best-known example of this is the increase in
+the number of glands in the axilla which takes place during lactation;
+when this function ceases, many of the glands become involuted and are
+transformed into fat, and in the event of a subsequent lactation they
+are again developed. After glands have been removed by operation, new
+ones may be formed.
+
+The following are the more important groups of glands, and the areas
+drained by them in the head and neck and in the extremities.
+
+#Head and Neck.#--_The anterior auricular (parotid and pre-auricular)
+glands_ lie beneath the parotid fascia in front of the ear, and some
+are partly embedded in the substance of the parotid gland; they drain
+the parts about the temple, cheek, eyelids, and auricle, and are
+frequently the seat of tuberculous disease. _The occipital gland_,
+situated over the origin of the trapezius from the superior curved line,
+drains the top and back of the head; it is rarely infected. _The
+posterior auricular (mastoid) glands_ lie over the mastoid process, and
+drain the side of the head and auricle. These three groups pour their
+lymph into the superficial cervical glands. _The submaxillary_--two to
+six in number--lie along the lower order of the mandible from the
+symphysis to the angle, the posterior ones (paramandibular) being
+closely connected with the submaxillary salivary gland. They receive
+lymph from the face, lips, floor of the mouth, gums, teeth, anterior
+part of tongue, and the alae nasi, and from the pre-auricular glands. The
+lymph passes from them into the deeper cervical glands. They are
+frequently infected with tubercle, with epithelioma which has spread to
+them from the mouth, and also with pyogenic organisms. _The submental
+glands_ lie in or close to the median line between the anterior bellies
+of the digastric muscles, and receive lymph from the lips. It is rare
+for them to be the seat of tubercle, but in epithelioma of the lower lip
+and floor of the mouth they are infected at an early stage of the
+disease. _The supra-hyoid gland_ lies a little farther back, immediately
+above the hyoid bone, and receives lymph from the tongue. _The
+superficial cervical (external jugular) glands_, when present, lie along
+the external jugular vein, and receives lymph from the occipital and
+auricular glands and from the auricle. _The sterno-mastoid
+glands_--glandulae concatinatae--form a chain along the posterior edge of
+the sterno-mastoid muscle, some of them lying beneath the muscle. They
+are commonly enlarged in secondary syphilis. _The superior deep cervical
+(internal jugular) glands_--from six to twenty in number--form a
+continuous chain along the internal jugular vein, beneath the
+sterno-mastoid muscle. They drain the various groups of glands which lie
+nearer the surface, also the interior of the skull, the larynx, trachea,
+thyreoid, and lower part of the pharynx, and pour their lymph into the
+main trunks at the root of the neck. Belonging to this group is one
+large gland (the tonsillar gland) which lies behind the posterior belly
+of the digastric, and rests in the angle between the internal jugular
+and common facial veins. It is commonly enlarged in affections of the
+tonsil and posterior part of the tongue. In the same group are three or
+four glands which lie entirely under cover of the upper end of the
+sterno-mastoid muscle, and surround the accessory nerve before it
+perforates the muscle. The deep cervical glands are commonly infected by
+tubercle and also by epithelioma secondary to disease in the tongue or
+throat. _The inferior deep cervical (supra-clavicular) glands_ lie in
+the posterior triangle, above the clavicle. They receive lymph from the
+lowest cervical glands, from the upper part of the chest wall, and from
+the highest axillary glands. They are frequently infected in cancer of
+the breast; those on the left side also in cancer of the stomach. The
+removal of diseased supra-clavicular glands is not to be lightly
+undertaken, as difficulties are liable to ensue in connection with the
+thoracic duct, the pleura, or the junction of the subclavian and
+internal jugular veins. _The retro-pharyngeal glands_ lie on each side
+of the median line upon the rectus capitis anticus major muscle and in
+front of the pre-vertebral layer of the cervical fascia. They receive
+part of the lymph from the posterior wall of the pharynx, the interior
+of the nose and its accessory cavities, the auditory (Eustachian) tube,
+and the tympanum. When they are infected with pyogenic organisms or
+with tubercle bacilli, they may lead to the formation of one form of
+retro-pharyngeal abscess.
+
+#Upper Extremity.#--_The epi-trochlear and cubital glands_ vary in
+number, that most commonly present lying about an inch and a half above
+the medial epi-condyle, and other and smaller glands may lie along the
+medial (internal) bicipital groove or at the bend of the elbow. They
+drain the ulnar side of the hand and forearm, and pour their lymph into
+the axillary group. The epi-trochlear gland is sometimes enlarged in
+syphilis. _The axillary glands_ are arranged in groups: a central group
+lies embedded in the axillary fascia and fat, and is often related to an
+opening in it; a posterior or subscapular group lies along the line of
+the subscapular vessels; anterior or pectoral groups lie behind the
+pectoralis minor, along the medial side of the axillary vein, and an
+inter-pectoral group, between the two pectoral muscles. The axillary
+glands receive lymph from the arm, mamma, and side of the chest, and
+pass it on into the lowest cervical glands and the main lymph trunk.
+They are frequently the seat of pyogenic, tuberculous, and cancerous
+infection, and their complete removal is an essential part of the
+operation for cancer of the breast.
+
+#Lower Extremity.#--_The popliteal glands_ include one superficial gland
+at the termination of the small saphenous vein, and several deeper ones
+in relation to the popliteal vessels. They receive lymph from the toes
+and foot, and transmit it to the inguinal glands. _The femoral glands_
+lie vertically along the upper part of the great saphenous vein, and
+receive lymph from the leg and foot; from them the lymph passes to the
+deep inguinal and external iliac glands. The femoral glands often
+participate in pyogenic infections entering through the skin of the toes
+and sole of the foot. _The superficial inguinal glands_ lie along the
+inguinal (Poupart's) ligament, and receive lymph from the external
+genitals, anus, perineum, buttock, and anterior abdominal wall. The
+lymph passes on to the deep inguinal and external iliac glands. The
+superficial glands through their relations to the genitals are
+frequently the subject of venereal infection, and also of epithelioma
+when this disease affects the genitals or anus; they are rarely the seat
+of tuberculosis. _The deep inguinal glands_ lie on the medial side of
+the femoral vein, and sometimes within the femoral canal. They receive
+lymph from the deep lymphatics of the lower limb, and some of the
+efferent vessels from the femoral and superficial inguinal glands. The
+lymph then passes on through the femoral canal to the external iliac
+glands. The extension of malignant disease, whether cancer or sarcoma,
+can often be traced along these deeper lymphatics into the pelvis, and
+as the obstruction to the flow of lymph increases there is a
+corresponding increase in the swollen dropsical condition of the lower
+limb on the same side.
+
+The glands of the _thorax_ and _abdomen_ will be considered with the
+surgery of these regions.
+
+
+INJURIES OF LYMPH VESSELS
+
+Lymph vessels are divided in all wounds, and the lymph that escapes from
+them is added to any discharge that may be present. In injuries of
+larger trunks the lymph may escape in considerable quantity as a
+colourless, watery fluid--_lymphorrhagia_; and the opening through which
+it escapes is known as a _lymphatic fistula_. This has been observed
+chiefly after extensive operation for the removal of malignant glands in
+the groin where there already exists a considerable degree of
+obstruction to the lymph stream, and in such cases the lymph, including
+that which has accumulated in the vessels of the limb, may escape in
+such abundance as to soak through large dressings and delay healing.
+Ultimately new lymph channels are formed, so that at the end of from
+four to six weeks the discharge of lymph ceases and the wound heals.
+
+_Lymphatic Oedema._--When the lymphatic return from a limb has been
+seriously interfered with,--as, for example, when the axillary contents
+has been completely cleared out in operating for cancer of the
+breast,--a condition of lymphatic oedema may result, the arm becoming
+swollen, tight, and heavy.
+
+Various degrees of the conditions are met with; in the severe forms,
+there is pain, as well as incapacity of the limb. As in ordinary oedema,
+the condition is relieved by elevation of the limb, but not nearly to
+the same degree; in time the tissues become so hard and tense as
+scarcely to pit on pressure; this is in part due to the formation of new
+connective tissue and hypertrophy of the skin; in advanced cases there
+is a gradual transition into one form of elephantiasis.
+
+Handley has devised a method of treatment--_lymphangioplasty_--the
+object of which is to drain the lymph by embedding a number of silk
+threads in the subcutaneous cellular tissue.
+
+#Wounds of the Thoracic Duct.#--The thoracic duct usually opens at the
+angle formed by the junction of the left internal jugular and subclavian
+veins, but it may open into either of these vessels by one or by several
+channels, or the duct may be double throughout its course. There is a
+smaller duct on the right side--the right lymphatic duct. The duct or
+ducts may be displaced by a tumour or a mass of enlarged glands, and may
+be accidentally wounded in dissections at the root of the neck; jets of
+milky fluid--chyle--may at once escape from it. The jets are rhythmical
+and coincide with expiration. The injury may, however, not be observed
+at the time of operation, but later through the dressings being soaked
+with chyle--_chylorrhoea_. If the wound involves the only existing main
+duct and all the chyle escapes, the patient suffers from intense thirst,
+emaciation, and weakness, and may die of inanition; but if, as is
+usually the case, only one of several collateral channels is implicated,
+the loss of chyle may be of little moment, as the discharge usually
+ceases. If the wound heals so that the chyle is prevented from escaping,
+a fluctuating swelling may form beneath the scar; in course of time it
+gradually disappears.
+
+An attempt should be made to close the wound in the duct by means of a
+fine suture; failing this, the duct must be occluded by a ligature as if
+it were a bleeding artery. The tissues are then stitched over it and the
+skin wound accurately closed, so as to obtain primary union, firm
+pressure being applied by dressings and an elastic webbing bandage. Even
+if the main duct is obliterated, a collateral circulation is usually
+established. A wound of the right lymphatic duct is of less importance.
+
+_Subcutaneous rupture of the thoracic duct_ may result from a crush of
+the thorax. The chyle escapes and accumulates in the cellular tissue of
+the posterior mediastinum, behind the peritoneum, in the pleural cavity
+(_chylo-thorax_), or in the peritoneal cavity (_chylous ascites_). There
+are physical signs of fluid in one or other of these situations, but, as
+a rule, the nature of the lesion is only recognised when chyle is
+withdrawn by the exploring needle.
+
+
+DISEASES OF LYMPH VESSELS
+
+#Lymphangitis.#--Inflammation of peripheral lymph vessels usually
+results from some primary source of pyogenic infection in the skin. This
+may be a wound or a purulent blister, and the streptococcus pyogenes is
+the organism most frequently present. _Septic_ lymphangitis is commonly
+met with in those who, from the nature of their occupation, handle
+infective material. A _gonococcal_ form has been observed in those
+suffering from gonorrhoea.
+
+The inflammation affects chiefly the walls of the vessels, and is
+attended with clotting of the lymph. There is also some degree of
+inflammation of the surrounding cellular tissue--_peri-lymphangitis_.
+One or more abscesses may form along the course of the vessels, or a
+spreading cellulitis may supervene.
+
+The _clinical features_ resemble those of other pyogenic infections, and
+there are wavy red lines running from the source of infection towards
+the nearest lymph glands. These correspond to the inflamed vessels, and
+are the seat of burning pain and tenderness. The associated glands are
+enlarged and painful. In severe cases the symptoms merge into those of
+septicaemia. When the deep lymph vessels alone are involved, the
+superficial red lines are absent, but the limb becomes greatly swollen
+and pits on pressure.
+
+In cases of extensive lymphangitis, especially when there are repeated
+attacks, the vessels are obliterated by the formation of new connective
+tissue and a persistent solid oedema results, culminating in one form of
+elephantiasis.
+
+_Treatment._--The primary source of infection is dealt with on the usual
+lines. If the lymphangitis affects an extremity, Bier's elastic bandage
+is applied, and if suppuration occurs, the pus is let out through one or
+more small incisions; in other parts of the body Klapp's suction bells
+are employed. An autogenous vaccine may be prepared and injected. When
+the condition has subsided, the limb is massaged and evenly bandaged to
+promote the disappearance of oedema.
+
+_Tuberculous Lymphangitis._--Although lymph vessels play an important
+role in the spread of tuberculosis, the clinical recognition of the
+disease in them is exceptional. The infection spreads upwards along the
+superficial lymphatics, which become nodularly thickened; at one or more
+points, larger, peri-lymphangitic nodules may form and break down into
+abscesses and ulcers; the nearest group of glands become infected at an
+early stage. When the disease is widely distributed throughout the
+lymphatics of the limb, it becomes swollen and hard--a condition
+illustrated by lupus elephantiasis.
+
+_Syphilitic lymphangitis_ is observed in cases of primary syphilis, in
+which the vessels of the dorsum of the penis can be felt as indurated
+cords.
+
+In addition to acting as channels for the conveyance of bacterial
+infection, _lymph vessels frequently convey the cells of malignant
+tumours_, and especially cancer, from the seat of the primary disease to
+the nearest lymph glands, and they may themselves become the seat of
+cancerous growth forming nodular cords. The permeation of cancer by way
+of the lymphatics, described by Sampson Handley, has already been
+referred to.
+
+#Lymphangiectasis# is a dilated or varicose condition of lymph vessels.
+It is met with as a congenital affection in the tongue and lips, or it
+may be acquired as the result of any condition which is attended with
+extensive obliteration or blocking of the main lymph trunks. An
+interesting type of lymphangiectasis is that which results from the
+presence of the _filaria Bancrofti_ in the vessels, and is observed
+chiefly in the groin, spermatic cord, and scrotum of persons who have
+lived in the tropics.
+
+_Filarial disease in the lymphatics of the groin_ appears as a soft,
+doughy swelling, varying in size from a walnut to a cocoa-nut; it may
+partly disappear on pressure and when the patient lies down.
+
+The patient gives a history of feverish attacks of the nature of
+lymphangitis during which the swelling becomes painful and tender. These
+attacks may show a remarkable periodicity, and each may be followed by
+an increase in the size of the swelling, which may extend along the
+inguinal canal into the abdomen, or down the spermatic cord into the
+scrotum. On dissection, the swelling is found to be made up of dilated,
+tortuous, and thickened lymph vessels in which the parent worm is
+sometimes found, and of greatly enlarged lymph glands which have
+undergone fibrosis, with giant-cell formation and eosinophile
+aggregations. The fluid in the dilated vessels is either clear or
+turbid, in the latter case resembling chyle. The affection is frequently
+bilateral, and may be associated with lymph scrotum, with elephantiasis,
+and with chyluria.
+
+The _diagnosis_ is to be made from such other swellings in the groin as
+hernia, lipoma, or cystic pouching of the great saphenous vein. It is
+confirmed by finding the recently dead or dying worms in the inflamed
+lymph glands.
+
+_Treatment._--When the disease is limited to the groin or scrotum,
+excision may bring about a permanent cure, but it may result in the
+formation of lymphatic sinuses and only afford temporary relief.
+
+#Lymphangioma.#--A lymphangioma is a swelling composed of a series of
+cavities and channels filled with lymph and freely communicating with
+one another. The cavities result either from the new formation of lymph
+spaces or vessels, or from the dilatation of those which already exist;
+their walls are composed of fibro-areolar tissue lined by endothelium
+and strengthened by non-striped muscle. They are rarely provided with a
+definite capsule, and frequently send prolongations of their substance
+between and into muscles and other structures in their vicinity. They
+are of congenital origin and usually make their appearance at or shortly
+after birth. When the tumour is made up of a meshwork of caverns and
+channels, it is called a _cavernous lymphangioma_; when it is composed
+of one or more cysts, it is called a _cystic lymphangioma_. It is
+probable that the cysts are derived from the caverns by breaking down
+and absorption of the intervening septa, as transition forms between the
+cavernous and cystic varieties are sometimes met with.
+
+The _cavernous lymphangioma_ appears as an ill-defined, soft swelling,
+presenting many of the characters of a subcutaneous haemangioma, but it
+is not capable of being emptied by pressure, it does not become tense
+when the blood pressure is raised, as in crying, and if the tumour is
+punctured, it yields lymph instead of blood. It also resembles a lipoma,
+especially the congenital variety which grows from the periosteum, and
+the differential diagnosis between these is rarely completed until the
+swelling is punctured or explored by operation. If treatment is called
+for, it is carried out on the same lines as for haemangioma, by means of
+electrolysis, igni-puncture, or excision. Complete excision is rarely
+possible because of the want of definition and encapsulation, but it is
+not necessary for cure, as the parts that remain undergo cicatrisation.
+
+[Illustration: FIG. 76.--Congenital Cystic Tumour or Hygroma of Axilla.
+
+(From a photograph lent by Dr. Lediard.)]
+
+The _cystic lymphangioma_, _lymphatic cyst_, or _congenital cystic
+hygroma_ is most often met with in the neck--_hydrocele of the neck_; it
+is situated beneath the deep fascia, and projects either in front of or
+behind the sterno-mastoid muscle. It may attain a large size, the
+overlying skin and cyst wall may be so thin as to be translucent, and it
+has been known to cause serious impairment of respiration through
+pressing on the trachea. In the axilla also the cystic tumour may attain
+a considerable size (Fig. 76); less frequent situations are the groin,
+and the floor of the mouth, where it constitutes one form of ranula.
+
+The nature of these swellings is to be recognised by their situation, by
+their having existed from infancy, and, if necessary, by drawing off
+some of the contents of the cyst through a fine needle. They are usually
+remarkably indolent, persisting often for a long term of years without
+change, and, like the haemangioma, they sometimes undergo spontaneous
+cicatrisation and cure. Sometimes the cystic tumour becomes infected and
+forms an abscess--another, although less desirable, method of cure.
+Those situated in the neck are most liable to suppurate, probably
+because of pyogenic organisms being brought to them by the lymphatics
+taking origin in the scalp, ear, or throat.
+
+If operative interference is called for, the cysts may be tapped and
+injected with iodine, or excised; the operation for removal may entail a
+considerable dissection amongst the deeper structures at the root of the
+neck, and should not be lightly undertaken; parts left behind may be
+induced to cicatrise by inserting a tube of radium and leaving it for a
+few days.
+
+Lymphangiomas are met with in the abdomen in the form of _omental
+cysts_.
+
+
+DISEASES OF LYMPH GLANDS
+
+#Lymphadenitis.#--Inflammation of lymph glands results from the advent
+of an irritant, usually bacterial or toxic, brought to the glands by the
+afferent lymph vessels. These vessels may share in the inflammation and
+be the seat of lymphangitis, or they may show no evidence of the passage
+of the noxa. It is exceptional for the irritant to reach the gland
+through the blood-stream.
+
+A strain or other form of trauma is sometimes blamed for the onset of
+lymphadenitis, especially in the glands of the groin (bubo), but it is
+usually possible to discover some source of pyogenic infection which is
+responsible for the mischief, or to obtain a history of some antecedent
+infection such as gonorrhoea. It is possible for gonococci to lie latent
+in the inguinal glands for long periods, and only give rise to
+lymphadenitis if the glands be subsequently subjected to injury. The
+glands most frequently affected are those in the neck, axilla, and
+groin.
+
+The characters of the lymphadenitis vary with the nature of the
+irritant. Sometimes it is mild and evanescent, as in the glandular
+enlargement in the neck which attends tonsillitis and other forms of
+sore throat. Sometimes it is more persistent, as in the enlargement
+that is associated with adenoids, hypertrophied tonsils, carious teeth,
+eczema of the scalp, and otorrhoea; and it is possible that this indolent
+enlargement predisposes to tuberculous infection. A similar enlargement
+is met with in the axilla in cases of chronic interstitial mastitis, and
+in the groin as a result of chronic irritation about the external
+genitals, such as balanitis.
+
+Sometimes the lymphadenitis is of an acute character, and the tendency
+is towards the formation of an abscess. This is illustrated in the
+axillary glands as a result of infected wounds of the fingers; in the
+femoral glands in infected wounds or purulent blisters on the foot; in
+the inguinal glands in gonorrhoea and soft sore; and in the cervical
+glands in the severer forms of sore throat associated with diphtheria
+and scarlet fever. The most acute suppurations result from infection
+with streptococci.
+
+Superficial glands, when inflamed and suppurating, become enlarged,
+tender, fixed, and matted to one another. In the glands of the groin the
+suppurative process is often remarkably sluggish; purulent foci form in
+the interior of individual glands, and some time may elapse before the
+pus erupts through their respective capsules. In the deeply placed
+cervical glands, especially in cases of streptococcal throat infections,
+the suppuration rapidly involves the surrounding cellular tissue, and
+the clinical features are those of an acute cellulitis and deeply seated
+abscess. When this is incised the necrosed glands may be found lying in
+the pus, and on bacteriological examination are found to be swarming
+with streptococci. In suppuration of the axillary glands the abscess may
+be quite superficial, or it may be deeply placed beneath the strong
+fascia and pectoral muscles, according to the group of glands involved.
+
+The _diagnosis_ of septic lymphadenitis is usually easy. The indolent
+enlargements are not always to be distinguished, however, from
+commencing tuberculous disease, except by the use of the tuberculin
+test, and by the fact that they usually disappear on removing the
+peripheral source of irritation.
+
+_Treatment._--The first indication is to discover and deal with the
+source of infection, and in the indolent forms of lymphadenitis this
+will usually be followed by recovery. In the acute forms following on
+pyogenic infection, the best results are obtained from the hyperaemic
+treatment carried out by means of suction bells. If suppuration is not
+thereby prevented, or if it has already taken place, each separate
+collection of pus is punctured with a narrow-bladed knife and the use of
+the suction bell is persevered with. If there is a large periglandular
+abscess, as is often the case, in the neck and axilla, the opening may
+require to be made by Hilton's method, and it may be necessary to insert
+a drainage-tube.
+
+[Illustration: FIG. 77.--Tuberculous Cervical Gland with abscess
+formation in subcutaneous cellular tissue, in a boy aet. 10.]
+
+#Tuberculous Disease of Glands.#--This is a disease of great frequency
+and importance. The tubercle bacilli usually gain access to the gland
+through the afferent lymph vessels, which convey them from some lesion
+of the surface within the area drained by them. Tuberculous infection
+may supervene in glands that are already enlarged as a result of chronic
+septic irritation. While any of the glands in the body may be affected,
+the disease is most often met with in the cervical groups which derive
+their lymph from the mouth, nose, throat, and ear.
+
+_The appearance of the glands on section_ varies with the stage of the
+disease. In the early stages the gland is enlarged, it may be to many
+times its natural size, is normal in appearance and consistence, and as
+there is no peri-adenitis it is easily shelled out from its
+surroundings. On microscopical examination, however, there is evidence
+of infection in the shape of bacilli and of characteristic giant and
+epithelioid cells. At a later stage, the gland tissue is studded with
+minute yellow foci which tend to enlarge and in time to become
+confluent, so that the whole gland is ultimately converted into a
+caseous mass. This caseous material is surrounded by the thickened
+capsule which, as a result of peri-adenitis, tends to become adherent to
+and fused with surrounding structures, and particularly with layers of
+fascia and with the walls of veins. The caseated tissue often remains
+unchanged for long periods; it may become calcified, but more frequently
+it breaks down and liquefies.
+
+#Tuberculous disease in the cervical glands# is a common accompaniment
+or sequel of adenoids, enlarged tonsils, carious teeth, pharyngitis,
+middle-ear disease, and conjunctivitis. These lesions afford the bacilli
+a chance of entry into the lymph vessels, in which they are carried to
+the glands, where they give rise to disease.
+
+The enlargement may affect only one gland, usually below the angle of
+the mandible, and remain confined to it, the gland reaching the size of
+a hazel-nut, and being ovoid, firm, and painless. More commonly the
+disease affects several glands, on one or on both sides of the neck.
+When the disease commences in the pre-auricular or submaxillary glands,
+it tends to spread to those along the carotid sheath: when the posterior
+auricular and occipital glands are first involved, the spread is to
+those along the posterior border of the sterno-mastoid. In many cases
+all the chains in front of, beneath, and behind this muscle are
+involved, the enlarged glands extending from the mastoid to the
+clavicle. They are at first discrete and movable, and may even vary in
+size from time to time; but with the addition of peri-adenitis they
+become fixed and matted together, forming lobulated or nodular masses
+(Fig. 78). They become adherent not only to one another, but also to the
+structures in their vicinity,--and notably to the internal jugular
+vein,--a point of importance in regard to their removal by operation.
+
+At any stage the disease may be arrested and the glands remain for long
+periods without further change. It is possible that the tuberculous
+tissue may undergo cicatrisation. More commonly suppuration ensues, and
+a cold abscess forms, but if there is a mixed infection, the pyogenic
+factor being usually derived from the throat, it may take on active
+features.
+
+[Illustration: FIG. 78.--Mass of Tuberculous Glands removed from Axilla
+(cf. Fig. 79).]
+
+The transition from the solid to the liquefied stage is attended with
+pain and tenderness in the gland, which at the same time becomes fixed
+and globular, and finally fluctuation can be elicited.
+
+If left to itself, the softened tubercle erupts through the capsule of
+the gland and infects the cellular tissue. The cervical fascia is
+perforated and a cold abscess, often much larger than the gland from
+which it took origin, forms between the fascia and the overlying skin.
+The further stages--reddening, undermining of skin and external rupture,
+with the formation of ulcers and sinuses--have been described with
+tuberculous abscess. The ulcers and sinuses persist indefinitely, or
+they heal and then break out again; sometimes the skin becomes infected,
+and a condition like lupus spreads over a considerable area. Spontaneous
+healing finally takes place after the caseous tubercle has been
+extruded; the resulting scars are extremely unsightly, being puckered or
+bridled, or hypertrophied like keloid.
+
+While the disease is most common in childhood and youth, it may be met
+with even in advanced life; and although often associated with impaired
+health and unhealthy surroundings, it may affect those who are
+apparently robust and are in affluent circumstances.
+
+_Diagnosis._--The chief importance lies in differentiating tuberculous
+disease from lympho-sarcoma and from lymphadenoma, and this is usually
+possible from the history and from the nature of the enlargement. Signs
+of liquefaction and suppuration support the diagnosis of tubercle. If
+any doubt remains, one of the glands should be removed and submitted to
+microscopical examination. Other forms of sarcoma, and the enlargement
+of an accessory thyreoid, are less likely to be confused with
+tuberculous glands. Calcified tuberculous glands give definite shadows
+with the X-rays.
+
+Enlargement of the cervical glands from secondary cancer may simulate
+tuberculosis, but is differentiated by its association with cancer in
+the mouth or throat, and by the characteristic, stone-like induration of
+epithelioma.
+
+The cold abscess which results from tuberculous glands is to be
+distinguished from that due to disease in the cervical spine,
+retro-pharyngeal abscess, as well as from congenital and other cystic
+swellings in the neck.
+
+_Prognosis._--Next to lupus, glandular disease is of all tuberculous
+lesions the least dangerous to life; but while it is the rule to recover
+from tuberculous disease of glands with or without an operation, it is
+unfortunately quite common for such persons to become the subjects of
+tuberculosis in other parts of the body at any subsequent period of
+life.
+
+_Treatment._--There is considerable difference of opinion regarding the
+treatment of glandular tuberculosis. Some authorities, impressed with
+the undoubted possibility of natural cure, are satisfied with promoting
+this by measures directed towards improving the general health, by the
+prolonged administration of tuberculin, and by repeated exposures to the
+X-rays and to sunlight. Others again, influenced by the risk of
+extension of the disease and by the destruction of tissue and
+disfigurement caused by breaking down of the tuberculous tissue and
+mixed infection, advocate the removal of the glands by operation.
+
+The conditions vary widely in different cases, and the treatment should
+be adapted to the individual requirements. If the disease remains
+confined to the glands originally infected and there are no signs of
+breaking down, "expectant measures" may be persevered with.
+
+[Illustration: FIG. 79.--Tuberculous Axillary Glands (cf. Fig. 78).]
+
+If, on the other hand, the disease exhibits aggressive tendencies, the
+question of operation should be considered. The undesirable results of
+the breaking down and liquefaction of the diseased gland may be avoided
+by the timely withdrawal of the fluid contents through a hollow needle.
+
+_The excision of tuberculous glands_ is often a difficult operation,
+because of the number and deep situation of the glands to be removed,
+and of the adhesions to surrounding structures. The skin incision must
+be sufficiently extensive to give access to the whole of the affected
+area, and to avoid disfigurement should, whenever possible, be made in
+the line of the natural creases of the skin. In exposing the glands the
+common facial and other venous trunks may require to be clamped and
+tied. Care must be taken not to injure the important nerves,
+particularly the accessory, the vagus, and the phrenic. The
+inframaxillary branches of the facial, the hypoglossal and its
+descending branches, and the motor branches of the deep cervical plexus,
+are also liable to be injured. The dissection is rendered easier and is
+attended with less risk of injury to the nerves, if the patient is
+placed in the sitting posture so as to empty the veins, and, instead of
+a knife, the conical scissors of Mayo are employed. When the glands are
+extensively affected on both sides of the neck, it is advisable to allow
+an interval to elapse rather than to operate on both sides at one
+sitting. (_Op. Surg._, p. 189.)
+
+If the tonsils are enlarged they should not be removed at the same time,
+as, by so doing, there is a risk of pyogenic infection from the throat
+being carried to the wound in the neck, but they should be removed,
+after an interval, to prevent relapse of disease in the glands.
+
+_When the skin is broken_ and caseous tuberculous tissue is exposed,
+healing is promoted by cutting away diseased skin, removing the
+granulation tissue with the spoon, scraping sinuses, and packing the
+cavity with iodoform worsted and treating it by the open method and
+secondary suture if necessary. Exposure to the sunshine on the seashore
+and to the X-rays is often beneficial in these cases.
+
+#Tuberculous disease in the axillary glands# may be a result of
+extension from those in the neck, from the mamma, ribs, or sternum, or
+more rarely from the upper extremity. We have seen it from an infected
+wound of a finger. In some cases no source of infection is discoverable.
+The individual glands attain a considerable size, and they fuse together
+to form a large tumour which fills up the axillary space. The disease
+progresses more rapidly than it does in the cervical glands, and almost
+always goes on to suppuration with the formation of sinuses.
+Conservative measures need not be considered, as the only satisfactory
+treatment is excision, and that without delay.
+
+#Tuberculous disease in the glands of the groin# is comparatively rare.
+We have chiefly observed it in the femoral glands as a result of
+inoculation tubercle on the toes or sole of the foot. The affected
+glands nearly always break down and suppurate, and after destroying the
+overlying skin give rise to fungating ulcers. The treatment consists in
+excising the glands and the affected skin. The dissection may be
+attended with troublesome haemorrhage from the numerous veins that
+converge towards the femoral trunk.
+
+Tuberculous disease in the _mesenteric_ and _bronchial glands_ is
+described with the surgery of regions.
+
+#Syphilitic Disease of Glands.#--Enlargement of lymph glands is a
+prominent feature of acquired syphilis, especially in the form of the
+indolent or bullet-bubo which accompanies the primary lesion, and the
+general enlargement of glands that occurs in secondary syphilis.
+Gummatous disease in glands is extremely rare; the affected gland
+rapidly enlarges to the size of a walnut, and may then persist for a
+long period without further change; if it breaks down, the overlying
+skin is destroyed and the caseated tissue of the gumma exposed.
+
+#Lymphadenoma.#--_Hodgkin's Disease_ (Pseudo-leukaemia of German
+authors).--This is a rare disease, the origin of which is as yet
+unknown, but analogy would suggest that it is due to infection with a
+slowly growing micro-organism. It is chiefly met with in young subjects,
+and is characterised by a painless enlargement of a particular group of
+glands, most commonly those in the cervical region (Fig. 80).
+
+[Illustration: FIG. 80.--Chronic Hodgkin's Disease in a boy aet. 11.]
+
+The glands are usually larger than in tuberculosis, and they remain
+longer discrete and movable; they are firm in consistence, and on
+section present a granular appearance due to overgrowth of the
+connective-tissue framework. In time the glandular masses may form
+enormous projecting tumours, the swelling being added to by lymphatic
+oedema of the overlying cellular tissue and skin.
+
+The enlargement spreads along the chain of glands to those above the
+clavicle, to those in the axilla, and to those of the opposite side
+(Fig. 81). Later, the glands in the groin become enlarged, and it is
+probable that the infection has spread from the neck along the
+mediastinal, bronchial, retro-peritoneal, and mesenteric glands, and has
+branched off to the iliac and inguinal groups.
+
+Two clinical types are recognised, one in which the disease progresses
+slowly and remains confined to the cervical glands for two or more
+years; the other, in which the disease is more rapidly disseminated and
+causes death in from twelve to eighteen months.
+
+[Illustration: FIG. 81.--Lymphadenoma (Hodgkin's Disease) affecting left
+side of neck and left axilla, in a woman aet. 44. Three years' duration.]
+
+In the acute form, the health suffers, there is fever, and the glands
+may vary in size with variations in the temperature; the blood presents
+the characters met with in secondary anaemia. The spleen, liver, testes,
+and mammae may be enlarged; the glandular swellings press on important
+structures, such as the trachea, oesophagus, or great veins, and symptoms
+referable to such pressure manifest themselves.
+
+_Diagnosis._--Considerable difficulty attends the diagnosis of
+lymphadenoma at an early stage. The negative results of tuberculin tests
+may assist in the differentiation from tuberculous disease, but the more
+certain means of excising one of the suspected glands and submitting it
+to microscopical examination should be had recourse to. The sections
+show proliferation of endothelial cells, the formation of numerous giant
+cells quite unlike those of tuberculosis and a progressive fibrosis.
+Lympho-sarcoma can usually be differentiated by the rapid assumption of
+the local features of malignant disease, and in a gland removed for
+examination, a predominance of small round cells with scanty protoplasm.
+The enlargement associated with leucocythaemia is differentiated by the
+characteristic changes in the blood.
+
+_Treatment._--In the acute form of lymphadenoma, treatment is of little
+avail. Arsenic may be given in full doses either by the mouth or by
+subcutaneous injection; the intravenous administration of neo-salvarsan
+may be tried. Exposure to the X-rays and to radium has been more
+successful than any other form of treatment. Excision of glands,
+although sometimes beneficial, seldom arrests the progress of the
+disease. The ease and rapidity with which large masses of glands may be
+shelled out is in remarkable contrast to what is observed in tuberculous
+disease. Surgical interference may give relief when important structures
+are being pressed upon--tracheotomy, for example, may be required where
+life is threatened by asphyxia.
+
+#Leucocythaemia.#--This is a disease of the blood and of the
+blood-forming organs, in which there is a great increase in the number,
+and an alteration of the character, of the leucocytes present in the
+blood. It may simulate lymphadenoma, because, in certain forms of the
+disease, the lymph glands, especially those in the neck, axilla, and
+groin, are greatly enlarged.
+
+
+TUMOURS OF LYMPH GLANDS
+
+#Primary Tumours.#--_Lympho-sarcoma_, which may be regarded as a sarcoma
+starting in a lymph gland, appears in the neck, axilla, or groin as a
+rapidly growing tumour consisting of one enlarged gland with numerous
+satellites. As the tumour increases in size, the sarcomatous tissue
+erupts through the capsule of the gland, and infiltrates the surrounding
+tissues, whereby it becomes fixed to these and to the skin.
+
+[Illustration: FIG. 82.--Lympho-Sarcoma removed from Groin. It will be
+observed that there is one large central parent tumour surrounded by
+satellites.]
+
+The prognosis is grave in the extreme, and the only hope is in early
+excision, followed by the use of radium and X-rays. We have observed a
+case of lympho-sarcoma above the clavicle, in which excision of all that
+was removable, followed by the insertion of a tube of radium for ten
+days, was followed by a disappearance of the disease over a period which
+extended to nearly five years, when death resulted from a tumour in the
+mediastinum. In a second case in which the growth was in the groin, the
+patient, a young man, remained well for over two years and was then lost
+sight of.
+
+#Secondary Tumours.#--Next to tuberculosis, _secondary cancer_ is the
+most common disease of lymph glands. In the neck it is met with in
+association with epithelioma of the lip, tongue, or fauces. The glands
+form tumours of variable size, and are often larger than the primary
+growth, the characters of which they reproduce. The glands are at first
+movable, but soon become fixed both to each other and to their
+surroundings; when fixed to the mandible they form a swelling of
+bone-like hardness; in time they soften, liquefy, and burst through the
+skin, forming foul, fungating ulcers. A similar condition is met with in
+the groin from epithelioma of the penis, scrotum, or vulva. In cancer of
+the breast, the infection of the axillary glands is an important
+complication.
+
+In _pigmented_ or _melanotic cancers_ of the skin, the glands are early
+infected and increase rapidly, so that, when the primary growth is still
+of small size--as, for example, on the sole of the foot--the femoral
+glands may already constitute large pigmented tumours.
+
+[Illustration: FIG. 83.--Cancerous Glands in Neck secondary to
+Epithelioma of Lip.
+
+(Mr. G. L. Chiene's case.)]
+
+The implication of the glands in other forms of cancer will be
+considered with regional surgery.
+
+_Secondary sarcoma_ is seldom met with in the lymph glands except when
+the primary growth is a lympho-sarcoma and is situated in the tonsil,
+thyreoid, or testicle.
+
+
+
+
+CHAPTER XVI
+
+THE NERVES
+
+
+Anatomy--INJURIES OF NERVES: Changes in nerves after division;
+    Repair and its modifications; Clinical features; _Primary and
+    secondary suture_--SUBCUTANEOUS INJURIES OF
+    NERVES--DISEASES: _Neuritis_; _Tumours_--Surgery of
+    the individual nerves: _Brachial neuralgia_; _Sciatica_;
+    _Trigeminal neuralgia_.
+
+#Anatomy.#--A nerve-trunk is made up of a variable number of bundles of
+nerve fibres surrounded and supported by a framework of connective
+tissue. The nerve fibres are chiefly of the medullated type, and they
+run without interruption from a nerve cell or _neuron_ in the brain or
+spinal medulla to their peripheral terminations in muscle, skin, and
+secretory glands.
+
+Each nerve fibre consists of a number of nerve fibrils collected into a
+central bundle--the axis cylinder--which is surrounded by an envelope,
+the neurolemma or sheath of Schwann. Between the neurolemma and the axis
+cylinder is the medullated sheath, composed of a fatty substance known
+as myelin. This medullated sheath is interrupted at the nodes of
+Ranvier, and in each internode is a nucleus lying between the myelin and
+the neurolemma. The axis cylinder is the essential conducting structure
+of the nerve, while the neurolemma and the myelin act as insulating
+agents. The axis cylinder depends for its nutrition on the central
+neuron with which it is connected, and from which it originally
+developed, and it degenerates if it is separated from its neuron.
+
+The connective-tissue framework of a nerve-trunk consists of the
+_perineurium_, or general sheath, which surrounds all the bundles; the
+_epineurium_, surrounding individual groups of bundles; and the
+_endoneurium_, a delicate connective tissue separating the individual
+nerve fibres. The blood vessels and lymphatics run in these
+connective-tissue sheaths.
+
+According to Head and his co-workers, Sherren and Rivers, the afferent
+fibres in the peripheral nerves can be divided into three systems:--
+
+1. Those which subserve _deep sensibility_ and conduct the impulses
+produced by pressure as well as those which enable the patient to
+recognise the position of a joint on passive movement (joint-sensation),
+and the kinaesthetic sense, which recognises that active contraction of
+the muscle is taking place (active muscle-sensation). The fibres of this
+system run with the motor nerves, and pass to muscles, tendons, and
+joints. Even division of both the ulnar and the median nerves above the
+wrist produces little loss of deep sensibility, unless the tendons are
+also cut through. The failure to recognise this form of sensibility has
+been largely responsible for the conflicting statements as to the
+sensory phenomena following operations for the repair of divided nerves.
+
+2. Those which subserve _protopathic_ sensibility--that is, are capable
+of responding to painful cutaneous stimuli and to the extremes of heat
+and cold. These also endow the hairs with sensibility to pain. They are
+the first to regenerate after division.
+
+3. Those which subserve _epicritic_ sensibility, the most highly
+specialised, capable of appreciating light touch, _e.g._ with a wisp of
+cotton wool, as a well-localised sensation, and the finer grades of
+temperature, called cool and warm (72-104 F.), and of discriminating
+as separate the points of a pair of compasses 2 cms. apart. These are
+the last to regenerate.
+
+A nerve also exerts a trophic influence on the tissues in which it is
+distributed.
+
+The researches of Stoffel on the minute anatomy of the larger nerves,
+and the disposition in them of the bundles of nerve fibres supplying
+different groups of muscles, have opened up what promises to be a
+fruitful field of clinical investigation and therapeutics. He has shown
+that in the larger nerve-trunks the nerve bundles for special groups of
+muscles are not, as was formerly supposed, arranged irregularly and
+fortuitously, but that on the contrary the nerve fibres to a particular
+group of muscles have a typical and practically constant position within
+the nerve.
+
+In the large nerve-trunks of the limbs he has worked out the exact
+position of the bundles for the various groups of muscles, so that in a
+cross section of a particular nerve the component bundles can be
+labelled as confidently and accurately as can be the cortical areas in
+the brain. In the living subject, by using a fine needle-like electrode
+and a very weak galvanic current, he has been able to differentiate the
+nerve bundles for the various groups of muscles. In several cases of
+spastic paralysis he succeeded in picking out in the nerve-trunk of the
+affected limb the nerve bundles supplying the spastic muscles, and, by
+resecting portions of them, in relieving the spasm. In a case of spastic
+contracture of the pronator muscles of the forearm, for example, an
+incision is made along the line of the median nerve above the bend of
+the elbow. At the lateral side of the median nerve, where it lies in
+contact with the biceps muscle, is situated a well-defined and easily
+isolated bundle of fibres which supplies the pronator teres, the flexor
+carpi radialis, and the palmaris longus muscles. On incising the sheath
+of the nerve this bundle can be readily dissected up and its identity
+confirmed by stimulating it with a very weak galvanic current. An inch
+or more of the bundle is then resected.
+
+
+INJURIES OF NERVES
+
+Nerves are liable to be cut or torn across, bruised, compressed,
+stretched, or torn away from their connections with the spinal medulla.
+
+#Complete Division of a Mixed Nerve.#--Complete division is a common
+result of accidental wounds, especially above the wrist, where the
+ulnar, median, and radial nerves are frequently cut across, and in
+gun-shot injuries.
+
+_Changes in Structure and Function._--The mere interruption of the
+continuity of a nerve results in degeneration of its fibres, the myelin
+being broken up into droplets and absorbed, while the axis cylinders
+swell up, disintegrate, and finally disappear. Both the conducting and
+the insulating elements are thus lost. The degeneration in the central
+end of the divided nerve is usually limited to the immediate proximity
+of the lesion, and does not even involve all the nerve fibres. In the
+distal end, it extends throughout the entire peripheral distribution of
+the nerve, and appears to be due to the cutting off of the fibres from
+their trophic nerve cells in the spinal medulla. Immediate suturing of
+the ends does not affect the degeneration of the distal segment. The
+peripheral end undergoes complete degeneration in from six weeks to two
+months.
+
+The physiological effects of complete division are that the muscles
+supplied by the nerve are immediately paralysed, the area to which it
+furnishes the sole cutaneous supply becomes insensitive, and the other
+structures, including tendons, bones, and joints, lose sensation, and
+begin to atrophy from loss of the trophic influence.
+
+#Nerves divided in Amputation.#--In the case of nerves divided in an
+amputation, there is an active, although necessarily abortive, attempt
+at regeneration, which results in the formation of bulbous swellings at
+the cut ends of the nerves. When there has been suppuration, and
+especially if the nerves have been cut so as to be exposed in the wound,
+these bulbous swellings may attain an abnormal size, and are then known
+as "amputation" or "stump neuromas" (Fig. 84).
+
+When the nerves in a stump have not been cut sufficiently short, they
+may become involved in the cicatrix, and it may be necessary, on account
+of pain, to free them from their adhesions, and to resect enough of the
+terminal portions to prevent them again becoming adherent. When this is
+difficult, a portion may be resected from each of the nerve-trunks at a
+higher level; and if this fails to give relief, a fresh amputation may
+be performed. When there is agonising pain dependent upon an ascending
+neuritis, it may be necessary to resect the corresponding posterior
+nerve roots within the vertebral canal.
+
+[Illustration: FIG. 84.--Stump Neuromas of Sciatic Nerve, excised forty
+years after the original amputation by Mr. A. G. Miller.]
+
+#Other Injuries of Nerves.#--_Contusion_ of a nerve-trunk is attended
+with extravasation of blood into the connective-tissue sheaths, and is
+followed by degeneration of the contused nerve fibres. Function is
+usually restored, the conducting paths being re-established by the
+formation of new nerve fibres.
+
+When a nerve is _torn across_ or badly _crushed_--as, for example, by a
+fractured bone--the changes are similar to those in a divided nerve, and
+the ultimate result depends on the amount of separation between the ends
+and the possibility of the young axis cylinders bridging the gap.
+
+_Involvement of Nerves in Scar Tissue._--Pressure or traction may be
+exerted upon a nerve by contracting scar tissue, or a process of
+neuritis or perineuritis may be induced.
+
+When terminal filaments are involved in a scar, it is best to dissect
+out the scar, and along with it the ends of the nerves pressed upon.
+When a nerve-trunk, such as the sciatic, is involved in cicatricial
+tissue, the nerve must be exposed and freed from its surroundings
+(_neurolysis_), and then stretched so as to tear any adhesions that may
+be present above or below the part exposed. It may be advisable to
+displace the liberated nerve from its original position so as to
+minimise the risk of its incorporation in the scar of the original wound
+or in that resulting from the operation--for example, the radial nerve
+may be buried in the substance of the triceps, or it may be surrounded
+by a segment of vein or portion of fat-bearing fascia.
+
+_Injuries of nerves resulting from_ #gun-shot wounds# include: (1) those
+in which the nerve is directly damaged by the bullet, and (2) those in
+which the nerve-trunk is involved secondarily either by scar tissue in
+its vicinity or by callus following fracture of an adjacent bone. The
+primary injuries include contusion, partial or complete division, and
+perforation of the nerve-trunk. One of the most constant symptoms is the
+early occurrence of severe neuralgic pain, and this is usually
+associated with marked hyperaesthesia.
+
+#Regeneration.#--_Process of Repair when the Ends are in Contact._--_If
+the wound is aseptic_, and the ends of the divided nerve are sutured or
+remain in contact, they become united, and the conducting paths are
+re-established by a regeneration of nerve fibres. There is a difference
+of opinion as to the method of regeneration. The Wallerian doctrine is
+that the axis cylinders in the central end grow downwards, and enter the
+nerve sheaths of the distal portion, and continue growing until they
+reach the peripheral terminations in muscle and skin, and in course of
+time acquire a myelin sheath; the cells of the neurolemma multiply and
+form long chains in both ends of the nerve, and are believed to provide
+for the nourishment and support of the actively lengthening axis
+cylinders. Another view is that the formation of new axis cylinders is
+not confined to the central end, but that it goes on also in the
+peripheral segment, in which, however, the new axis cylinders do not
+attain maturity until continuity with the central end has been
+re-established.
+
+_If the wound becomes infected_ and suppuration occurs, the young nerve
+fibres are destroyed and efficient regeneration is prevented; the
+formation of scar tissue also may constitute a permanent obstacle to new
+nerve fibres bridging the gap.
+
+_When the ends are not in contact_, reunion of the divided nerve fibres
+does not take place whether the wound is infected or not. At the
+proximal end there forms a bulbous swelling, which becomes adherent to
+the scar tissue. It consists of branching axis cylinders running in all
+directions, these having failed to reach the distal end because of the
+extent of the gap. The peripheral end is completely degenerated, and is
+represented by a fibrous cord, the cut end of which is often slightly
+swollen or bulbous, and is also incorporated with the scar tissue of
+the wound.
+
+#Clinical Features.#--The symptoms resulting from division and non-union
+of a nerve-trunk necessarily vary with the functions of the affected
+nerve. The following description refers to a mixed sensori-motor trunk,
+such as the median or radial (musculo-spiral) nerve.
+
+_Sensory Phenomena._--Superficial touch is tested by means of a wisp of
+cotton wool stroked gently across the skin; the capacity of
+discriminating two points as separate, by a pair of blunt-pointed
+compasses; the sensation of pressure, by means of a pencil or other
+blunt object; of pain, by pricking or scratching with a needle; and of
+sensibility to heat and cold, by test-tubes containing water at
+different temperatures. While these tests are being carried out, the
+patient's eyes are screened off.
+
+After division of a nerve containing sensory fibres, there is an area of
+absolute cutaneous insensibility to touch (anaesthesia), to pain
+(analgesia), and to all degrees of temperature--_loss of protopathic
+sensibility_; surrounded by an area in which there is loss of sensation
+to light touch, inability to recognise minor differences of temperature
+(72-104 F.), and to appreciate as separate impressions the contact of
+the two points of a compass--_loss of epicritic sensibility_ (Head and
+Sherren) (Figs. 91, 92).
+
+_Motor Phenomena._--There is immediate and complete loss of voluntary
+power in the muscles supplied by the divided nerve. The muscles rapidly
+waste, and within from three to five days, they cease to react to the
+faradic current. When tested with the galvanic current, it is found that
+a stronger current must be used to call forth contraction than in a
+healthy muscle, and the contraction appears first at the closing of the
+circuit when the anode is used as the testing electrode. The loss of
+excitability to the interrupted current, and the specific alteration in
+the type of contraction with the constant current, is known as the
+_reaction of degeneration_. After a few weeks all electric excitability
+is lost. The paralysed muscles undergo fatty degeneration, which attains
+its maximum three or four months after the division of the nerve.
+Further changes may take place, and result in the transformation of the
+muscle into fibrous tissue, which by undergoing shortening may cause
+deformity known as _paralytic contracture_.
+
+_Vaso-motor Phenomena._--In the majority of cases there is an initial
+rise in the temperature of the part (2 to 3 F.), with redness and
+increased vascularity. This is followed by a fall in the local
+temperature, which may amount to 8 or 10 F., the parts becoming pale
+and cold. Sometimes the hyperaemia resulting from vaso-motor paralysis is
+more persistent, and is associated with swelling of the parts from
+oedema--the so-called _angio-neurotic oedema_. The vascularity varies with
+external influences, and in cold weather the parts present a bluish
+appearance.
+
+_Trophic Phenomena._--Owing to the disappearance of the subcutaneous
+fat, the skin is smooth and thin, and may be abnormally dry. The hair is
+harsh, dry, and easily shed. The nails become brittle and furrowed, or
+thick and curved, and the ends of the fingers become club-shaped. Skin
+eruptions, especially in the form of blisters, occur, or there may be
+actual ulcers of the skin, especially in winter. In aggravated cases the
+tips of the fingers disappear from progressive ulceration, and in the
+sole of the foot a perforating ulcer may develop. Arthropathies are
+occasionally met with, the joints becoming the seat of a painless
+effusion or hydrops, which is followed by fibrous thickening of the
+capsular and other ligaments, and terminates in stiffness and fibrous
+ankylosis. In this way the fingers are seriously crippled and deformed.
+
+#Treatment of Divided Nerves.#--The treatment consists in approximating
+the divided ends of the nerve and placing them under the most favourable
+conditions for repair, and this should be done at the earliest possible
+opportunity. (_Op. Surg._, pp. 45, 46.)
+
+#Primary Suture.#--The reunion of a recently divided nerve is spoken of
+as primary suture, and for its success asepsis is essential. As the
+suturing of the ends of the nerve is extremely painful, an anaesthetic is
+required.
+
+When the wound is healed and while waiting for the restoration of
+function, measures are employed to maintain the nutrition of the damaged
+nerve and of the parts supplied by it. The limb is exercised, massaged,
+and douched, and protected from cold and other injurious influences. The
+nutrition of the paralysed muscles is further improved by electricity.
+The galvanic current is employed, using at first a mild current of not
+more than 5 milliamperes for about ten minutes, the current being made
+to flow downwards in the course of the nerve, with the positive
+electrode applied to the spine, and the negative over the affected nerve
+near its termination. It is an advantage to have a metronome in the
+circuit whereby the current is opened and closed automatically at
+intervals, so as to cause contraction of the muscles.
+
+_The results_ of primary suture, when it has been performed under
+favourable conditions, are usually satisfactory. In a series of cases
+investigated by Head and Sherren, the period between the operation and
+the first return of sensation averaged 65 days. According to Purves
+Stewart protopathic sensation commences to appear in about six weeks and
+is completely restored in six months; electric sensation and motor power
+reappear together in about six months, and restoration is complete in a
+year. When sensation returns, the area of insensibility to pain steadily
+diminishes and disappears; sensibility to extremes of temperature
+appears soon after; and last of all, after a considerable interval,
+there is simultaneous return of appreciation of light touch, moderate
+degrees of temperature, and the points of a compass.
+
+A clinical means of estimating how regeneration in a divided nerve is
+progressing has been described by Tinel. He found that a tingling
+sensation, similar to that experienced in the foot, when it is
+recovering from the "sleeping" condition induced by prolonged pressure
+on the sciatic nerve from sitting on a hard bench, can be elicited on
+percussing over _growing_ axis cylinders. Tapping over the proximal end
+of a _newly divided nerve_, _e.g._ the common peroneal behind the head
+of the fibula, produces no tingling, but when in about three weeks
+axis cylinders begin to grow in the proximal end-bulb, local tingling is
+induced by tapping there. The downward growth of the axis cylinders can
+be traced by tapping over the distal segment of the nerve, the tingling
+sensation being elicited as far down as the young axis cylinders have
+reached. When the regeneration of the axis cylinders is complete,
+tapping no longer causes tingling. It usually takes about one hundred
+days for this stage to be reached.
+
+Tinel's sign is present before voluntary movement, muscular tone, or the
+normal electrical reactions reappear.
+
+In cases of complete nerve paralysis that have not been operated upon,
+the tingling test is helpful in determining whether or not regeneration
+is taking place. Its detection may prevent an unnecessary operation
+being performed.
+
+Primary suture should not be attempted so long as the wound shows signs
+of infection, as it is almost certain to end in failure. The ends should
+be sutured, however, as soon as the wound is aseptic or has healed.
+
+#Secondary Suture.#--The term secondary suture is applied to the
+operation of stitching the ends of the divided nerve after the wound has
+healed.
+
+_Results of Secondary Suture._--When secondary suture has been performed
+under favourable conditions, the prognosis is good, but a longer time is
+required for restoration of function than after primary suture. Purves
+Stewart says protopathic sensation is sometimes observed much earlier
+than in primary suture, because partial regeneration of axis cylinders
+in the peripheral segment has already taken place. Sensation is
+recovered first, but it seldom returns before three or four months.
+There then follows an improvement or disappearance of any trophic
+disturbances that may be present. Recovery of motion may be deferred for
+long periods--rather because of the changes in the muscles than from
+want of conductivity in the nerve--and if the muscles have undergone
+complete degeneration, it may never take place at all. While waiting for
+recovery, every effort should be made to maintain the nutrition of the
+damaged nerve, and of the parts which it supplies.
+
+When suture is found to be impossible, recourse must be had to other
+methods, known as nerve bridging and nerve implantation.
+
+#Incomplete Division of a Mixed Nerve.#--The effects of partial division
+of a mixed nerve vary according to the destination of the nerve bundles
+that have been interrupted. Within their area of distribution the
+paralysis is as complete as if the whole trunk had been cut across. The
+uninjured nerve-bundles continue to transmit impulses with the result
+that there is a _dissociated paralysis_ within the distribution of the
+affected nerve, some muscles continuing to act and to respond normally
+to electric stimulation, while others behave as if the whole nerve-trunk
+had been severed.
+
+In addition to vasomotor and trophic changes, there is often severe pain
+of a burning kind (_causalgia_ or _thermalgia_) which comes on about a
+fortnight after the injury and causes intense and continuous suffering
+which may last for months. Paroxysms of pain may be excited by the
+slightest touch or by heat, and the patient usually learns for himself
+that the constant application of cold wet cloths allays the pain. The
+thermalgic area sweats profusely.
+
+Operative treatment is indicated where there is no sign of improvement
+within three months, when recovery is arrested before complete
+restoration of function is attained, or when thermalgic pain is
+excessive.
+
+#Subcutaneous Injuries of Nerves.#--Several varieties of subcutaneous
+injuries of nerves are met with. One of the best known is the
+compression paralysis of the nerves of the upper arm which results from
+sleeping with the arm resting on the back of a chair or the edge of a
+table--the so-called "drunkard's palsy"; and from the pressure of a
+crutch in the axilla--"crutch paralysis." In some of these injuries,
+notably "drunkard's palsy," the disability appears to be due not to
+damage of the nerve, but to overstretching of the extensors of the wrist
+and fingers (Jones). A similar form of paralysis is sometimes met with
+from the pressure of a tourniquet, from tight bandages or splints, from
+the pressure exerted by a dislocated bone or by excessive callus, and
+from hyper-extension of the arm during anaesthesia.
+
+In all these forms there is impaired sensation, rarely amounting to
+anaesthesia, marked muscular wasting, and diminution or loss of voluntary
+motor power, while--and this is a point of great importance--the normal
+electrical reactions are preserved. There may also develop trophic
+changes such as blisters, superficial ulcers, and clubbing of the tips
+of the fingers. The prognosis is usually favourable, as recovery is the
+rule within from one to three months. If, however, neuritis supervenes,
+the electrical reactions are altered, the muscles degenerate, and
+recovery may be retarded or may fail to take place.
+
+Injuries which act abruptly or instantaneously are illustrated in the
+crushing of a nerve by the sudden displacement of a sharp-edged fragment
+of bone, as may occur in comminuted fractures of the humerus. The
+symptoms include perversion or loss of sensation, motor paralysis, and
+atrophy of muscles, which show the reaction of degeneration from the
+eighth day onwards. The presence of the reaction of degeneration
+influences both the prognosis and the treatment, for it implies a lesion
+which is probably incapable of spontaneous recovery, and which can only
+be remedied by operation.
+
+The _treatment_ varies with the cause and nature of the lesion. When,
+for example, a displaced bone or a mass of callus is pressing upon the
+nerve, steps must be taken to relieve the pressure, by operation if
+necessary. When there is reason to believe that the nerve is severely
+crushed or torn across, it should be exposed by incision, and, after
+removal of the damaged ends, should be united by sutures. When it is
+impossible to make a definite diagnosis as to the state of the nerve, it
+is better to expose it by operation, and thus learn the exact state of
+affairs without delay; in the event of the nerve being torn, the ends
+should be united by sutures.
+
+#Dislocation of Nerves.#--This injury, which resembles the dislocation
+of tendons from their grooves, is seldom met with except in the ulnar
+nerve at the elbow, and is described with injuries of that nerve.
+
+
+DISEASES OF NERVES
+
+#Traumatic Neuritis.#--This consists in an overgrowth of the
+connective-tissue framework of a nerve, which causes irritation and
+pressure upon the nerve fibres, sometimes resulting in their
+degeneration. It may originate in connection with a wound in the
+vicinity of a nerve, as, for example, when the brachial nerves are
+involved in scar tissue subsequent to an operation for clearing out the
+axilla for cancer; or in contusion and compression of a nerve--for
+example, by the pressure of the head of the humerus in a dislocation of
+the shoulder. Some weeks or months after the injury, the patient
+complains of increasing hyperaesthesia and of neuralgic pains in the
+course of the nerve. The nerve is very sensitive to pressure, and, if
+superficial, may be felt to be swollen. The associated muscles are
+wasted and weak, and are subject to twitchings. There are also trophic
+disturbances. It is rare to have complete sensory and motor paralysis.
+The disease is commonest in the nerves of the upper extremity, and the
+hand may become crippled and useless.
+
+_Treatment._--Any constitutional condition which predisposes to
+neuritis, such as gout, diabetes, or syphilis, must receive appropriate
+treatment. The symptoms may be relieved by rest and by soothing
+applications, such as belladonna, ichthyol, or menthol, by the use of
+hot-air and electric baths, and in obstinate cases by blistering or by
+the application of Corrigan's button. When such treatment fails the
+nerve may be stretched, or, in the case of a purely sensory trunk, a
+portion may be excised. Local causes, such as involvement of the nerve
+in a scar or in adhesions, may afford indications for operative
+treatment.
+
+#Multiple Peripheral Neuritis.#--Although this disease mainly comes
+under the cognizance of the physician, it may be attended with phenomena
+which call for surgical interference. In this country it is commonly due
+to alcoholism, but it may result from diabetes or from chronic poisoning
+with lead or arsenic, or from bacterial infections and intoxications
+such as occur in diphtheria, gonorrhoea, syphilis, leprosy, typhoid,
+influenza, beri-beri, and many other diseases.
+
+It is, as a rule, widely distributed throughout the peripheral nerves,
+but the distribution frequently varies with the cause--the alcoholic
+form, for example, mainly affecting the legs, the diphtheritic form the
+soft palate and pharynx, and that associated with lead poisoning the
+forearms. The essential lesion is a degeneration of the conducting
+fibres of the affected nerves, and the prominent symptoms are the result
+of this. In alcoholic neuritis there is great tenderness of the muscles.
+When the legs are affected the patient may be unable to walk, and the
+toes may droop and the heel be drawn up, resulting in one variety of pes
+equino-varus. Pressure sores and perforating ulcer of the foot are the
+most important trophic phenomena.
+
+Apart from the medical _treatment_, measures must be taken to prevent
+deformity, especially when the legs are affected. The bedclothes are
+supported by a cage, and the foot maintained at right angles to the leg
+by sand-bags or splints. When the disease is subsiding, the nutrition of
+the damaged nerves and muscles should be maintained by massage, baths,
+passive movements, and the use of the galvanic current. When deformity
+has been allowed to take place, operative measures may be required for
+its correction.
+
+
+NEUROMA[5]
+
+[5] We have followed the classification adopted by Alexis Thomson in his
+work _On Neuroma, and Neuro-fibromatosis_ (Edinburgh: 1900).
+
+Neuroma is a clinical term applied to all tumours, irrespective of their
+structure, which have their seat in nerves.
+
+A tumour composed of newly formed nerve tissue is spoken of as a #true
+neuroma#; when ganglionic cells are present in addition to nerve fibres,
+the name _ganglionic neuroma_ is applied. These tumours are rare, and
+are chiefly met with in the main cords or abdominal plexuses of the
+sympathetic system of children or young adults. They are quite
+insensitive, and their removal is only called for if they cause pain or
+show signs of malignancy.
+
+A #false neuroma# is an overgrowth of the sheath of a nerve. This
+overgrowth may result in the formation of a circumscribed tumour, or may
+take the form of a diffuse fibromatosis.
+
+_The circumscribed or solitary tumour_ grows from the sheath of a nerve
+which is otherwise healthy, and it may be innocent or malignant.
+
+_The innocent_ form is usually fibrous or myxomatous, and is definitely
+encapsulated. It may become cystic as a result of haemorrhage or of
+myxomatous degeneration. It grows very slowly, is usually elliptical in
+shape, and the solid form is rarely larger than a hazel-nut. The nerve
+fibres may be spread out all round the tumour, or may run only on one
+side of it. When subcutaneous and related to the smaller unnamed
+cutaneous nerves, it is known as a _painful subcutaneous nodule_ or
+_tubercle_. It is chiefly met with about the ankle, and most often in
+women. It is remarkably sensitive, even gentle handling causing intense
+pain, which usually radiates to the periphery of the nerve affected.
+When related to a deeper, named nerve-trunk, it is known as a
+_trunk-neuroma_. It is usually less sensitive than the "subcutaneous
+nodule," and rarely gives rise to motor symptoms unless it involves the
+nerve roots where they pass through bony canals.
+
+A trunk-neuroma is recognised clinically by its position in the line of
+a nerve, by the fact that it is movable in the transverse axis of the
+nerve but not in its long axis, and by being unduly painful and
+sensitive.
+
+[Illustration: FIG. 85.--Amputation Stump of Upper Arm, showing bulbous
+thickening of the ends of the nerves, embedded in scar tissue at the
+apex of the stamp.]
+
+_Treatment._--If the tumour causes suffering it should be removed,
+preferably by shelling it out from the investing nerve sheath or
+capsule. In the subcutaneous nodule the nerve is rarely recognisable,
+and is usually sacrificed. When removal of the tumour is incomplete, a
+tube of radium should be inserted into the cavity, to prevent recurrence
+of the tumour in a malignant form.
+
+_The malignant neuroma_ is a sarcoma growing from the sheath of a nerve.
+It has the same characters and clinical features as the innocent
+variety, only it grows more rapidly, and by destroying the nerve fibres
+causes motor symptoms--jerkings followed by paralysis. The sarcoma tends
+to spread along the lymph spaces in the long axis of the nerve, as well
+as to implicate the surrounding tissues, and it is liable to give rise
+to secondary growths. The malignant neuroma is met with chiefly in the
+sciatic and other large nerves of the limbs.
+
+The _treatment_ is conducted on the same lines as sarcoma in other
+situations; the insertion of a tube of radium after removal of the
+tumour diminishes the tendency to recurrence; a portion of the
+nerve-trunk being sacrificed, means must be taken to bridge the gap. In
+inoperable cases it may be possible to relieve pain by excising a
+portion of the nerve above the tumour, or, when this is impracticable,
+by resecting the posterior nerve roots and their ganglia within the
+vertebral canal.
+
+The so-called _amputation neuroma_ has already been referred to (p. 344).
+
+_Diffuse or Generalised Neuro-Fibromatosis--Recklinghausen's
+Disease._--These terms are now used to include what were formerly known
+as "multiple neuromata," as well as certain other overgrowths related to
+nerves. The essential lesion is an overgrowth of the endoneural
+connective tissue throughout the nerves of both the cerebro-spinal and
+sympathetic systems. The nerves are diffusely and unequally thickened,
+so that small twigs may become enlarged to the size of the median, while
+at irregular intervals along their course the connective-tissue
+overgrowth is exaggerated so as to form tumour-like swellings similar to
+the trunk-neuroma already described. The tumours, which vary greatly in
+size and number--as many as a thousand have been counted in one
+case--are enclosed in a capsule derived from the perineurium. The
+fibromatosis may also affect the cranial nerves, the ganglia on the
+posterior nerve roots, the nerves within the vertebral canal, and the
+sympathetic nerves and ganglia, as well as the continuations of the
+motor nerves within the muscles. The nerve fibres, although mechanically
+displaced and dissociated by the overgrown endoneurium, undergo no
+structural change except when compressed in passing through a bony
+canal.
+
+The disease probably originates before birth, although it may not make
+its appearance till adolescence or even till adult life. It is sometimes
+met with in several members of one family. It is recognised clinically
+by the presence of multiple tumours in the course of the nerves, and
+sometimes by palpable enlargement of the superficial nerve-trunks
+(Fig. 86). The tumours resemble the solitary trunk-neuroma, are usually
+quite insensitive, and many of them are unknown to the patient. As a
+result of injury or other exciting cause, however, one or other tumour
+may increase in size and become extremely sensitive; the pain is then
+agonising; it is increased by handling, and interferes with sleep. In
+these conditions, a malignant transformation of the fibroma into sarcoma
+is to be suspected. Motor disturbances are exceptional, unless in the
+case of tumours within the vertebral canal, which press on the spinal
+medulla and cause paraplegia.
+
+[Illustration: FIG. 86.--Diffuse enlargement of Nerves in generalised
+Neuro-fibromatosis.
+
+(After R. W. Smith.)]
+
+Neuro-fibromatosis is frequently accompanied by _pigmentation of the
+skin_ in the form of brown spots or patches scattered over the trunk.
+
+The disease is often stationary for long periods. In progressive cases
+the patient becomes exhausted, and usually dies of some intercurrent
+affection, particularly phthisis. The treatment is restricted to
+relieving symptoms and complications; removal of one of the tumours is
+to be strongly deprecated.
+
+In a considerable proportion of cases one of the multiple tumours takes
+on the characters of a malignant growth ("secondary malignant neuroma,"
+Garre). This malignant transformation may follow upon injury, or on an
+unsuccessful attempt to remove the tumour. The features are those of a
+rapidly growing sarcoma involving a nerve-trunk, with agonising pain
+and muscular cramps, followed by paralysis from destruction of the
+nerve fibres. The removal of the tumour is usually followed by
+recurrence, so that high amputation is the only treatment to be
+recommended. Metastasis to internal organs is exceptional.
+
+[Illustration: FIG. 87.--Plexiform Neuroma of small Sciatic Nerve, from
+a girl aet. 16.
+
+(Mr. Annandale's case.)]
+
+There are other types of neuro-fibromatosis which require brief mention.
+
+_The plexiform neuroma_ (Fig. 87) is a fibromatosis confined to the
+distribution of one or more contiguous nerves or of a plexus of nerves,
+and it may occur either by itself or along with multiple tumours of the
+nerve-trunks and with pigmentation of the skin. The clinical features
+are those of an ill-defined swelling composed of a number of tortuous,
+convoluted cords, lying in a loose areolar tissue and freely movable on
+one another. It is rarely the seat of pain or tenderness. It most often
+appears in the early years of life, sometimes in relation to a pigmented
+or hairy mole. It is of slow growth, may remain stationary for long
+periods, and has little or no tendency to become malignant. It is
+usually subcutaneous, and is frequently situated on the head or neck in
+the distribution of the trigeminal or superficial cervical nerves. There
+is no necessity for its removal, but this may be indicated because of
+disfigurement, especially on the face or scalp or because its bulk
+interferes with function. When involving the ophthalmic division of the
+trigeminus, for example, it may cause enlargement of the upper lid and
+proptosis, with danger to the function of the globe. The results of
+excision are usually satisfactory, even if the removal is not complete.
+
+[Illustration: FIG. 88.--Multiple Neuro-fibromas of Skin (Molluscum
+fibrosum, or Recklinghausen's disease).]
+
+_The cutaneous neuro-fibroma_ or _molluscum fibrosum_ has been shown by
+Recklinghausen to be a soft fibroma related to the terminal filaments of
+one of the cutaneous nerves (Fig. 88). The disease appears in the form
+of multiple, soft, projecting tumours, scattered all over the body,
+except the palms of the hands and soles of the feet. The tumours are of
+all sizes, some being no larger than a pin's head, whilst many are as
+big as a filbert and a few even larger. Many are sessile and others are
+distinctly pedunculated, but all are covered with skin. They are mobile,
+soft to the touch, and of the consistence of firm fat. In exceptional
+cases one of the skin tumours may attain an enormous size and cause a
+hideous deformity, hanging down by its own weight in lobulated or folded
+masses (pachy-dermatocele). The treatment consists in removing the
+larger swellings. In some cases molluscum fibrosum is associated with
+pigmentation of the skin and with multiple tumours of the nerve-trunks.
+The small multiple tumours rarely call for interference.
+
+[Illustration: FIG. 89.--Elephantiasis Neuromatosa in a woman aet. 28]
+
+_Elephantiasis neuromatosa_ is the name applied by Virchow to a
+condition in which a limb is swollen and misshapen as a result of the
+extension of a neuro-fibromatosis to the skin and subcutaneous cellular
+tissue of the extremity as a whole (Fig. 89). It usually begins in early
+life without apparent cause, and it may be associated with multiple
+tumours of the nerve-trunks. The inconvenience caused by the bulk and
+weight of the limb may justify its removal.
+
+
+SURGERY OF THE INDIVIDUAL NERVES[6]
+
+[6] We desire here to acknowledge our indebtedness to Mr. James
+Sherren's work on _Injuries of Nerves and their Treatment_.
+
+#The Brachial Plexus.#--Lesions of the brachial plexus may be divided
+into those above the clavicle and those below that bone.
+
+In the #supra-clavicular injuries#, the violence applied to the head or
+shoulder causes over-stretching of the anterior branches (primary
+divisions) of the cervical nerves, the fifth, or the fifth and sixth
+being those most liable to suffer. Sometimes the traction is exerted
+upon the plexus from below, as when a man in falling from a height
+endeavours to save himself by clutching at some projection, and the
+lesion then mainly affects the first dorsal nerve. There is tearing of
+the nerve sheaths, with haemorrhage, but in severe cases partial or
+complete severance of nerve fibres may occur and these give way at
+different levels. During the healing process an excess of fibrous tissue
+is formed, which may interfere with regeneration.
+
+_Post-anaesthetic paralysis_ occurs in patients in whom, during the
+course of an operation, the arm is abducted and rotated laterally or
+extended above the head, causing over-stretching of the plexus,
+especially of the fifth, or fifth and sixth, anterior branches.
+
+A _cervical rib_ may damage the plexus by direct pressure, the part
+usually affected being the medial cord, which is made up of fibres from
+the eighth cervical and first dorsal nerves.
+
+When a lesion of the plexus complicates a _fracture of the clavicle_,
+the nerve injury is due, not to pressure on or laceration of the nerves
+by fragments of bone, but to the violence causing the fracture, and this
+is usually applied to the point of the shoulder.
+
+Penetrating _wounds_, apart from those met with in military practice,
+are rare.
+
+In the #infra-clavicular injuries#, the lesion most often results from
+the pressure of the dislocated head of the humerus; occasionally from
+attempts made to reduce the dislocation by the heel-in-the-axilla
+method, or from fracture of the upper end of the humerus or of the neck
+of the scapula. The whole plexus may suffer, but more frequently the
+medial cord is alone implicated.
+
+_Clinical Features._--Three types of lesion result from indirect
+violence: the whole plexus; the upper-arm type; and the lower-arm type.
+
+_When the whole plexus is involved_, sensibility is lost over the entire
+forearm and hand and over the lateral surface of the arm in its distal
+two-thirds. All the muscles of the arm, forearm, and hand are paralysed,
+and, as a rule, also the pectorals and spinati, but the rhomboids and
+serratus anterior escape. There is paralysis of the sympathetic fibres
+to the eye and orbit, with narrowing of the palpebral fissure, recession
+of the globe, and the pupil is slow to dilate when shaded from the
+light.
+
+The _upper-arm type_--Erb-Duchenne paralysis--is that most frequently
+met with, and it is due to a lesion of the fifth anterior branch, or, it
+may be, also of the sixth. The position of the upper limb is typical:
+the arm and forearm hang close to the side, with the forearm extended
+and pronated; the deltoid, spinati, biceps, brachialis, and supinators
+are paralysed, and in some cases the radial extensors of the wrist and
+the pronator teres are also affected. The patient is unable to supinate
+the forearm or to abduct the arm, and in most cases to flex the forearm.
+He may, however, regain some power of flexing the forearm when it is
+fully pronated, the extensors of the wrist becoming feeble flexors of
+the elbow. There is, as a rule, no loss of sensibility, but complaint
+may be made of tickling and of pins-and-needles over the lateral aspect
+of the arm. The abnormal position of the limb may persist although the
+muscles regain the power of voluntary movement, and as the condition
+frequently follows a fall on the shoulder, great care is necessary in
+diagnosis, as the condition is apt to be attributed to an injury to the
+axillary (circumflex) nerve.
+
+The _lower-arm type_ of paralysis, associated with the name of Klumpke,
+is usually due to over-stretching of the plexus, and especially affects
+the anterior branch of the first dorsal nerve. In typical cases all the
+intrinsic muscles of the hand are affected, and the hand assumes the
+claw shape. Sensibility is usually altered over the medial side of the
+arm and forearm, and there is paralysis of the sympathetic.
+
+_Infra-clavicular injuries_, as already stated, are most often produced
+by a sub-coracoid dislocation of the humerus; the medial cord is that
+most frequently injured, and the muscles paralysed are those supplied by
+the ulnar nerve, with, in addition, those intrinsic muscles of the hand
+supplied by the median. Sensibility is affected over the medial surface
+of the forearm and ulnar area of the hand. Injury of the lateral and
+posterior cords is very rare.
+
+_Treatment_ is carried out on the lines already laid down for nerve
+injuries in general. It is impossible to diagnose between complete and
+incomplete rupture of the nerve cords, until sufficient time has elapsed
+to allow of the establishment of the reaction of degeneration. If this
+is present at the end of fourteen days, operation should not be delayed.
+Access to the cords of the plexus is obtained by a dissection similar to
+that employed for the subclavian artery, and the nerves are sought for
+as they emerge from under cover of the scalenus anterior, and are then
+traced until the seat of injury is found. In the case of the first
+dorsal nerve, it may be necessary temporarily to resect the clavicle.
+The usual after-treatment must be persisted in until recovery ensues,
+and care must be taken that the paralysed muscles do not become
+over-stretched. The prognosis is less favourable in the supra-clavicular
+lesions than in those below the clavicle, which nearly always recover
+without surgical intervention.
+
+In the _brachial birth-paralysis_ met with in infants, the lesion is due
+to over-stretching of the plexus, and is nearly always of the
+Erb-Duchenne type. The injury is usually unilateral, it occurs with
+almost equal frequency in breech and in vertex presentations, and the
+left arm is more often affected than the right. The lesion is seldom
+recognised at birth. The first symptom noticed is tenderness in the
+supra-clavicular region, the child crying when this part is touched or
+the arm is moved. The attitude may be that of the Erb-Duchenne type, or
+the whole of the muscles of the upper limb may be flaccid, and the arm
+hangs powerless. A considerable proportion of the cases recover
+spontaneously. The arm is to be kept at rest, with the affected muscles
+relaxed, and, as soon as tenderness has disappeared, daily massage and
+passive movements are employed. The reaction of degeneration can rarely
+be satisfactorily tested before the child is three months old, but if it
+is present, an operation should be performed. After operation, the
+shoulder should be elevated so that no traction is exerted on the
+affected cords.
+
+#The long thoracic nerve# (nerve of Bell), which supplies the serratus
+anterior, is rarely injured. In those whose occupation entails carrying
+weights upon the shoulder it may be contused, and the resulting
+paralysis of the serratus is usually combined with paralysis of the
+lower part of the trapezius, the branches from the third and fourth
+cervical nerves which supply this muscle also being exposed to pressure
+as they pass across the root of the neck. There is complaint of pain
+above the clavicle, and winging of the scapula; the patient is unable to
+raise the arm in front of the body above the level of the shoulder or to
+perform any forward pushing movements; on attempting either of these the
+winging of the scapula is at once increased. If the scapula is compared
+with that on the sound side, it is seen that, in addition to the lower
+angle being more prominent, the spine is more horizontal and the lower
+angle nearer the middle line. The majority of these cases recover if the
+limb is placed at absolute rest, the elbow supported, and massage and
+galvanism persevered with. If the paralysis persists, the sterno-costal
+portion of the pectoralis major may be transplanted to the lower angle
+of the scapula.
+
+The long thoracic nerve may be cut across while clearing out the axilla
+in operating for cancer of the breast. The displacement of the scapula
+is not so marked as in the preceding type, and the patient is able to
+perform pushing movements below the level of the shoulder. If the
+reaction of degeneration develops, an operation may be performed, the
+ends of the nerve being sutured, or the distal end grafted into the
+posterior cord of the brachial plexus.
+
+#The Axillary (Circumflex) Nerve.#--In the majority of cases in which
+paralysis of the deltoid follows upon an injury of the shoulder, it is
+due to a lesion of the fifth cervical nerve, as has already been
+described in injuries of the brachial plexus. The axillary nerve itself
+as it passes round the neck of the humerus is most liable to be injured
+from the pressure of a crutch, or of the head of the humerus in
+sub-glenoid dislocation, or in fracture of the neck of the scapula or of
+the humerus. In miners, who work for long periods lying on the side, the
+muscle may be paralysed by direct pressure on the terminal filaments of
+the nerve, and the nerve may also be involved as a result of disease in
+the sub-deltoid bursa.
+
+The deltoid is wasted, and the acromion unduly prominent. In recent
+cases paralysis of the muscle is easily detected. In cases of long
+standing it is not so simple, because other muscles, the spinati, the
+clavicular fibres of the pectoral and the serratus, take its place and
+elevate the arm; there is always loss of sensation on the lateral aspect
+of the shoulder. There is rarely any call for operative treatment, as
+the paralysis is usually compensated for by other muscles.
+
+When the _supra-scapular nerve_ is contused or stretched in injuries of
+the shoulder, the spinati muscles are paralysed and wasted, the spine of
+the scapula is unduly prominent, and there is impairment in the power of
+abducting the arm and rotating it laterally.
+
+The _musculo-cutaneous nerve_ is very rarely injured; when cut across,
+there is paralysis of the coraco-brachialis, biceps, and part of the
+brachialis, but no movements are abolished, the forearm being flexed, in
+the pronated position, by the brachio-radialis and long radial extensor
+of the wrist; in the supinated position, by that portion of the
+brachialis supplied by the radial nerve. Supination is feebly performed
+by the supinator muscle. Protopathic and epicritic sensibility are lost
+over the radial side of the forearm.
+
+#Radial (Musculo-Spiral) Nerve.#--From its anatomical relationships this
+trunk is more exposed to injury than any other nerve in the body. It is
+frequently compressed against the humerus in sleeping with the arm
+resting on the back of a chair, especially in the deep sleep of
+alcoholic intoxication (drunkard's palsy). It may be pressed upon by a
+crutch in the axilla, by the dislocated head of the humerus, or by
+violent compression of the arm, as when an elastic tourniquet is applied
+too tightly. The most serious and permanent injuries of this nerve are
+associated with fractures of the humerus, especially those from direct
+violence attended with comminution of the bone. The nerve may be crushed
+or torn by one of the fragments at the time of the injury, or at a later
+period may be compressed by callus.
+
+_Clinical Features._--Immediately after the injury it is impossible to
+tell whether the nerve is torn across or merely compressed. The patient
+may complain of numbness and tingling in the distribution of the
+superficial branch of the nerve, but it is a striking fact, that so long
+as the nerve is divided below the level at which it gives off the dorsal
+cutaneous nerve of the forearm (external cutaneous branch), there is no
+loss of sensation. When it is divided above the origin of the dorsal
+cutaneous branch, or when the dorsal branch of the musculo-cutaneous
+nerve is also divided, there is a loss of sensibility on the dorsum
+of the hand.
+
+The motor symptoms predominate, the muscles affected being the extensors
+of the wrist and fingers, and the supinators. There is a characteristic
+"drop-wrist"; the wrist is flexed and pronated, and the patient is
+unable to dorsiflex the wrist or fingers (Fig. 90). If the hand and
+proximal phalanges are supported, the second and third phalanges may be
+partly extended by the interossei and lumbricals. There is also
+considerable impairment of power in the muscles which antagonise those
+that are paralysed, so that the grasp of the hand is feeble, and the
+patient almost loses the use of it; in some cases this would appear to
+be due to the median nerve having been injured at the same time.
+
+[Illustration: FIG. 90.--Drop-wrist following Fracture of Shaft of
+Humerus.]
+
+If the lesion is high up, as it is, for example, in crutch paralysis,
+the triceps and anconeus may also suffer.
+
+_Treatment._--The slighter forms of injury by compression recover under
+massage, douching, and electricity. If there is drop-wrist, the hand and
+forearm are placed on a palmar splint, with the hand dorsiflexed to
+nearly a right angle, and this position is maintained until voluntary
+dorsiflexion at the wrist returns to the normal. Recovery is sometimes
+delayed for several months.
+
+In the more severe injuries associated with fracture of the humerus and
+attended with the reaction of degeneration, it is necessary to cut down
+upon the nerve and free it from the pressure of a fragment of bone or
+from callus or adhesions. If the nerve is torn across, the ends must be
+sutured, and if this is impossible owing to loss of tissue, the gap may
+be bridged by a graft taken from the superficial branch of the radial
+nerve, or the ends may be implanted into the median.
+
+Finally, in cases in which the paralysis is permanent and incurable, the
+disability may be relieved by operation. A fascial graft can be employed
+to act as a ligament permanently extending the wrist; it is attached to
+the third and fourth metacarpal bones distally and to the radius or ulna
+proximally. The flexor carpi radialis can then be joined up with the
+extensor digitorum communis by passing its tendon through an aperture in
+the interosseous membrane, or better still, through the pronator
+quadratus, as there is less likelihood of the formation of adhesions
+when the tendon passes through muscle than through interosseous
+membrane. The palmaris longus is anastomosed with the abductor pollicis
+longus (extensor ossis metacarpi pollicis), thus securing a fair amount
+of abduction of the thumb. The flexor carpi ulnaris may also be
+anastomosed with the common extensor of the fingers. The extensors of
+the wrist may be shortened, so as to place the hand in the position of
+dorsal flexion, and thus improve the attitude and grasp of the hand.
+
+_The superficial branch of the radial_ (radial nerve) _and the deep
+branch_ (posterior interosseous), apart from suffering in lesions of the
+radial, are liable to be contused or torn is dislocation of the head of
+the radius, and in fracture of the neck of the bone. The deep branch may
+be divided as it passes through the supinator in operations on old
+fractures and dislocations in the region of the elbow. Division of the
+superficial branch in the upper two-thirds of the forearm produces no
+loss of sensibility; division in the lower third after the nerve has
+become associated with branches from the musculo-cutaneous is followed
+by a loss of sensibility on the radial side of the hand and thumb. Wounds
+on the dorsal surface of the wrist and forearm are often followed by
+loss of sensibility over a larger area, because the musculo-cutaneous
+nerve is divided as well, and some of the fibres of the lower lateral
+cutaneous branch of the radial.
+
+[Illustration: FIG. 91.--To illustrate the Loss of Sensation produced by
+Division of the Median Nerve. The area of complete cutaneous
+insensibility is shaded black. The parts insensitive to light touch and
+to intermediate degrees of temperature are enclosed within the dotted
+line.
+
+(After Head and Sherren.)]
+
+#The Median Nerve# is most frequently injured in wounds made by broken
+glass in the region of the wrist. It may also be injured in fractures of
+the lower end of the humerus, in fractures of both bones of the forearm,
+and as a result of pressure by splints. After _division at the elbow_,
+there is impairment of mobility which affects the thumb, and to a less
+extent the index finger: the terminal phalanx of the thumb cannot be
+flexed owing to the paralysis of the flexor pollicis longus, and the
+index can only be flexed at its metacarpo-phalangeal joint by the
+interosseous muscles attached to it. Pronation of the forearm is feeble,
+and is completed by the weight of the hand. After _division at the
+wrist_, the abductor-opponens group of muscles and the two lateral
+lumbricals only are affected; the abduction of the thumb can be feebly
+imitated by the short extensor and the long abductor (ext. ossis
+metacarpi pollicis), while opposition may be simulated by contraction of
+the long flexor and the short abductor of the thumb; the paralysis of
+the two medial lumbricals produces no symptoms that can be recognised.
+It is important to remember that when the median nerve is divided at the
+wrist, deep touch can be appreciated over the whole of the area
+supplied by the nerve; the injury, therefore, is liable to be over
+looked. If, however, the tendons are divided as well as the nerve, there
+is insensibility to deep touch. The areas of epicritic and of
+protopathic insensibility are illustrated in Fig. 91. The division of
+the nerve at the elbow, or even at the axilla, does not increase the
+extent of the loss of epicritic or protopathic sensibility, but usually
+affects deep sensibility.
+
+[Illustration: FIG. 92.--To illustrate Loss of Sensation produced by
+complete Division of Ulnar Nerve. Loss of all forms of cutaneous
+sensibility is represented by the shaded area. The parts insensitive to
+light touch and to intermediate degrees of heat and cold are enclosed
+within the dotted line.
+
+(Head and Sherren.)]
+
+#The Ulnar Nerve.#--The most common injury of this nerve is its division
+in transverse accidental wounds just above the wrist. In the arm it may
+be contused, along with the radial, in crutch paralysis; in the region
+of the elbow it may be injured in fractures or dislocations, or it may
+be accidentally divided in the operation for excising the elbow-joint.
+
+When it is injured _at or above the elbow_, there is paralysis of the
+flexor carpi ulnaris, the ulnar half of the flexor digitorum profundus,
+all the interossei, the two medial lumbricals, and the adductors of the
+thumb. The hand assumes a characteristic attitude: the index and middle
+fingers are extended at the metacarpo-phalangeal joints owing to
+paralysis of the interosseous muscles attached to them; the little and
+ring fingers are hyper-extended at these joints in consequence of the
+paralysis of the lumbricals; all the fingers are flexed at the
+inter-phalangeal joints, the flexion being most marked in the little and
+ring fingers--claw-hand or _main en griffe_. On flexing the wrist, the
+hand is tilted to the radial side, but the paralysis of the flexor carpi
+ulnaris is often compensated for by the action of the palmaris longus.
+The little and ring fingers can be flexed to a slight degree by the
+slips of the flexor sublimis attached to them and supplied by the median
+nerve; flexion of the terminal phalanx of the little finger is almost
+impossible. Adduction and abduction movements of the fingers are lost.
+Adduction of the thumb is carried out, not by the paralysed adductor
+pollicis, but the movement may be simulated by the long flexor and
+extensor muscles of the thumb. Epicritic sensibility is lost over the
+little finger, the ulnar half of the ring finger, and that part of the
+palm and dorsum of the hand to the ulnar side of a line drawn
+longitudinally through the ring finger and continued upwards.
+Protopathic sensibility is lost over an area which varies in different
+cases. Deep sensibility is usually lost over an area almost as extensive
+as that of protopathic insensibility.
+
+When the nerve is _divided at the wrist_, the adjacent tendons are also
+frequently severed. If divided below the point at which its dorsal
+branch is given off, the sensory paralysis is much less marked, and the
+injury is therefore liable to be overlooked until the wasting of muscles
+and typical _main en griffe_ ensue. The loss of sensibility after
+division of the nerve before the dorsal branch is given off resembles
+that after division at the elbow, except that in uncomplicated cases
+deep sensibility is usually retained. If the tendons are divided as
+well, however, deep touch is also lost.
+
+Care must be taken in all these injuries to prevent deformity; a splint
+must be worn, at least during the night, until the muscles regain their
+power of voluntary movement, and then exercises should be instituted.
+
+#Dislocation of the ulnar nerve# at the elbow results from sudden and
+violent flexion of the joint, the muscular effort causing stretching or
+laceration of the fascia that holds the nerve in its groove; it is
+predisposed to if the groove is shallow as a result of imperfect
+development of the medial condyle of the humerus, and by cubitus valgus.
+
+The nerve slips forward, and may be felt lying on the medial aspect of
+the condyle. It may retain this position, or it may slip backwards and
+forwards with the movements of the arm. The symptoms at the time of the
+displacement are some disability at the elbow, and pain and tingling
+along the nerve, which are exaggerated by movement and by pressure. The
+symptoms may subside altogether, or a neuritis may develop, with severe
+pain shooting up the nerve.
+
+The dislocated nerve is easily replaced, but is difficult to retain in
+position. In recent cases the arm may be placed in the extended position
+with a pad over the condyle, care being taken to avoid pressure on the
+nerve. Failing relief, it is better to make a bed for the nerve by
+dividing the deep fascia behind the medial condyle and to stitch the
+edges of the fascia over the nerve. This operation has been successful
+in all the recorded cases.
+
+#The Sciatic Nerve.#--When this nerve is compressed, as by sitting on a
+fence, there is tingling and powerlessness in the limb as a whole, known
+as "sleeping" of the limb, but these phenomena are evanescent. _Injuries
+to the great sciatic nerve_ are rare except in war. Partial division is
+more common than complete, and it is noteworthy that the fibres destined
+for the peroneal nerve are more often and more severely injured than
+those for the tibial (internal popliteal). After complete division, all
+the muscles of the leg are paralysed; if the section is in the upper
+part of the thigh, the hamstrings are also paralysed. The limb is at
+first quite powerless, but the patient usually recovers sufficiently to
+be able to walk with a little support, and although the hamstrings are
+paralysed the knee can be flexed by the sartorius and gracilis. The
+chief feature is drop-foot. There is also loss of sensation below the
+knee except along the course of the long saphenous nerve on the medial
+side of the leg and foot. Sensibility to deep touch is only lost over a
+comparatively small area on the dorsum of the foot.
+
+#The Common Peroneal (external popliteal) nerve# is exposed to injury
+where it winds round the neck of the fibula, because it is superficial
+and lies against the unyielding bone. It may be compressed by a
+tourniquet, or it may be bruised or torn in fractures of the upper end
+of the bone. It has been divided in accidental wounds,--by a scythe, for
+example,--in incising for cellulitis, and in performing subcutaneous
+tenotomy of the biceps tendon. Cases have been observed of paralysis of
+the nerve as a result of prolonged acute flexion of the knee in certain
+occupations.
+
+When the nerve is divided, the most obvious result is "drop-foot"; the
+patient is unable to dorsiflex the foot and cannot lift his toes off the
+ground, so that in walking he is obliged to jerk the foot forwards and
+laterally. The loss of sensibility depends upon whether the nerve is
+divided above or below the origin of the large cutaneous branch which
+comes off just before it passes round the neck of the fibula. In course
+of time the foot becomes inverted and the toes are pointed--pes
+equino-varus--and trophic sores are liable to form.
+
+#The Tibial (internal popliteal) nerve# is rarely injured.
+
+#The Cranial nerves# are considered with affections of the head and neck
+(Vol. II.).
+
+
+NEURALGIA
+
+The term neuralgia is applied clinically to any pain which follows the
+course of a nerve, and is not referable to any discoverable cause. It
+should not be applied to pain which results from pressure on a nerve by
+a tumour, a mass of callus, an aneurysm, or by any similar gross lesion.
+We shall only consider here those forms of neuralgia which are amenable
+to surgical treatment.
+
+#Brachial Neuralgia.#--The pain is definitely located in the
+distribution of one of the branches or nerve roots, is often
+intermittent, and is usually associated with tingling and disturbance of
+tactile sensation. The root of the neck should be examined to exclude
+pressure as the cause of the pain by a cervical rib, a tumour, or an
+aneurysm. When medical treatment fails, the nerve-trunks may be injected
+with saline solution or recourse may be had to operative measures, the
+affected cords being exposed and stretched through an incision in the
+posterior triangle of the neck. If this fails to give relief, the more
+serious operation of resecting the posterior roots of the affected
+nerves within the vertebral canal may be considered.
+
+_Neuralgia of the sciatic nerve_--#sciatica#--is the most common form of
+neuralgia met with in surgical practice.
+
+It is chiefly met with in adults of gouty or rheumatic tendencies who
+suffer from indigestion, constipation, and oxaluria--in fact, the same
+type of patients who are liable to lumbago, and the two affections are
+frequently associated. In hospital practice it is commonly met with in
+coal-miners and others who assume a squatting position at work. The
+onset of the pain may follow over-exertion and exposure to cold and wet,
+especially in those who do not take regular exercise. Any error of diet
+or indulgence in beer or wine may contribute to its development.
+
+The essential symptom is paroxysmal or continuous pain along the course
+of the nerve in the buttock, thigh, or leg. It may be comparatively
+slight, or it may be so severe as to prevent sleep. It is aggravated by
+movement, so that the patient walks lame or is obliged to lie up. It is
+aggravated also by any movement which tends to put the nerve on the
+stretch, as in bending down to put on the shoes, such movements also
+causing tingling down the nerve, and sometimes numbness in the foot.
+This may be demonstrated by flexing the thigh on the abdomen, the knee
+being kept extended; there is no pain if the same manoeuvre is repeated
+with the knee flexed. The nerve is sensitive to pressure, the most
+tender points being its emergence from the greater sciatic foramen, the
+hollow between the trochanter and the ischial tuberosity, and where the
+common peroneal nerve winds round the neck of the fibula. The muscles of
+the thigh are often wasted and are liable to twitch.
+
+The clinical features vary a good deal in different cases; the affection
+is often obstinate, and may last for many weeks or even months.
+
+In the sciatica that results from neuritis and perineuritis, there is
+marked tenderness on pressure due to the involvement of the nerve
+filaments in the sheath of the nerve, and there may be patches of
+cutaneous anaesthesia, loss of tendon reflexes, localised wasting of
+muscles, and vaso-motor and trophic changes. The presence of the
+reaction of degeneration confirms the diagnosis of neuritis. In
+long-standing cases the pain and discomfort may lead to a postural
+scoliosis (_ischias-scoliotica_).
+
+_Diagnosis._--Pain referred along the course of the sciatic nerve on one
+side, or, as is sometimes the case, on both sides, is a symptom of
+tumours of the uterus, the rectum, or the pelvic bones. It may result
+also from the pressure of an abscess or an aneurysm either inside the
+pelvis or in the buttock, and is sometimes associated with disease of
+the spinal medulla, such as tabes. Gluteal fibrositis may be mistaken
+for sciatica. It is also necessary to exclude such conditions as disease
+in the hip or sacro-iliac joint, especially tuberculous disease and
+arthritis deformans, before arriving at a diagnosis of sciatica. A
+digital examination of the rectum or vagina is of great value in
+excluding intra-pelvic tumours.
+
+_Treatment_ is both general and local. Any constitutional tendency, such
+as gout or rheumatism, must be counteracted, and indigestion, oxaluria,
+and constipation should receive appropriate treatment. In acute cases
+the patient is confined to bed between blankets, the limb is wrapped in
+thermogene wool, and the knee is flexed over a pillow; in some cases
+relief is experienced from the use of a long splint, or slinging the leg
+in a Salter's cradle. A rubber hot-bottle may be applied over the seat
+of greatest pain. The bowels should be well opened by castor oil or by
+calomel followed by a saline. Salicylate of soda in full doses, or
+aspirin, usually proves effectual in relieving pain, but when this is
+very intense it may call for injections of heroin or morphin. Potassium
+iodide is of benefit in chronic cases.
+
+Relief usually results from bathing, douching, and massage, and from
+repeated gentle stretching of the nerve. This may be carried out by
+passive movements of the limb--the hip being flexed while the knee is
+kept extended; and by active movements--the patient flexing the limb at
+the hip, the knee being maintained in the extended position. These
+exercises, which may be preceded by massage, are carried out night and
+morning, and should be practised systematically by those who are liable
+to sciatica.
+
+Benefit has followed the injection into the nerve itself, or into the
+tissues surrounding it, of normal saline solution; from 70-100 c.c. are
+injected at one time. If the pain recurs, the injection may require to
+be repeated on many occasions at different points up and down the nerve.
+Needling or acupuncture consists in piercing the nerve at intervals in
+the buttock and thigh with long steel needles. Six or eight needles are
+inserted and left in position for from fifteen to thirty minutes.
+
+In obstinate and severe cases the nerve may be _forcibly stretched_.
+This may be done bloodlessly by placing the patient on his back with the
+hip flexed to a right angle, and then gradually extending the knee until
+it is in a straight line with the thigh (Billroth). A general anaesthetic
+is usually required. A more effectual method is to expose the nerve
+through an incision at the fold of the buttock, and forcibly pull upon
+it. This operation is most successful when the pain is due to the nerve
+being involved in adhesions.
+
+#Trigeminal Neuralgia.#--A severe form of epileptiform neuralgia occurs
+in the branches of the fifth nerve, and is one of the most painful
+affections to which human flesh is liable. So far as its pathology is
+known, it is believed to be due to degenerative changes in the semilunar
+(Gasserian) ganglion. It is met with in adults, is almost invariably
+unilateral, and develops without apparent cause. The pain, which occurs
+in paroxysms, is at first of moderate severity, but gradually becomes
+agonising. In the early stages the paroxysms occur at wide intervals,
+but later they recur with such frequency as to be almost continuous.
+They are usually excited by some trivial cause, such as moving the jaws
+in eating or speaking, touching the face as in washing, or exposure to a
+draught of cold air. Between the paroxysms the patient is free from
+pain, but is in constant terror of its return, and the face wears an
+expression of extreme suffering and anxiety. When the paroxysm is
+accompanied by twitching of the facial muscles, it is called _spasmodic
+tic_.
+
+The skin of the affected area may be glazed and red, or may be pale and
+moist with inspissated sweat, the patient not daring to touch or wash
+it.
+
+There is excessive tenderness at the points of emergence of the
+different branches on the face, and pressure over one or other of these
+points may excite a paroxysm. In typical cases the patient is unable to
+take any active part in life. The attempt to eat is attended with such
+severe pain that he avoids taking food. In some cases the suffering is
+so great that the patient only obtains sleep by the use of hypnotics,
+and he is often on the verge of suicide.
+
+_Diagnosis._--There is seldom any difficulty in recognising the disease.
+It is important, however, to exclude the hysterical form of neuralgia,
+which is characterised by its occurrence earlier in life, by the pain
+varying in situation, being frequently bilateral, and being more often
+constant than paroxysmal.
+
+_Treatment._--Before having recourse to the measures described below, it
+is advisable to give a thorough trial to the medical measures used in
+the treatment of neuralgia.
+
+_The Injection of Alcohol into the Nerve._--The alcohol acts by
+destroying the nerve fibres, and must be brought into direct contact
+with them; if the nerve has been properly struck the injection is
+followed by complete anaesthesia in the distribution of the nerve. The
+relief may last for from six months to three years; if the pain returns,
+the injection may be repeated. The strength of the alcohol should be 85
+per cent., and the amount injected about 2 c.c.; a general, or
+preferably a local, anaesthetic (novocain) should be employed
+(Schlosser); the needle is 8 cm. long, and 0.7 mm. in diameter. The
+severe pain which the alcohol causes may be lessened, after the needle
+has penetrated to the necessary depth, by passing a few cubic
+centimetres of a 2 per cent. solution of _novocain-suprarenin_ through
+it before the alcohol is injected. The treatment by injection of alcohol
+is superior to the resection of branches of the nerve, for though
+relapses occur after the treatment with alcohol, renewed freedom from
+pain may be obtained by its repetition. The ophthalmic division should
+not, however, be treated in this manner, for the alcohol may escape into
+the orbit and endanger other nerves in this region. Harris recommends
+the injection of alcohol into the semilunar ganglion.
+
+_Operative Treatment._--This consists in the removal of the affected
+nerve or nerves, either by resection--_neurectomy_; or by a combination
+of resection with twisting or tearing of the nerve from its central
+connections--_avulsion_. To prevent the regeneration of the nerve after
+these operations, the canal of exit through the bone should be
+obliterated; this is best accomplished by a silver screw-nail driven
+home by an ordinary screw-driver (Charles H. Mayo).
+
+When the neuralgia involves branches of two or of all three trunks, or
+when it has recurred after temporary relief following resection of
+individual branches, the _removal of the semilunar ganglion_, along with
+the main trunks of the maxillary and mandibular divisions, should be
+considered.
+
+The operation is a difficult and serious one, but the results are
+satisfactory so far as the cure of the neuralgia is concerned. There is
+little or no disability from the unilateral paralysis of the muscles of
+mastication; but on account of the insensitiveness of the cornea, the
+eye must be protected from irritation, especially during the first month
+or two after the operation; this may be done by fixing a large
+watch-glass around the edge of the orbit with adhesive plaster.
+
+If the ophthalmic branch is not involved, neither it nor the ganglion
+should be interfered with; the maxillary and mandibular divisions should
+be divided within the skull, and the foramen rotundum and foramen ovale
+obliterated.
+
+
+
+
+CHAPTER XVII
+
+THE SKIN AND SUBCUTANEOUS TISSUE
+
+
+Structure of skin--_Blisters_--_Callosities_--_Corns_--_Chilblains_
+    --_Boils_--_Carbuncle_--_Abscess_--_Veldt sores_--Tuberculosis of
+    skin: _Inoculation tubercle_--_Lupus_: _Varieties_--Sporotrichosis
+    --Elephantiasis--Sebaceous cysts or wens--Moles--Horns--New growths:
+    _Fibroma_; _Papilloma_; _Adenoma_; _Epithelioma_; _Rodent cancer_;
+    _Melanotic cancer_; _Sarcoma_--AFFECTIONS OF CICATRICES--_Varieties
+    of scars_--_Keloid_--_Tumours_--AFFECTIONS OF NAILS.
+
+#Structure of Skin.#--The skin is composed of a superficial cellular
+layer--the epidermis, and the corium or true skin. The _epidermis_ is
+differentiated from without inwards into the stratum corneum, the
+stratum lucidum, the stratum granulosum, and the rete Malpighii or
+germinal layer, from which all the others are developed. The _corium_ or
+_true skin_ consists of connective tissue, in which ramify the blood
+vessels, lymphatics, and nerves. That part of the corium immediately
+adjoining the epidermis is known as the papillary portion, and contains
+the terminal loops of the cutaneous blood vessels and the terminations
+of the cutaneous nerves. The deeper portion of the true skin is known as
+the reticular portion, and is largely composed of adipose tissue.
+
+#Blisters# result from the exudation of serous fluid beneath the horny
+layer of the epidermis. The fluid may be clear, as in the blisters of a
+recent burn, or blood-stained, as in the blisters commonly accompanying
+fractures of the leg. It may become purulent as a result of infection,
+and this may be the starting-point of lymphangitis or cellulitis.
+
+The skin should be disinfected and the blisters punctured. When
+infected, the separated horny layer must be cut away with scissors to
+allow of the necessary purification.
+
+#Callosities# are prominent, indurated masses of the horny layer of the
+epidermis, where it has been exposed to prolonged friction and pressure.
+They occur on the fingers and hand as a result of certain occupations
+and sports, but are most common under the balls of the toes or heel. A
+bursa may form beneath a callosity, and if it becomes inflamed may cause
+considerable suffering; if suppuration ensues, a sinus may form,
+resembling a perforating ulcer of the foot.
+
+The _treatment_ of callosities on the foot consists in removing pressure
+by wearing properly fitting boots, and in applying a ring pad around the
+callosity; another method is to fit a sock of spongiopilene with a hole
+cut out opposite the callosity. After soaking in hot water, the
+overgrown horny layer is pared away, and the part painted daily with a
+saturated solution of salicylic acid in flexile collodion.
+
+[Illustration: FIG. 93.--Callosities and Corns on the Sole and Plantar
+Aspect of the Toes in a woman who was also the subject of flat-foot.]
+
+#Corns.#--A corn is a localised overgrowth of the horny layer of the
+epidermis, which grows downwards, pressing upon and displacing the
+sensitive papillae of the corium. Corns are due to the friction and
+pressure of ill-fitting boots, and are met with chiefly on the toes and
+sole of the foot. A corn is usually hard, dry, and white; but it may be
+sodden from moisture, as in "soft corns" between the toes. A bursa may
+form beneath a corn, and if inflamed constitutes one form of bunion.
+When suppuration takes place in relation to a corn, there is great pain
+and disability, and it may prove the starting-point of lymphangitis.
+
+The _treatment_ consists in the wearing of properly fitting boots and
+stockings, and, if the symptoms persist, the corn should be removed.
+This is done after the manner of chiropodists by digging out the corn
+with a suitably shaped knife. A more radical procedure is to excise,
+under local anaesthesia, the portion of skin containing the corn and
+the underlying bursa. The majority of so-called corn solvents consist of
+a solution of salicylic acid in collodion; if this is painted on daily,
+the epidermis dies and can then be pared away. The unskilful paring of
+corns may determine the occurrence of senile gangrene in those who are
+predisposed to it by disease of the arteries.
+
+[Illustration: FIG. 94.--Ulcerated Chilblains on Fingers of a Child.]
+
+#Chilblains.#--Chilblain or _erythema pernio_ is a vascular disturbance
+resulting from the alternate action of cold and heat on the distal parts
+of the body. Chilblains are met with chiefly on the fingers and toes in
+children and anaemic girls. In the mild form there is a sensation of
+burning and itching, the part becomes swollen, of a dusky red colour,
+and the skin is tense and shiny. In more severe cases the burning and
+itching are attended with pain, and the skin becomes of a violet or
+wine-red colour. There is a third degree, closely approaching
+frost-bite, in which the skin tends to blister and give way, leaving an
+indolent raw surface popularly known as a "broken chilblain."
+
+Those liable to chilblains should take open-air exercise, nourishing
+food, cod-liver oil, and tonics. Woollen stockings and gloves should be
+worn in cold weather, and sudden changes of temperature avoided. The
+symptoms may be relieved by ichthyol ointment, glycerin and belladonna,
+or a mixture of Venice turpentine, castor oil, and collodion applied on
+lint which is wrapped round the toe. Another favourite application is
+one of equal parts of tincture of capsicum and compound liniment of
+camphor, painted over the area night and morning. Balsam of Peru or
+resin ointment spread on gauze should be applied to broken chilblains.
+The most effective treatment is Bier's bandage applied for about six
+hours twice daily; it can be worn while the patient is following his
+occupation; in chronic cases this may be supplemented with hot-air
+baths.
+
+#Boils and Carbuncles.#--These result from infection with the
+staphylococcus aureus, which enters the orifices of the ducts of the
+skin under the influence of friction and pressure, as was demonstrated
+by the well-known experiment of Garre, who produced a crop of pustules
+and boils on his own forearm by rubbing in a culture of the
+staphylococcus aureus.
+
+A #boil# results when the infection is located in a hair follicle or
+sebaceous gland. A hard, painful, conical swelling develops, to which,
+so long as the skin retains its normal appearance, the term "blind
+boil" is applied. Usually, however, the skin becomes red, and after a
+time breaks, giving exit to a drop or two of thick pus. After an
+interval of from six to ten days a soft white slough is discharged; this
+is known as the "core," and consists of the necrosed hair follicle or
+sebaceous gland. After the separation of the core the boil heals
+rapidly, leaving a small depressed scar.
+
+Boils are most frequently met with on the back of the neck and the
+buttocks, and on other parts where the skin is coarse and thick and is
+exposed to friction and pressure. The occurrence of a number or a
+succession of boils is due to spread of the infection, the cocci from
+the original boil obtaining access to adjacent hair follicles. The
+spread of boils may be unwittingly promoted by the use of a domestic
+poultice or the wearing of infected underclothing.
+
+While boils are frequently met with in debilitated persons, and
+particularly in those suffering from diabetes or Bright's disease, they
+also occur in those who enjoy vigorous health. They seldom prove
+dangerous to life except in diabetic subjects, but when they occur on
+the face there is a risk of lymphatic and of general pyogenic infection.
+Boils may be differentiated from syphilitic lesions of the skin by
+their acute onset and progress, and by the absence of other evidence of
+syphilis; and from the malignant or anthrax pustule by the absence of
+the central black eschar and of the circumstances which attend upon
+anthrax infection.
+
+_Treatment._--The skin of the affected area should be painted with
+iodine, and a Klapp's suction bell applied thrice daily. If pus forms,
+the skin is frozen with ethyl-chloride and a small incision made, after
+which the application of the suction bell is persevered with. The
+further treatment consists in the use of diluted boracic or resin
+ointment. In multiple boils on the trunk and limbs, lysol or boracic
+baths are of service; the underclothing should be frequently changed,
+and that which is discarded must be disinfected. In patients with
+recurrence of boils about the neck, re-infection frequently takes place
+from the scalp, to which therefore treatment should be directed.
+
+Any impaired condition of health should be corrected; when, there is
+sugar or albumen in the urine the conditions on which these depend must
+receive appropriate treatment. When there are successive crops of boils,
+recourse should be had to vaccines. In refractory cases benefit has
+followed the subcutaneous injection of lipoid solution containing tin.
+
+#Carbuncle# may be looked upon as an aggregation of boils, and is
+characterised by a densely hard base and a brownish-red discoloration of
+the skin. It is usually about the size of a crown-piece, but it may
+continue to enlarge until it attains the size of a dinner-plate. The
+patient is ill and feverish, and the pain may be so severe as to prevent
+sleep. As time goes on several points of suppuration appear, and when
+these burst there are formed a number of openings in the skin, giving it
+a cribriform appearance; these openings exude pus. The different
+openings ultimately fuse and the large adherent greyish-white slough is
+exposed. The separation of the slough is a tedious process, and the
+patient may become exhausted by pain, discharge, and toxin absorption.
+When the slough is finally thrown off, a deep gap is left, which takes a
+long time to heal. A large carbuncle is a grave disease, especially in a
+weakly person suffering from diabetes or chronic alcoholism; we have on
+several occasions seen diabetic coma supervene and the patient die
+without recovering consciousness. In the majority of cases the patient
+is laid aside for several months. It is most common in male adults over
+forty years of age, and is usually situated on the back between the
+shoulders. When it occurs on the face or anterior part of the neck it is
+especially dangerous, because of the greater risk of dissemination of
+the infection.
+
+A carbuncle is to be differentiated from an ulcerated gumma and from
+anthrax pustule.
+
+[Illustration: FIG. 95.--Carbuncle of seventeen days' duration in a
+woman aet. 57.]
+
+_Treatment._--Pain is relieved by full doses of opium or codein, and
+these drugs are specially indicated when sugar is present in the urine.
+Vaccines may be given a trial. The diet should be liberal and easily
+digested, and strychnin and other stimulants may be of service. Locally
+the treatment is carried out on the same lines as for boils.
+
+In some cases it is advisable to excise the carbuncle or to make
+incisions across it in different directions, so that the resulting wound
+presents a stellate appearance.
+
+#Acute Abscesses of the Skin and Subcutaneous Tissue in Young
+Children.#--In young infants, abscesses are not infrequently met with
+scattered over the trunk and limbs, and are probably the result of
+infection of the sebaceous glands from dirty underclothing. The
+abscesses should be opened, and the further spread of infection
+prevented by cleansing of the skin and by the use of clean under-linen.
+Similar abscesses are met with on the scalp in association with eczema,
+impetigo, and pediculosis.
+
+#Veldt Sore.#--This sore usually originates in an abrasion of the
+epidermis, such as a sun blister, the bite of an insect, or a scratch. A
+pustule forms and bursts, and a brownish-yellow scab forms over it. When
+this is removed, an ulcer is left which has little tendency to heal.
+These sores are most common about the hands, arms, neck, and feet, and
+are most apt to occur in those who have had no opportunities of washing,
+and who have lived for a long time on tinned foods.
+
+#Tuberculosis of the Skin.#--Interest attaches chiefly to the primary
+forms of tuberculosis of the skin in which the bacilli penetrate from
+without--inoculation tubercle and lupus.
+
+#Inoculation Tubercle.#--The appearances vary with the conditions under
+which the inoculation takes place. As observed on the fingers of adults,
+the affection takes the form of an indolent painless swelling, the
+epidermis being red and glazed, or warty, and irregularly fissured.
+Sometimes the epidermis gives way, forming an ulcer with flabby
+granulations. The infection rarely spreads to the lymphatics, but we
+have seen inoculation tubercle of the index-finger followed by a large
+cold abscess on the median side of the upper arm and by a huge mass of
+breaking down glands in the axilla.
+
+In children who run about barefooted in towns, tubercle may be
+inoculated into wounds in the sole or about the toes, and although the
+local appearances may not be characteristic, the nature of the infection
+is revealed by its tendency to spread up the limb along the lymph
+vessels, giving rise to abscesses and fungating ulcers in relation to
+the femoral glands.
+
+#Tuberculous Lupus.#--This is an extremely chronic affection of the
+skin. It rarely extends to the lymph glands, and of all tuberculous
+lesions is the least dangerous to life. The commonest form of
+lupus--_lupus vulgaris_--usually commences in childhood or youth, and is
+most often met with on the nose or cheek. The early and typical
+appearance is that of brownish-yellow or pink nodules in the skin, about
+the size of hemp seed. Healing frequently occurs in the centre of the
+affected area while the disease continues to extend at the margin.
+
+When there is actual destruction of tissue and ulceration--the so-called
+"_lupus excedens_" or "_ulcerans_"--healing is attended with
+cicatricial contraction, which may cause unsightly deformity. When the
+cheek is affected, the lower eyelid may be drawn down and everted; when
+the lips are affected, the mouth may be distorted or seriously
+diminished in size. When the nose is attacked, both the skin and mucous
+surfaces are usually involved, and the nasal orifices may be narrowed or
+even obliterated; sometimes the soft parts, including the cartilages,
+are destroyed, leaving only the bones covered by tightly stretched scar
+tissue.
+
+The disease progresses slowly, healing in some places and spreading at
+others. The patient complains of a burning sensation, but little of
+pain, and is chiefly concerned about the disfigurement. Nothing is more
+characteristic of lupus than the appearance of fresh nodules in parts
+which have already healed. In the course of years large tracts of the
+face and neck may become affected. From the lips it may spread to the
+gum and palate, giving to the mucous membrane the appearance of a
+raised, bright-red, papillary or villous surface. When the disease
+affects the gums, the teeth may become loose and fall out.
+
+[Illustration: FIG. 96.--Tuberculous Elephantiasis in a woman aet. 35.]
+
+On parts of the body other than the face, the disease is even more
+chronic, and is often attended with a considerable production of dense
+fibrous tissue--the so-called _fibroid lupus_. Sometimes there is a
+warty thickening of the epidermis--_lupus verrucosus_. In the fingers
+and toes it may lead to a progressive destruction of tissue like that
+observed in leprosy, and from the resulting loss of portions of the
+digits it has been called _lupus mutilans_. In the lower extremity a
+remarkable form of the disease is sometimes met with, to which the term
+_lupus elephantiasis_ (Fig. 96) has been applied. It commences as an
+ordinary lupus of the toes or dorsum of the foot, from which the
+tuberculous infection spreads to the lymph vessels, and the limb as a
+whole becomes enormously swollen and unshapely.
+
+Finally, a long-standing lupus, especially on the cheek, may become the
+seat of epithelioma--_lupus epithelioma_--usually of the exuberant or
+cauliflower type, which, like other epitheliomas that originate in scar
+tissue, presents little tendency to infect the lymphatics.
+
+The _diagnosis_ of lupus is founded on the chronic progress and long
+duration, and the central scarring with peripheral extension of the
+disease. On the face it is most liable to be confused with syphilis and
+with rodent cancer. The syphilitic lesion belongs to the tertiary
+period, and although presenting a superficial resemblance to
+tuberculosis, its progress is more rapid, so that within a few months it
+may involve an area of skin as wide as would be affected by lupus in as
+many years. Further, it readily yields to anti-syphilitic treatment. In
+cases of tertiary syphilis in which the nose is destroyed, it will be
+noticed that the bones have suffered most, while in lupus the
+destruction of tissue involves chiefly the soft parts.
+
+Rodent cancer is liable to be mistaken for lupus, because it affects the
+same parts of the face; it is equally chronic, and may partly heal. It
+begins later in life, however, the margin of the ulcer is more sharply
+defined, and often presents a "rolled" appearance.
+
+_Treatment._--When the disease is confined to a limited area, the most
+rapid and certain cure is obtained by _excision_; larger areas are
+scraped with the sharp spoon. The _ray treatment_ includes the use of
+luminous, Rontgen, or radium rays, and possesses the advantage of being
+comparatively painless and of being followed by the least amount of
+scarring and deformity.
+
+Encouraging results have also been obtained by the application of carbon
+dioxide snow.
+
+#Multiple subcutaneous tuberculous nodules# are met with chiefly in
+children. They are indolent and painless, and rarely attract attention
+until they break down and form abscesses, which are usually about the
+size of a cherry, and when these burst sinuses or ulcers result. If the
+overlying skin is still intact, the best treatment is excision. If the
+abscess has already infected the skin, each focus should be scraped and
+packed.
+
+#Sporotrichosis# is a mycotic infection due to the sporothrix Shenkii.
+It presents so many features resembling syphilis and tubercle that it is
+frequently mistaken for one or other of these affections. It occurs
+chiefly in males between fifteen and forty-five, who are farmers, fruit
+and vegetable dealers, or florists. There is usually a history of trauma
+of the nature of a scratch or a cut, and after a long incubation period
+there develop a series of small, hard, round nodules in the skin and
+subcutaneous tissue which, without pain or temperature, soften into
+cold abscesses and leave indolent ulcers or sinuses. The infection is
+of slow progress and follows the course of the lymphatics. From the
+gelatinous pus the organism is cultivated without difficulty, and this
+is the essential step in arriving at a diagnosis. The disease yields in
+a few weeks to full doses of iodide of potassium.
+
+#Elephantiasis.#--This term is applied to an excessive enlargement of a
+part depending upon an overgrowth of the skin and subcutaneous cellular
+tissue, and it may result from a number of causes, acting independently
+or in combination. The condition is observed chiefly in the extremities
+and in the external organs of generation.
+
+_Elephantiasis from Lymphatic or Venous Obstruction._--Of this the
+best-known example is _tropical elephantiasis_ (E. arabum), which is
+endemic in Samoa, Barbadoes, and other places. It attacks the lower
+extremity or the genitals in either sex (Figs. 97, 98). The disease is
+usually ushered in with fever, and signs of lymphangitis in the part
+affected. After a number of such attacks, the lymph vessels appear to
+become obliterated, and the skin and subcutaneous cellular tissue, being
+bathed in stagnant lymph--which possibly contains the products of
+streptococci--take on an overgrowth, which continues until the part
+assumes gigantic proportions. In certain cases the lymph trunks have
+been found to be blocked with the parent worms of the filaria Bancrofti.
+Cases of elephantiasis of the lower extremity are met with in this
+country in which there are no filarial parasites in the lymph vessels,
+and these present features closely resembling the tropical variety, and
+usually follow upon repeated attacks of lymphangitis or erysipelas.
+
+The part affected is enormously increased in size, and causes
+inconvenience from its bulk and weight. In contrast to ordinary dropsy,
+there is no pitting on pressure, and the swelling does not disappear on
+elevation of the limb. The skin becomes rough and warty, and may hang
+down in pendulous folds. Blisters form on the surface and yield an
+abundant exudate of clear lymph. From neglect of cleanliness, the skin
+becomes the seat of eczema or even of ulceration attended with foul
+discharge.
+
+Samson Handley has sought to replace the blocked lymph vessels by
+burying in the subcutaneous tissue of the swollen part a number of stout
+silk threads--_lymphangioplasty_. By their capillary action they drain
+the lymph to a healthy region above, and thus enable it to enter the
+circulation. It has been more successful in the face and upper limb than
+in the lower extremity. If the tissues are infected with pus organisms,
+a course of vaccines should precede the operation.
+
+[Illustration: FIG. 97.--Elephantiasis in a woman aet. 45.]
+
+A similar type of elephantiasis may occur after extirpation of the lymph
+glands in the axilla or groin; in the leg in long-standing standing
+varix and phlebitis with chronic ulcer; in the arm as a result of
+extensive cancerous disease of the lymphatics in the axilla secondarily
+to cancer of the breast; and in extensive tuberculous disease of the
+lymphatics. The last-named is chiefly observed in the lower limb in
+young adult women, and from its following upon lupus of the toes or foot
+it has been called _lupus elephantiasis_. The tuberculous infection
+spreads slowly up the limb by way of the lymph vessels, and as these are
+obliterated the skin and cellular tissues become hypertrophied, and the
+surface is studded over with fungating tuberculous masses of a livid
+blue colour. As the more severe forms of the disease may prove dangerous
+to life by pyogenic complications inducing gangrene of the limb, the
+question of amputation may have to be considered.
+
+[Illustration: FIG. 98.--Elephantiasis of Penis and Scrotum in native of
+Demerara.
+
+(Mr. Annandale's case.)]
+
+Belonging to this group also is a form of _congenital elephantiasis_
+resulting from the circular constriction of a limb _in utero_ by
+amniotic bands.
+
+_Elephantiasis occurring apart from lymphatic or venous obstruction_ is
+illustrated by _elephantiasis nervorum_, in which there is an overgrowth
+of the skin and cellular tissue of an extremity in association with
+neuro-fibromatosis of the cutaneous nerves (Fig. 89); and by
+_elephantiasis Graecorum_--a form of leprosy in which the skin of the
+face becomes the seat of tumour-like masses consisting of leprous
+nodules. It is also illustrated by _elephantiasis involving the scrotum_
+as a result of prolonged irritation by the urine in cases in which the
+penis has been amputated and the urine has infiltrated the scrotal
+tissues over a period of years.
+
+#Sebaceous Cysts.#--Atheromatous cysts or wens are formed in relation to
+the sebaceous glands and hair follicles. They are commonly met with in
+adults, on the scalp (Fig. 99), face, neck, back, and external genitals.
+Sometimes they are multiple, and they may be met with in several members
+of the same family. They are smooth, rounded, or discoid cysts, varying
+in size from a split-pea to a Tangerine orange. In consistence they are
+firm and elastic, or fluctuating, and are incorporated with the
+overlying skin, but movable on the deeper structures. The orifice of the
+partly blocked sebaceous follicle is sometimes visible, and the contents
+of the cyst can be squeezed through the opening. The wall of the cyst is
+composed of a connective-tissue capsule lined by stratified squamous
+epithelium. The contents consist of accumulated epithelial cells, and
+are at first dry and pearly white in appearance, but as a result of
+fatty degeneration they break down into a greyish-yellow pultaceous and
+semi-fluid material having a peculiar stale odour. It is probable that
+the decomposition of the contents is the result of the presence of
+bacteria, and that from the surgical point of view they should be
+regarded as infective. A sebaceous cyst may remain indefinitely without
+change, or may slowly increase in size, the skin over it becoming
+stretched and closely adherent to the cyst wall as a result of friction
+and pressure. The contents may ooze from the orifice of the duct and dry
+on the skin surface, leading to the formation of a sebaceous horn
+(Fig. 100). As a result of injury the cyst may undergo sudden
+enlargement from haemorrhage into its interior.
+
+Recurrent attacks of inflammation frequently occur, especially in wens
+of the face and scalp. Suppuration may ensue and be followed by cure of
+the cyst, or an offensive fungating ulcer forms which may be mistaken
+for epithelioma. True cancerous transformation is rare.
+
+Wens are to be _diagnosed_ from dermoids, from fatty tumours, and from
+cold abscesses. Dermoids usually appear before adult life, and as they
+nearly always lie beneath the fascia, the skin is movable over them. A
+fatty tumour is movable, and is often lobulated. The confusion with a
+cold abscess is most likely to occur in wens of the neck or back, and it
+may be impossible without the use of an exploring needle to
+differentiate between them.
+
+[Illustration: FIG. 99.--Multiple Sebaceous Cysts or Wens; the larger
+ones are of many years' duration.]
+
+_Treatment._--The removal of wens is to be recommended while they are
+small and freely movable, as they are then easily shelled out after
+incising the overlying skin; sometimes splitting the cyst makes its
+removal easier. Local anaesthesia is to be preferred. It is important
+that none of the cyst wall be left behind. In large and adherent wens an
+ellipse of skin is removed along with the cyst. When inflamed, it may be
+impossible to dissect out the cyst, and the wall should be destroyed
+with carbolic acid, the resulting wound being treated by the open
+method.
+
+#Moles.#--The term mole is applied to a pigmented, and usually hairy,
+patch of skin, present at or appearing shortly after birth. The colour
+varies from brown to black, according to the amount of melanin pigment
+present. The lesion consists in an overgrowth of epidermis which often
+presents an alveolar arrangement. Moles vary greatly in size: some are
+mere dots, others are as large as the palm of the hand, and occasionally
+a mole covers half the face. In addition to being unsightly, they bleed
+freely when abraded, are liable to ulcerate from friction and pressure,
+and occasionally become the starting-point of melanotic cancer. Rodent
+cancer sometimes originates in the slightly pigmented moles met with on
+the face. Overgrowths in relation to the cutaneous nerves, especially
+the plexiform neuroma, occasionally originate in pigmented moles. Soldau
+believes that the pigmentation and overgrowth of the epidermis in moles
+are associated with, and probably result from, a fibromatosis of the
+cutaneous nerves.
+
+_Treatment._--The quickest way to get rid of a mole is to excise it; if
+the edges of the gap cannot be brought together with sutures, recourse
+should be had to grafting. In large hairy moles of the face whose size
+forbids excision, radium or the X-rays should be employed. Excellent
+results have been obtained by refrigeration with solid carbon dioxide.
+In children and women with delicate skin, applications of from ten to
+thirty seconds suffice. In persons with coarse skin an application of
+one minute may be necessary, and it may have to be repeated.
+
+#Horns.#--The _sebaceous_ horn results from the accumulation of the
+dried contents of a wen on the surface of the skin: the sebaceous
+material after drying up becomes cornified, and as fresh material is
+added to the base the horn increases in length (Fig. 100). The _wart_
+horn grows from a warty papilloma of the skin. _Cicatrix_ horns are
+formed by the heaping up of epidermis in the scars that result from
+burns. _Nail_ horns are overgrown nails (keratomata of the nail bed),
+and are met with chiefly in the great toe of elderly bedridden patients.
+If an ulcer forms at the base of a horn, it may prove the starting-point
+of epithelioma, and for this reason, as well as for others, horns should
+be removed.
+
+[Illustration: FIG. 100.--Sebaceous Horn growing from Auricle.
+
+(Dr. Kenneth Maclachan's case.)]
+
+#New Growths in the Skin and Subcutaneous Tissue.#--The _Angioma_ has
+been described with diseases of blood vessels. _Fibroma._--Various types
+of fibroma occur in the skin. A soft pedunculated fibroma, about the
+size of a pea, is commonly met with, especially on the neck and trunk;
+it is usually solitary, and is easily removed with scissors. The
+multiple, soft fibroma known as _molluscum fibrosum_, which depends upon
+a neuro-fibromatosis of the cutaneous nerves, is described with the
+tumours of nerves. Hard fibromas occurring singly or in groups may be
+met with, especially in the skin of the buttock, and may present a local
+malignancy, recurring after removal like the "recurrent fibroid" of
+Paget. The "painful subcutaneous nodule" is a solitary fibroma related
+to one of the cutaneous nerves. The hard fibroma known as _keloid_ is
+described with the affections of scars.
+
+#Papilloma.#--The _common wart_ or verruca is an outgrowth of the
+surface epidermis. It may be sessile or pedunculated hard or soft. The
+surface may be smooth, or fissured and foliated like a cauliflower, or
+it may be divided up into a number of spines. Warts are met with chiefly
+on the hands, and are often multiple, occurring in clusters or in
+successive crops. Multiple warts appear to result from some contagion,
+the nature of which is unknown; they sometimes occur in an epidemic form
+among school-children, and show a remarkable tendency to disappear
+spontaneously. The solitary flat-topped wart which occurs on the face
+of old people may, if irritated, become the seat of epithelioma. A warty
+growth of the epidermis is a frequent accompaniment of moles and of that
+variety of lupus known as _lupus verrucosus_.
+
+_Treatment._--In the multiple warts of children the health should be
+braced up by a change to the seaside. A dusting-powder, consisting of
+boracic acid with 5 per cent. salicylic acid, may be rubbed into the
+hands after washing and drying. The persistent warts of young adults
+should be excised after freezing with chloride of ethyl. When cutting is
+objected to, they may be painted night and morning with salicylic
+collodion, the epidermis being dehydrated with alcohol before each
+application.
+
+_Venereal warts_ occur on the genitals of either sex, and may form large
+cauliflower-like masses on the inner surface of the prepuce or of the
+labia majora. Although frequently co-existing with gonorrhoea or
+syphilis, they occur independently of these diseases, being probably
+acquired by contact with another individual suffering from warts
+(C. W. Cathcart). They give rise to considerable irritation and
+suffering, and when cleanliness is neglected there may be an offensive
+discharge.
+
+In the female, the cauliflower-like masses are dissected from the labia;
+in the male, the prepuce is removed and the warts on the glans are
+snipped off with scissors. In milder cases, the warts usually disappear
+if the parts are kept absolutely dry and clean. A useful dusting-powder
+is one consisting of calamine and 5 per cent. salicylic acid; the
+exsiccated sulphate of iron, in the form of a powder, may be employed in
+cases which resist this treatment.
+
+#Adenoma.#--This is a comparatively rare tumour growing from the glands
+of the skin. One variety, known as the "tomato tumour," which apparently
+originates from _the sweat glands_, is met with on the scalp and face in
+women past middle life. These growths are often multiple; the individual
+tumours vary in size, and the skin, which is almost devoid of hairs, is
+glistening and tightly stretched over them. A similar tumour may occur
+on the nose. The _sebaceous adenoma_, which originates from the
+sebaceous glands, forms a projecting tumour on the face or scalp, and
+when the skin is irritated it may ulcerate and fungate. The treatment
+consists in the removal of the tumour along with the overlying skin.
+
+The exuberant masses on the nose known as "rhinophyma," "lipoma nasi,"
+or "potato nose" are of the nature of sebaceous adenoma, and are removed
+by shaving them off with a knife until the normal shape of the nose is
+restored Healing takes place with remarkable rapidity.
+
+#Cancer.#--There are several types of primary cancer of the skin, the
+most important being squamous epithelioma, rodent cancer, and melanotic
+cancer.
+
+[Illustration: FIG. 101.--Paraffin Epithelioma.]
+
+#Epithelioma# occurs in a variety of forms. When originating in a small
+ulcer or wart-for example on the face in old people--it presents the
+features of a chronic indurated ulcer. A more exuberant and rapidly
+growing form of epithelial cancer, described by Hutchinson as the
+_crateriform ulcer_, commences on the face as a small red pimple which
+rapidly develops into an elevated mass shaped like a bee-hive, and
+breaks down in the centre. Epithelioma may develop anywhere on the body
+in relation to long-standing ulcers, especially that resulting from a
+burn or from lupus; this form usually presents an exuberant outgrowth of
+epidermis not unlike a cauliflower. An interesting example of
+epithelioma has been described by Neve of Kashmir. The natives in that
+province are in the habit of carrying a fire-basket suspended from the
+waist, which often burns the skin and causes a chronic ulcer, and many
+of these ulcers become the seat of epithelioma, due, in Neve's opinion,
+to the actual contact of the sooty pan with the skin.
+
+The term _trade epithelioma_ has been applied to that form met with in
+those who follow certain occupations, such as paraffin workers and
+chimney-sweeps. The most recent member of this group is the _X-ray
+carcinoma_, which is met with in those who are constantly exposed to the
+irritation of the X-rays; there is first a chronic dermatitis with warty
+overgrowth of the surface epithelium, pigmentation, and the formation of
+fissures and warts. The trade epithelioma varies a good deal in
+malignancy, but it tends to cause death in the same manner as other
+epitheliomas.
+
+Epithelial cancer has also been observed in those who have taken arsenic
+over long periods for medicinal purposes.
+
+[Illustration: FIG. 102.--Rodent Cancer of Inner Canthus.]
+
+#Rodent Cancer# (Rodent Ulcer).--This is a cancer originating in the
+sweat glands or sebaceous follicles, or in the foetal residues of
+cutaneous glands. The cells are small and closely packed together in
+alveoli or in reticulated columns; cell nests are rare. It is remarkably
+constant in its seat of origin, being nearly always located on the
+lateral aspect of the nose or in the vicinity of the lower eyelid
+(Fig. 102). It is rare on the trunk or limbs. It commences as a small
+flattened nodule in the skin, the epidermis over it being stretched and
+shining. The centre becomes depressed, while the margins extend in the
+form of an elevated ridge. Sooner or later the epidermis gives way in
+the centre, exposing a smooth raw surface devoid of granulations.
+
+[Illustration: FIG. 103.--Rodent Cancer of fifteen years' duration,
+which has destroyed the contents of the Orbit.
+
+(Sir Montagu Cotterill's case)]
+
+The margin, while in parts irregular, is typically represented by a
+well-defined "rolled" border which consists of the peripheral portion of
+the cancer that has not broken down. The central ulcer may temporarily
+heal. There is itching but little pain, and the condition progresses
+extremely slowly; rodent cancers which have existed for many years are
+frequently met with. The disease attacks and destroys every structure
+with which it comes in contact, such as the eyelids, the walls of the
+nasal cavities, and the bones of the face; hence it may produce the most
+hideous deformities (Fig. 103). The patient may succumb to haemorrhage or
+to infective complications such as erysipelas or meningitis.
+
+Secondary growths in the lymph glands, while not unknown, are extremely
+rare. We have only seen them once--in a case of rodent cancer in the
+groin.
+
+_Diagnosis._--Lupus is the disease most often mistaken for rodent
+cancer. Lupus usually begins earlier in life, it presents apple-jelly
+nodules, and lacks the rounded, elevated border. Syphilitic lesions
+progress more rapidly, and also lack the characteristic margin. The
+differentiation from squamous epithelioma is of considerable importance,
+as the latter affection spreads more rapidly, involves the lymph glands
+early, and is much more dangerous to life.
+
+_Treatment._--In rodent cancers of limited size--say less than one inch
+in diameter--free excision is the most rapid and certain method of
+treatment. The alternative is the application of radium or of the
+Rontgen rays, which, although requiring many exposures, results in cure
+with the minimum of disfigurement. If the cancer already covers an
+extensive area, or has invaded the cavity of the orbit or nose, radium
+or X-rays yield the best results. The effect is soon shown by the
+ingrowth of healthy epithelium from the surrounding skin, and at the
+same time the discharge is lessened. Good results are also reported from
+the application of carbon dioxide snow, especially when this follows
+upon a course of X-ray treatment.
+
+#Paget's disease# of the nipple is an epithelioma occurring in women
+over forty years of age: a similar form of epithelioma is sometimes met
+with at the umbilicus or on the genitals.
+
+#Melanotic Cancer.#--Under this head are included all new growths which
+contain an excess of melanin pigment. Many of these were formerly
+described as melanotic sarcoma. They nearly always originate in a
+pigmented mole which has been subjected to irritation. The primary
+growth may remain so small that its presence is not even suspected, or
+it may increase in size, ulcerate, and fungate. The amount of pigment
+varies: when small in amount the growth is brown, when abundant it is a
+deep black. The most remarkable feature is the rapidity with which the
+disease becomes disseminated along the lymphatics, the first evidence of
+which is an enlargement of the lymph glands. As the primary growth is
+often situated on the sole of the foot or in the matrix of the nail of
+the great toe, the femoral and inguinal glands become enlarged in
+succession, forming tumours much larger than the primary growth.
+Sometimes the dissemination involves the lymph vessels of the limb,
+forming a series of indurated pigmented cords and nodules (Fig. 104).
+Lastly, the dissemination may be universal throughout the body, and this
+usually occurs at a comparatively early stage. The secondary growths are
+deeply pigmented, being usually of a coal-black colour, and melanin
+pigment may be present in the urine. When recurrence takes place in or
+near the scar left by the operation, the cancer nodules are not
+necessarily pigmented.
+
+[Illustration: FIG. 104.--Diffuse Melanotic Cancer of Lymphatics of Skin
+secondary to a Growth in the Sole of the Foot.]
+
+To extirpate the disease it is necessary to excise the tumour, with a
+zone of healthy skin around it and a somewhat large zone of the
+underlying subcutaneous tissue and deep fascia. Hogarth Pringle
+recommends that a broad strip of subcutaneous fascia up to and including
+the nearest anatomical group of glands should be removed with the tumour
+in one continuous piece.
+
+#Secondary Cancer of the Skin.#--Cancer may spread to the skin from a
+subjacent growth by direct continuity or by way of the lymphatics. Both
+of these processes are so well illustrated in cases of mammary cancer
+that they will be described in relation to that disease.
+
+#Sarcoma# of various types is met with in the skin. The fibroma, after
+excision, may recur as a fibro-sarcoma. The alveolar sarcoma commences
+as a hard lump and increases in size until the epidermis gives way and
+an ulcer is formed.
+
+[Illustration: FIG. 105.--Melanotic Cancer of Forehead with Metastases
+in Lymph Vessels and Glands.
+
+(Mr. D. P. D. Wilkie's case.)]
+
+A number of fresh tumours may spring up around the original growth.
+Sometimes the primary growth appears in the form of multiple nodules
+which tend to become confluent. Excision, unless performed early, is of
+little avail, and in any case should be followed up by exposure to
+radium.
+
+
+AFFECTIONS OF CICATRICES
+
+A cicatrix or scar consists of closely packed bundles of white fibres
+covered by epidermis; the skin glands and hair follicles are usually
+absent. The size, shape, and level of the cicatrix depend upon the
+conditions which preceded healing.
+
+A healthy scar, when recently formed, has a smooth, glossy surface of a
+pinkish colour, which tends to become whiter as a result of obliteration
+of the blood vessels concerned in its formation.
+
+_Weak Scars._--A scar is said to be weak when it readily breaks down as
+a result of irritation or pressure. The scars resulting from severe
+burns and those over amputation stumps are especially liable to break
+down from trivial causes. The treatment is to excise the weak portion of
+the scar and bring the edges of the gap together.
+
+_Contracted scars_ frequently cause deformity either by displacing
+parts, such as the eyelid or lip, or by fixing parts and preventing the
+normal movements--for example, a scar on the flexor aspect of a joint
+may prevent extension of the forearm (Fig. 63). These are treated by
+dividing the scar, correcting the deformity, and filling up the gap with
+epithelial grafts, or with a flap of the whole thickness of the skin.
+When deformity results from _depression of a scar_, as is not uncommon
+after the healing of a sinus, the treatment is to excise the scar.
+Depressed scars may be raised by the injection of paraffin into the
+subcutaneous tissue.
+
+_Painful Scars._--Pain in relation to a scar is usually due to nerve
+fibres being compressed or stretched in the cicatricial tissue; and in
+some cases to ascending neuritis. The treatment consists in excising the
+scar or in stretching or excising a portion of the nerve affected.
+
+_Pigmented or Discoloured Scars._--The best-known examples are the blue
+coloration which results from coal-dust or gunpowder, the brown scars
+resulting from chronic ulcer with venous congestion of the leg, and the
+variously coloured scars caused by tattooing. The only satisfactory
+method of getting rid of the coloration is to excise the scar; the edges
+are brought together by sutures, or the raw surface is covered with
+skin-grafts according to the size of the gap.
+
+_Hypertrophied Scars._--Scars occasionally broaden out and become
+prominent, and on exposed parts this may prove a source of
+disappointment after operations such as those for goitre or tuberculous
+glands in the neck. There is sometimes considerable improvement from
+exposure to the X-rays.
+
+_Keloid._--This term is applied to an overgrowth of scar tissue which
+extends beyond the area of the original wound, and the name is derived
+from the fact that this extension occurs in the form of radiating
+processes, suggesting the claws of a crab. It is essentially a fibroma
+or new growth of fibrous tissue, which commences in relation to the
+walls of the smaller blood vessels; the bundles of fibrous tissue are
+for the most part parallel with the surface, and the epidermis is
+tightly stretched over them. It is more frequent in the negro and in
+those who are, or have been, the subjects of tuberculous disease.
+
+[Illustration: FIG. 106.--Recurrent Keloid in scar left by operation for
+tuberculous glands in a girl aet. 7.]
+
+Keloid may attack scars of any kind, such as those resulting from
+leech-bites, acne pustules, boils or blisters; those resulting from
+operation or accidental wounds; and the scars resulting from burns,
+especially when situated over the sternum, appear to be specially
+liable. The scar becomes more and more conspicuous, is elevated above
+the surface, of a pinkish or brownish-pink pink colour, and sends out
+irregular prolongations around its margins. The patient may complain of
+itching and burning, and of great sensitiveness of the scar, even to
+contact with the clothing.
+
+There is a natural hesitation to excise keloid because of the fear of
+its returning in the new scar. The application of radium is, so far as
+we know, the only means of preventing such return. The irritation
+associated with keloid may be relieved by the application of salicylic
+collodion or of salicylic and creosote plaster.
+
+_Epithelioma_ is liable to attack scars in old people, especially those
+which result from burns sustained early in childhood and have never
+really healed. From the absence of lymphatics in scar tissue, the
+disease does not spread to the glands until it has invaded the tissues
+outside the scar; the prognosis is therefore better than in epithelioma
+in general. It should be excised widely; in the lower extremity when
+there is also extensive destruction of tissue from an antecedent chronic
+ulcer or osteomyelitis, it may be better to amputate the limb.
+
+
+AFFECTION OF THE NAILS
+
+_Injuries._--When a nail is contused or crushed, blood is extravasated
+beneath it, and the nail is usually shed, a new one growing in its
+place. A splinter driven underneath the nail causes great pain, and if
+organisms are carried in along with it, may give rise to infective
+complications. The free edge of the nail should be clipped away to allow
+of the removal of the foreign body and the necessary disinfection.
+
+_Trophic Changes._--The growth of the nails may be interfered with in
+any disturbance of the general health. In nerve lesions, such as a
+divided nerve-trunk, the nails are apt to suffer, becoming curved,
+brittle, or furrowed, or they may be shed.
+
+_Onychia_ is the term applied to an infection of the soft parts around
+the nail or of the matrix beneath it. The commonest form of onychia has
+already been referred to with whitlow. There is a superficial variety
+resulting from the extension of a purulent blister beneath the nail
+lifting it up from its bed, the pus being visible through the nail. The
+nail as well as the raised horny layer of the epidermis should be
+removed. A deeper and more troublesome onychia results from infection at
+the nail-fold; the infection spreads slowly beneath the fold until it
+reaches the matrix, and a drop or two of pus forms beneath the nail,
+usually in the region of the lunule. This affection entails a
+disability of the finger which may last for weeks unless it is properly
+treated. Treatment by hyperaemia, using a suction bell, should first be
+tried, and, failing improvement, the nail-fold and lunule should be
+frozen, and a considerable portion removed with the knife; if only a
+small portion of the nail is removed, the opening is blocked by
+granulations springing from the matrix. A new nail is formed, but it is
+liable to be misshapen.
+
+_Tuberculous onychia_ is met with in children and adolescents. It
+appears as a livid or red swelling at the root of the nail and spreading
+around its margins. The epidermis, which is thin and shiny, gives way,
+and the nail is usually shed.
+
+[Illustration: FIG. 107.--Subungual Exostosis growing from Distal
+Phalanx of Great Toe, showing Ulceration of Skin and Displacement of
+Nail.
+
+_a._ Surface view.   _b._ On section.]
+
+_Syphilitic_ affections of the nails assume various aspects. A primary
+chancre at the edge of the nail may be mistaken for a whitlow,
+especially if it is attended with much pain. Other forms of onychia
+occur during secondary syphilis simultaneously with the skin eruptions,
+and may prove obstinate and lead to shedding of the nails. They also
+occur in inherited syphilis. In addition to general treatment, an
+ointment containing 5 per cent. of oleate of mercury should be applied
+locally.
+
+_Ingrowing Toe-nail._--This is more accurately described as an
+overgrowth of the soft tissues along the edge of the nail. It is most
+frequently met with in the great toe in young adults with flat-foot
+whose feet perspire freely, who wear ill-fitting shoes, and who cut
+their toe-nails carelessly or tear them with their fingers. Where the
+soft tissues are pressed against the edge of the nail, the skin gives
+way and there is the formation of exuberant granulations and of
+discharge which is sometimes foetid. The affection is a painful one and
+may unfit the patient for work. In mild cases the condition may be
+remedied by getting rid of contributing causes and by disinfecting the
+skin and nail; the nail is cut evenly, and the groove between it and the
+skin packed with an antiseptic dusting-powder, such as boracic acid. In
+more severe cases it may be necessary to remove an ellipse of tissue
+consisting of the edge of the nail, together with the subjacent matrix
+and the redundant nail-fold.
+
+_Subungual exostosis_ is an osteoma growing from the terminal phalanx of
+the great toe (Fig. 107). It raises the nail and may be accompanied by
+ulceration of the skin over the most prominent part of the growth. The
+soft parts, including the nail, should be reflected towards the dorsum
+in the form of a flap, the base of the exostosis divided with the
+chisel, and the exostosis removed.
+
+_Malignant disease_ in relation to the nails is rare. Squamous
+epithelioma and melanotic cancer are the forms met with. Treatment
+consists in amputating the digit concerned, and in removing the
+associated lymph glands.
+
+
+
+
+CHAPTER XVIII
+
+THE MUSCLES, TENDONS, AND TENDON SHEATHS
+
+
+INJURIES: _Contusion_; _Sprain_; _Rupture_--Hernia of
+    muscle--Dislocation of tendons--Wounds--Avulsion of tendon.
+    DISEASES OF MUSCLE AND OF TENDONS: _Atrophy_; _"Muscular
+    rheumatism"_--_Fibrositis_; _Contracture_; _Myositis_;
+    _Calcification and Ossification_; _Tumours_. DISEASES OF TENDON
+    SHEATHS: _Teno-synovitis_.
+
+
+INJURIES
+
+#Contusion of Muscle.#--Contusion of muscle, which consists in bruising
+of its fibres and blood vessels, may be due to violence acting from
+without, as in a blow, a kick, or a fall; or from within, as by the
+displacement of bone in a fracture or dislocation.
+
+The symptoms are those common to all contusions, and the patient
+complains of severe pain on attempting to use the muscle, and maintains
+an attitude which relaxes it. If the sheath of the muscle also is torn,
+there is subcutaneous ecchymosis, and the accumulation of blood may
+result in the formation of a haematoma.
+
+Restoration of function is usually complete; but when the nerve
+supplying the muscle is bruised at the same time, as may occur in the
+deltoid, wasting and loss of function may be persistent. In exceptional
+cases the process of repair may be attended with the formation of bone
+in the substance of the muscle, and this may likewise impair its
+function.
+
+A contused muscle should be placed at rest and supported by cotton wool
+and a bandage; after an interval, massage and appropriate exercises are
+employed.
+
+#Sprain and Partial Rupture of Muscle.#--This lesion consists in
+overstretching and partial rupture of the fibres of a muscle or its
+aponeurosis. It is of common occurrence in athletes and in those who
+follow laborious occupations. It may follow upon a single or repeated
+effort--especially in those who are out of training. Familiar examples
+of muscular sprain are the "labourer's" or "golfer's back," affecting
+the latissimus dorsi or the sacrospinalis (erector spinae); the
+"tennis-player's elbow," and the "sculler's sprain," affecting the
+muscles and ligaments about the elbow; the "angler's elbow," affecting
+the common origin of the extensors and supinators; the "sprinter's
+sprain," affecting the flexors of the hip; and the "jumper's and
+dancer's sprain," affecting the muscles of the calf. The patient
+complains of pain, often sudden in onset, of tenderness on pressure, and
+of inability to carry out the particular movement by which the sprain
+was produced. The disability varies in different cases, and it may
+incapacitate the patient from following his occupation or sport for
+weeks or, if imperfectly treated, even for months.
+
+The _treatment_ consists in resting the muscle from the particular
+effort concerned in the production of the sprain, in gently exercising
+it in other directions, in the use of massage, and the induction of
+hyperaemia by means of heat. In neglected cases, that is, where the
+muscle has not been exercised, the patient shrinks from using it and the
+disablement threatens to be permanent; it is sometimes said that
+adhesions have formed and that these interfere with the recovery of
+function. The condition may be overcome by graduated movements or by a
+sudden forcible movement under an anaesthetic. These cases afford a
+fruitful field for the bone-setter.
+
+#Rupture of Muscle or Tendon.#--A muscle or a tendon may be ruptured in
+its continuity or torn from its attachment to bone. The site of rupture
+in individual muscles is remarkably constant, and is usually at the
+junction of the muscular and tendinous portions. When rupture takes
+place through the belly of a muscle, the ends retract, the amount of
+retraction depending on the length of the muscle, and the extent of its
+attachment to adjacent aponeurosis or bone. The biceps in the arm, and
+the sartorius in the thigh, furnish examples of muscles in which the
+separation between the ends may be considerable.
+
+The gap in the muscle becomes filled with blood, and this in time is
+replaced by connective tissue, which forms a bond of union between the
+ends. When the space is considerable the connecting medium consists of
+fibrous tissue, but when the ends are in contact it contains a number of
+newly formed muscle fibres. In the process of repair, one or both ends
+of the muscle or tendon may become fixed by adhesions to adjacent
+structures, and if the distal portion of a muscle is deprived of its
+nerve supply it may undergo degeneration and so have its function
+impaired.
+
+Rupture of a muscle or tendon is usually the result of a sudden, and
+often involuntary, movement. As examples may be cited the rupture of
+the quadriceps extensor in attempting to regain the balance when falling
+backwards; of the gastrocnemius, plantaris, or tendo-calcaneus in
+jumping or dancing; of the adductors of the thigh in gripping a horse
+when it swerves--"rider's sprain"; of the abdominal muscles in vomiting,
+and of the biceps in sudden movements of the arm. Sometimes the effort
+is one that would scarcely be thought likely to rupture a muscle, as in
+the case recorded by Pagenstecher, where a professional athlete, while
+sitting at table, ruptured his biceps in a sudden effort to catch a
+falling glass. It would appear that the rupture is brought about not so
+much by the contraction of the muscle concerned, as by the contraction
+of the antagonistic muscles taking place before that of the muscle which
+undergoes rupture is completed. The violent muscular contractions of
+epilepsy, tetanus, or delirium rarely cause rupture.
+
+The _clinical features_ are usually characteristic. The patient
+experiences a sudden pain, with the sensation of being struck with a
+whip, and of something giving way; sometimes a distant snap is heard.
+The limb becomes powerless. At the seat of rupture there is tenderness
+and swelling, and there may be ecchymosis. As the swelling subsides, a
+gap may be felt between the retracted ends, and this becomes wider when
+the muscle is thrown into contraction. If untreated, a hard, fibrous
+cord remains at the seat of rupture.
+
+_Treatment._--The ends are approximated by placing the limb in an
+attitude which relaxes the muscle, and the position is maintained by
+bandages, splints, or special apparatus. When it is impossible thus to
+approximate the ends satisfactorily, the muscle or tendon is exposed by
+incision, and the ends brought into accurate contact by catgut sutures.
+This operation of primary suture yields the most satisfactory results,
+and is most successful when it is done within five or six days of the
+accident. Secondary suture after an interval of months is rendered
+difficult by the retraction of the ends and by their adhesion to
+adjacent structures.
+
+_Rupture of the biceps of the arm_ may involve the long or the short
+head, or the belly of the muscle. Most interest attaches to rupture of
+the long tendon of origin. There is pain and tenderness in front of the
+upper end of the humerus, the patient is unable to abduct or to elevate
+the arm, and he may be unable to flex the elbow when the forearm is
+supinated. The long axis of the muscle, instead of being parallel with
+the humerus, inclines downwards and outwards. When the patient is asked
+to contract the muscle, its belly is seen to be drawn towards the
+elbow.
+
+The _adductor longus_ may be ruptured, or torn from the pubes, by a
+violent effort to adduct the limb. A swelling forms in the upper and
+medial part of the thigh, which becomes smaller and harder when the
+muscle is thrown into contraction.
+
+The _quadriceps femoris_ is usually ruptured close to its insertion into
+the patella, in the attempt to avoid falling backwards. The injury is
+sometimes bilateral. The injured limb is rendered useless for
+progression, as it suddenly gives way whenever the knee is flexed.
+Treatment is conducted on the same lines as in transverse fracture of
+the patella; in the majority of cases the continuity of the quadriceps
+should be re-established by suture within five or six days of the
+accident.
+
+The _tendo calcaneus_ (Achillis) is comparatively easily ruptured, and
+the symptoms are sometimes so slight that the nature of the injury may
+be overlooked. The limb should be put up with the knee flexed and the
+toes pointed. This may be effected by attaching one end of an elastic
+band to the heel of a slipper, and securing the other to the lower third
+of the thigh. If this is not sufficient to bring the ends into
+apposition they should be approximated by an open operation.
+
+The _plantaris_ is not infrequently ruptured from trivial causes, such
+as a sudden movement in boxing, tennis, or hockey. A sharp stinging pain
+like the stroke of a whip is felt in the calf; there is marked
+tenderness at the seat of rupture, and the patient is unable to raise
+the heel without pain. The injury is of little importance, and if the
+patient does not raise the heel from the ground in walking, it is
+recovered from in a couple of weeks or so, without it being necessary to
+lay him up.
+
+#Hernia of Muscle.#--This is a rare condition, in which, owing to the
+fascia covering a muscle becoming stretched or torn, the muscular
+substance is protruded through the rent. It has been observed chiefly in
+the adductor longus. An oval swelling forms in the upper part of the
+thigh, is soft and prominent when the muscle is relaxed, less prominent
+when it is passively extended, and disappears when the muscle is thrown
+into contraction. It is liable to be mistaken, according to its
+situation, for a tumour, a cyst, a pouched vein, or a femoral or
+obturator hernia. Treatment is only called for when it is causing
+inconvenience, the muscle being exposed by a suitable incision, the
+herniated portion excised, and the rent in the sheath closed by sutures.
+
+#Dislocation of Tendons.#--Tendons which run in grooves may be displaced
+as a result of rupture of the confining sheath. This injury is met with
+chiefly in the tendons at the ankle and in the long tendon of the
+biceps.
+
+Dislocation of the _peronei tendons_ may occur, for example, from a
+violent twist of the foot. There is severe pain and considerable
+swelling on the lateral aspect of the ankle; the peroneus longus by
+itself, or together with the brevis, can be felt on the lateral aspect
+or in front of the lateral malleolus; the patient is unable to move the
+foot. By a little manipulation the tendons are replaced in their
+grooves, and are retained there by a series of strips of plaster. At the
+end of three weeks massage and exercises are employed.
+
+In other cases there is no history of injury, but whenever the foot is
+everted the tendon of the peroneus longus is liable to be jerked
+forwards out of its groove, sometimes with an audible snap. The patient
+suffers pain and is disabled until the tendon is replaced. Reduction is
+easy, but as the displacement tends to recur, an operation is required
+to fix the tendon in its place. An incision is made over the tendon; if
+the sheath is slack or torn, it is tightened up or closed with catgut
+sutures; or an artificial sheath is made by raising up a quadrilateral
+flap of periosteum from the lateral aspect of the fibula, and stitching
+it over the tendon.
+
+Similarly the _tibialis posterior_ may be displaced over the medial
+malleolus as a result of inversion of the foot.
+
+The _long tendon of the biceps_ may be dislocated laterally--or more
+frequently medially--as a result of violent or repeated rotation
+movements of the arm, such as are performed in wringing clothes. The
+patient is aware of the displacement taking place, and is unable to
+extend the forearm until the displaced tendon has been reduced by
+abducting the arm. In recurrent cases the patient may be able to
+dislocate the tendon at will, but the disability is so inconsiderable
+that there is rarely any occasion for interference.
+
+#Wounds of Muscles and Tendons.#--When a muscle is cut across in a
+wound, its ends should be brought together with sutures. If the ends are
+allowed to retract, and especially if the wound suppurates, they become
+united by scar tissue and fixed to bone or other adjacent structure. In
+a limb this interferes with the functions of the muscle; in the
+abdominal wall the scar tissue may stretch, and so favour the
+development of a ventral hernia.
+
+Tendons may be cut across accidentally, especially in those wounds so
+commonly met with above the wrist as a result, for example, of the hand
+being thrust through a pane of glass. It is essential that the ends
+should be sutured to each other, and as the proximal end is retracted
+the original wound may require to be enlarged in an upward direction.
+When primary suture has been omitted, or has failed in consequence of
+suppuration, the separated ends of the tendon become adherent to
+adjacent structures, and the function of the associated muscle is
+impaired or lost. Under these conditions the operation of secondary
+suture is indicated.
+
+A free incision is necessary to discover and isolate the ends of the
+tendon; if the interval is too wide to admit of their being approximated
+by sutures, means must be taken to lengthen the tendon, or one from some
+other part may be inserted in the gap. A new sheath may be provided for
+the tendon by resecting a portion of the great saphenous vein.
+
+_Injuries of the tendons of the fingers_ are comparatively common. One
+of the best known is the partial or complete rupture of the aponeurosis
+of the extensor tendon close to its insertion into the terminal
+phalanx--_drop-_ or _mallet-finger_. This may result from comparatively
+slight violence, such as striking the tip of the extended finger against
+an object, or the violence may be more severe, as in attempting to catch
+a cricket ball or in falling. The terminal phalanx is flexed towards the
+palm and the patient is unable to extend it. The treatment consists in
+putting up the finger with the middle joint strongly flexed. In
+neglected cases, a perfect functional result can only be obtained by
+operation; under a local anaesthetic, the ruptured tendon is exposed and
+is sutured to the base of the phalanx, which may be drilled for the
+passage of the sutures.
+
+_Subcutaneous rupture_ of one or other _of the digital tendons_ in the
+hand or at the wrist can be remedied only by operation. When some time
+has elapsed since the accident, the proximal end may be so retracted
+that it cannot be brought down into contact with the distal end, in
+which case a slip may be taken from an adjacent tendon; in the case of
+one of the extensors of the thumb, the extensor carpi radialis longus
+may be detached from its insertion and stitched to the distal end of the
+tendon of the thumb.
+
+Subcutaneous _rupture of the tendon of the extensor pollicis longus_ at
+the wrist takes place just after its emergence from beneath the annular
+ligament; the actual rupture may occur painlessly, more frequently a
+sharp pain is felt over the back of the wrist. The prominence of the
+tendon, which normally forms the ulnar border of the snuff-box,
+disappears. This lesion is chiefly met with in drummer-boys and is the
+cause of drummer's palsy. The only chance of restoring function is in
+uniting the ruptured tendon by open operation.
+
+[Illustration: FIG. 108.--Avulsion of Tendon with Terminal Phalanx of
+Thumb.
+
+(Surgical Museum, University of Edinburgh.)]
+
+_Avulsion of Tendons._--This is a rare injury, in which the tendons of a
+finger or toe are torn from their attachments along with a portion of
+the digit concerned. In the hand, it is usually brought about by the
+fingers being caught in the reins of a runaway horse, or being seized in
+a horse's teeth, or in machinery. It is usually the terminal phalanx
+that is separated, and with it the tendon of the deep flexor, which
+ruptures at its junction with the belly of the muscle (Fig. 108). The
+treatment consists in disinfecting the wound, closing the tendon-sheath,
+and trimming the mutilated finger so as to provide a useful stump.
+
+
+DISEASES OF MUSCLES AND TENDONS
+
+_Congenital absence_ of muscles is sometimes met with, usually in
+association with other deformities. The pectoralis major, for example,
+may be absent on one or on both sides, without, however, causing any
+disability, as other muscles enlarge and take on its functions.
+
+_Atrophy of Muscle._--Simple atrophy, in which the muscle elements are
+merely diminished in size without undergoing any structural alteration,
+is commonly met with as a result of disuse, as when a patient is
+confined to bed for a long period.
+
+In cases of joint disease, the muscles acting on the joint become
+atrophied more rapidly than is accounted for by disuse alone, and this
+is attributed to an interference with the trophic innervation of the
+muscles reflected from centres in the spinal medulla. It is more marked
+in the extensor than in the flexor groups of muscles. Those affected
+become soft and flaccid, exhibit tremors on attempted movement, and
+their excitability to the faradic current is diminished.
+
+_Neuropathic atrophy_ is associated with lesions of the nervous system.
+It is most pronounced in lesions of the motor nerve-trunks, probably
+because vaso-motor and trophic fibres are involved as well as those that
+are purely motor in function. It is attended with definite structural
+alterations, the muscle elements first undergoing fatty degeneration,
+and then being absorbed, and replaced to a large extent by ordinary
+connective tissue and fat. At a certain stage the muscles exhibit the
+reaction of degeneration. In the common form of paralysis resulting from
+poliomyelitis, many fibres undergo fatty degeneration and are replaced
+by fat, while at the same time there is a regeneration of muscle fibres.
+
+#Fibrositis# or "#Muscular Rheumatism#."--This clinical term is applied
+to a group of affections of which lumbago is the best-known example. The
+group includes lumbago, stiff-neck, and pleurodynia--conditions which
+have this in common, that sudden and severe pain is excited by movement
+of the affected part. The lesion consists in inflammatory hyperplasia of
+the connective tissue; the new tissue differs from normal fibrous tissue
+in its tendency to contract, in being swollen, painful and tender on
+pressure, and in the fact that it can be massaged away (Stockman). It
+would appear to involve mainly the fibrous tissue of muscles, although
+it may extend from this to aponeuroses, ligaments, periosteum, and the
+sheaths of nerves. The term _fibrositis_ was applied to it by Gowers in
+1904.
+
+In _lumbago_--_lumbo-sacral fibrositis_--the pain is usually located
+over the sacrum, the sacro-iliac joint, or the aponeurosis of the lumbar
+muscles on one or both sides. The amount of tenderness varies, and so
+long as the patient is still he is free from pain. The slightest
+attempt to alter his position, however, is attended by pain, which may
+be so severe as to render him helpless for the moment. The pain is most
+marked on rising from the stooping or sitting posture, and may extend
+down the back of the hip, especially if, as is commonly the case,
+lumbago and gluteal fibrosis coexist. Once a patient has suffered from
+lumbago, it is liable to recur, and an attack may be determined by
+errors of diet, changes of weather, exposure to cold or unwonted
+exertion. It is met with chiefly in male adults, and is most apt to
+occur in those who are gouty or are the subjects of oxaluric dyspepsia.
+
+_Gluteal fibrositis_ usually follows exposure to wet, and affects the
+gluteal muscles, particularly the medius, and their aponeurotic
+coverings. When the condition has lasted for some time, indurated
+strands or nodules can be detected on palpating the relaxed muscles. The
+patient complains of persistent aching and stiffness over the buttock,
+and sometimes extending down the lateral aspect of the thigh. The pain
+is aggravated by such movements as bring the affected muscles into
+action. It is not referred to the line of the sciatic nerve, nor is
+there tenderness on pressing over the nerve, or sensations of tingling
+or numbness in the leg or foot.
+
+If untreated, the morbid process may implicate the sheath of the sciatic
+nerve and cause genuine sciatic neuralgia (Llewellyn and Jones). A
+similar condition may implicate the fascia lata of the thigh, or the
+calf muscles and their aponeuroses--_crural fibrositis_.
+
+In _painful stiff-neck_, or "rheumatic torticollis," the pain is located
+in one side of the neck, and is excited by some inadvertent movement.
+The head is held stiffly on one side as in wry-neck, the patient
+contracting the sterno-mastoid. There may be tenderness over the
+vertebral spines or in the lines of the cervical nerves, and the
+sterno-mastoid may undergo atrophy. This affection is more often met
+with in children.
+
+In _pleurodynia_--_intercostal fibrositis_--the pain is in the line of
+the intercostal nerves, and is excited by movement of the chest, as in
+coughing, or by any bodily exertion. There is often marked tenderness.
+
+A similar affection is met with in the _shoulder and arm_--_brachial
+fibrositis_--especially on waking from sleep. There is acute pain on
+attempting to abduct the arm, and there may be localised tenderness in
+the region of the axillary nerve.
+
+_Treatment._--The general treatment is concerned with the diet,
+attention to the stomach, bowels, and kidneys and with the correction
+of any gouty tendencies that may be present. Remedies such as
+salicylates are given for the relief of pain, and for this purpose drugs
+of the aspirin type are to be preferred, and these may be followed by
+large doses of iodide of potassium. Great benefit is derived from
+massage, and from the induction of hyperaemia by means of heat. Cupping
+or needling, or, in exceptional cases, hypodermic injections of
+antipyrin or morphin, may be called for. To prevent relapses of lumbago,
+the patient must take systematic exercises of all kinds, especially such
+as bring out the movements of the vertebral column and hip-joints.
+
+[Illustration: FIG. 109.--Volkmann's Ischaemic Contracture. When the
+wrist is flexed to a right angle it is possible to extend the fingers.
+
+(Photographs lent by Mr. Lawford Knaggs)]
+
+#Contracture of Muscles.#--Permanent shortening of muscles results from
+the prolonged approximation of their points of attachment, or from
+structural changes in their substance produced by injury or by disease.
+It is a frequent accompaniment and sometimes a cause of deformities, in
+the treatment of which lengthening of the shortened muscles or their
+tendons may be an essential step.
+
+#Myositis.#--_Ischaemic Myositis._--Volkmann was the first to describe a
+form of myositis followed by contracture, resulting from interference
+with the arterial blood supply. It is most frequently observed in the
+flexor muscles of the forearm in children and young persons under
+treatment for fractures in the region of the elbow, the splints and
+bandages causing compression of the blood vessels. There is considerable
+effusion of blood, the skin is tense, and the muscles, vessels, and
+nerves are compressed; this is further increased if the elbow is flexed
+and splints and tight bandages are applied. The muscles acquire a
+board-like hardness and no longer contract under the will, and passive
+motion is painful and restricted. Slight contracture of the fingers is
+usually the first sign of the malady; in time the muscles undergo
+further contraction, and this brings about a claw-like deformity of the
+hand. The affected muscles usually show the reaction of degeneration. In
+severe cases the median and ulnar nerves are also the seat of
+cicatricial changes (ischaemic neuritis).
+
+By means of splints, the interphalangeal, metacarpo-phalangeal, and
+wrist joints should be gradually extended until the deformity is
+over-corrected (R. Jones). Murphy advises resection of the radius and
+ulna sufficient to admit of dorsiflexion of the joints and lengthening
+of the flexor tendons.
+
+Various forms of _pyogenic_ infection are met with in muscle, most
+frequently in relation to pyaemia and to typhoid fever. These may result
+in overgrowth of the connective-tissue framework of the muscle and
+degeneration of its fibres, or in suppuration and the formation of one
+or more abscesses in the muscle substance. Repair may be associated with
+contracture.
+
+A _gonorrhoeal_ form of myositis is sometimes met with; it is painful,
+but rarely goes on to suppuration.
+
+In the early secondary period of _syphilis_, the muscles may be the seat
+of dull, aching, nocturnal pains, especially in the neck and back.
+_Syphilitic contracture_ is a condition which has been observed chiefly
+in the later secondary period; the biceps of the arm and the hamstrings
+in the thigh are the muscles more commonly affected. The striking
+feature is a gradually increasing difficulty of extending the limb at
+the elbow or knee, and progressive flexion of the joint. The affected
+muscle is larger and firmer than normal, and its electric excitability
+is diminished. In tertiary syphilis, individual muscles may become the
+seat of interstitial myositis or of gummata, and these affections
+readily yield to anti-syphilitic remedies.
+
+_Tuberculous disease_ in muscle, while usually due to extension from
+adjacent tissues, is sometimes the result of a primary infection through
+the blood-stream. Tuberculous nodules are found disseminated throughout
+the muscle; the surrounding tissues are indurated, and central caseation
+may take place and lead to abscess formation and sinuses. We have
+observed this form of tuberculous disease in the gastrocnemius and in
+the psoas--in the latter muscle apart from tuberculous disease in the
+vertebrae.
+
+#Tendinitis.#--German authors describe an inflammation of tendon as
+distinguished from inflammation of its sheath, and give it the name
+tendinitis. It is met with most frequently in the tendo-calcaneus in
+gouty and rheumatic subjects who have overstrained the tendon,
+especially during cold and damp weather. There is localised pain which
+is aggravated by walking, and the tendon is sensitive and swollen from a
+little above its insertion to its junction with the muscle. Gouty
+nodules may form in its substance. Constitutional measures, massage, and
+douching should be employed, and the tendon should be protected from
+strain.
+
+#Calcification and Ossification in Muscles, Tendons, and
+Fasciae.#--_Myositis ossificans._--Ossifications in muscles, tendons,
+fasciae, and ligaments, in those who are the subjects of arthritis
+deformans, are seldom recognised clinically, but are frequently met with
+in dissecting-rooms and museums. Similar localised ossifications are met
+with in Charcot's disease of joints, and in fractures which have
+repaired with exuberant callus. The new bone may be in the form of
+spicules, plates, or irregular masses, which, when connected with a
+bone, are called _false exostoses_ (Fig. 110).
+
+[Illustration: FIG. 110.--Ossification in Tendon of Ilio-psoas Muscle.]
+
+_Traumatic Ossification in Relation to Muscle._--Various forms of
+ossification are met with in muscle as the result of a single or of
+repeated injury. Ossification in the crureus or vastus lateralis muscle
+has been frequently observed as a result of a kick from a horse. Within
+a week or two a swelling appears at the site of injury, and becomes
+progressively harder until its consistence is that of bone. If the mass
+of new bone moves with the affected muscle, it causes little
+inconvenience. If, as is commonly the case, it is fixed to the femur,
+the action of the muscle is impaired, and the patient complains of pain
+and difficulty in flexing the knee. A skiagram shows the extent of the
+mass and its relationship to the femur. The treatment consists in
+excising the bony mass.
+
+Difficulty may arise in differentiating such a mass of bone from
+sarcoma; the ossification in muscle is uniformly hard, while the sarcoma
+varies in consistence at different parts, and the X-ray picture shows a
+clear outline of the bone in the vicinity of the ossification in
+muscle, whereas in sarcoma the involvement of the bone is shown by
+indentations and irregularity in its contour.
+
+A similar ossification has been observed in relation to the insertion of
+the brachialis muscle as a sequel of dislocation of the elbow. After
+reduction of the dislocation, the range of movement gradually diminishes
+and a hard swelling appears in front of the lower end of the humerus.
+The lump continues to increase in size and in three to four weeks the
+disability becomes complete. A radiogram shows a shadow in the muscle,
+attached at one part as a rule to the coronoid process. During the next
+three or four months, the lump in front of the elbow remains stationary
+in size; a gradual decrease then ensues, but the swelling persists, as a
+rule, for several years.
+
+[Illustration: FIG. 111.--Calcification and Ossification in Biceps and
+Triceps.
+
+(From a radiogram lent by Dr. C. A. Adair Dighton.)]
+
+Ossification in the adductor longus was first described by Billroth
+under the name of "rider's bone." It follows bruising and partial
+rupture of the muscle, and has been observed chiefly in cavalry
+soldiers. If it causes inconvenience the bone may be removed by
+operation.
+
+Ossification in the deltoid and pectoral muscles has been observed in
+foot-soldiers in the German army, and has received the name of
+"drill-bone"; it is due to bruising of the muscle by the recoil of the
+rifle.
+
+_Progressive Ossifying Myositis._--This is a rare and interesting
+disease, in which the muscles, tendons, and fasciae throughout the body
+become the seat of ossification. It affects almost exclusively the male
+sex, and usually begins in childhood or youth, sometimes after an
+injury, sometimes without apparent cause. The muscles of the back,
+especially the trapezius and latissimus, are the first to be affected,
+and the initial complaint is limitation of movement.
+
+[Illustration: FIG. 112.--Ossification in Muscles of Trunk in a case of
+generalised Ossifying Myositis.
+
+(Photograph lent by Dr. Rustomjee.)]
+
+The affected muscles show swellings which are rounded or oval, firm and
+elastic, sharply defined, without tenderness and without discoloration
+of the overlying skin. Skiagrams show that a considerable deposit of
+lime salts may precede the formation of bone, as is seen in Fig. 111. In
+course of time the vertebral column becomes rigid, the head is bent
+forward, the hips are flexed, and abduction and other movements of the
+arms are limited. The disease progresses by fits and starts, until all
+the striped muscles of the body are replaced by bone, and all movements,
+even those of the jaws, are abolished. The subjects of this disease
+usually succumb to pulmonary tuberculosis.
+
+There is no means of arresting the disease, and surgical treatment is
+restricted to the removal or division of any mass of bone that
+interferes with an important movement.
+
+A remarkable feature of this disease is the frequent presence of a
+deformity of the great toe, which usually takes the form of hallux
+valgus, the great toe coming to lie beneath the second one; the
+shortening is usually ascribed to absence of the first phalanx, but it
+has been shown to depend also on a synostosis and imperfect development
+of the phalanges. A similar deformity of the thumb is sometimes met
+with.
+
+Microscopical examination of the muscles shows that, prior to the
+deposition of lime salts and the formation of bone, there occurs a
+proliferation of the intra-muscular connective tissue and a gradual
+replacement and absorption of the muscle fibres. The bone is spongy in
+character, and its development takes place along similar lines to those
+observed in ossification from the periosteum.
+
+#Tumours of Muscle.#--With the exception of congenital varieties, such
+as the rhabdomyoma, tumours of muscle grow from the connective-tissue
+framework and not from the muscle fibres. Innocent tumours, such as the
+fibroma, lipoma, angioma, and neuro-fibroma, are rare. Malignant tumours
+may be primary in the muscle, or may result from extension from adjacent
+growths--for example, implication of the pectoral muscle in cancer of
+the breast--or they may be derived from tumours situated elsewhere. The
+diagnosis of an intra-muscular tumour is made by observing that the
+swelling is situated beneath the deep fascia, that it becomes firm and
+fixed when the muscle contracts, and that, when the muscle is relaxed,
+it becomes softer, and can be moved in the transverse axis of the
+muscle, but not in its long axis.
+
+Clinical interest attaches to that form of slowly growing
+fibro-sarcoma--_the recurrent fibroid of Paget_--which is most
+frequently met with in the muscles of the abdominal wall. A rarer
+variety is the ossifying chondro-sarcoma, which undergoes ossification
+to such an extent as to be visible in skiagrams.
+
+In primary sarcoma the treatment consists in removing the muscle. In the
+limbs, the function of the muscle that is removed may be retained by
+transplanting an adjacent muscle in its place.
+
+_Hydatid cysts_ of muscle resemble those developing in other tissues.
+
+
+DISEASES OF TENDON SHEATHS
+
+Tendon sheaths have the same structure and function as the synovial
+membranes of joints, and are liable to the same diseases. Apart from the
+tendon sheaths displayed in anatomical dissections, there is a loose
+peritendinous and perimuscular cellular tissue which is subject to the
+same pathological conditions as the tendon sheaths proper.
+
+#Teno-synovitis.#--The toxic or infective agent is conveyed to the
+tendon sheaths through the blood-stream, as in the gouty, gonorrhoeal,
+and tuberculous varieties, or is introduced directly through a wound, as
+in the common pyogenic form of teno-synovitis.
+
+_Teno-synovitis Crepitans._--In the simple or traumatic form of
+teno-synovitis, although the most prominent etiological factor is a
+strain or over-use of the tendon, there would appear to be some other,
+probably a toxic, factor in its production, otherwise the affection
+would be much more common than it is: only a small proportion of those
+who strain or over-use their tendons become the subjects of
+teno-synovitis. The opposed surfaces of the tendon and its sheath are
+covered with fibrinous lymph, so that there is friction when they move
+on one another.
+
+The _clinical features_ are pain on movement, tenderness on pressure
+over the affected tendon, and a sensation of crepitation or friction
+when the tendon is moved in its sheath. The crepitation may be soft like
+the friction of snow, or may resemble the creaking of new
+leather--"saddle-back creaking." There may be swelling in the long axis
+of the tendon, and redness and oedema of the skin. If there is an
+effusion of fluid into the sheath, the swelling is more marked and
+crepitation is absent. There is little tendency to the formation of
+adhesions.
+
+In the upper extremity, the sheath of the long tendon of the biceps may
+be affected, but the condition is most common in the tendons about the
+wrist, particularly in the extensors of the thumb, and it is most
+frequently met with in those who follow occupations which involve
+prolonged use or excessive straining of these tendons--for example,
+washerwomen or riveters. It also occurs as a result of excessive
+piano-playing, fencing, or rowing.
+
+At the ankle it affects the peronei, the extensor digitorum longus, or
+the tibialis anterior. It is most often met with in relation to the
+tendo-calcaneus--_Achillo-dynia_--and results from the pressure of
+ill-fitting boots or from the excessive use and strain of the tendon in
+cycling, walking, or dancing. There is pain in raising the heel from the
+ground, and creaking can be felt on palpation.
+
+The _treatment_ consists in putting the affected tendon at rest, and
+with this object a splint may be helpful; the usual remedies for
+inflammation are indicated: Bier's hyperaemia, lead and opium
+fomentations, and ichthyol and glycerine. The affection readily subsides
+under treatment, but is liable to relapse on a repetition of the
+exciting cause.
+
+_Gouty Teno-synovitis._--A deposit of urate of soda beneath the
+endothelial covering of tendons or of that lining their sheaths is
+commonly met with in gouty subjects. The accumulation of urates may
+result in the formation of visible nodular swellings, varying in size
+from a pea to a cherry, attached to the tendon and moving with it. They
+may be merely unsightly, or they may interfere with the use of the
+tendon. Recurrent attacks of inflammation are prone to occur. We have
+removed such gouty masses with satisfactory results.
+
+_Suppurative Teno-synovitis._--This form usually follows upon infected
+wounds of the fingers--especially of the thumb or little finger--and is
+a frequent sequel to whitlow; it may also follow amputation of a finger.
+Once the infection has gained access to the sheath, it tends to spread,
+and may reach the palm or even the forearm, being then associated with
+cellulitis. In moderately acute cases the tendon and its sheath become
+covered with granulations, which subsequently lead to the formation of
+adhesions; while in more acute cases the tendon sloughs. The pus may
+burst into the cellular tissue outside the sheath, and the suppuration
+is liable to spread to neighbouring sheaths or to adjacent bones or
+joints--for example, those of the wrist.
+
+The _treatment_ consists in inducing hyperaemia and making small
+incisions for the escape of pus. The site of incision is determined by
+the point of greatest tenderness on pressure. After the inflammation has
+subsided, active and passive movements are employed to prevent the
+formation of adhesions between the tendon and its sheath. If the tendon
+sloughs, the dead portion should be cut away, as its separation is
+extremely slow and is attended with prolonged suppuration.
+
+_Gonorrhoeal Teno-synovitis._--This is met with especially in the tendon
+sheaths about the wrist and ankle. It may occur in a mild form, with
+pain, impairment of movement, and oedema, and sometimes an elongated,
+fluctuating swelling, the result of serous effusion into the sheath.
+This condition may alternate with a gonorrhoeal affection of one of the
+larger joints. It may subside under rest and soothing applications, but
+is liable to relapse. In the more severe variety the skin is red, and
+the swelling partakes of the characters of a phlegmon with threatening
+suppuration; it may result in crippling from adhesions. Even if pus
+forms in the sheath, the tendon rarely sloughs. The treatment consists
+in inducing hyperaemia by Bier's method; and a vaccine may be employed
+with satisfactory results.
+
+#Tuberculous Disease of Tendon Sheaths.#--This is a comparatively common
+affection, and is analogous to tuberculous disease of the synovial
+membrane of joints. It may originate in the sheath, or may spread to it
+from an adjacent bone.
+
+The commonest form--hydrops--is that in which the synovial sheath is
+distended with a viscous fluid, and the fibrinous material on the free
+surface becomes detached and is moulded into melon-seed bodies by the
+movement of the tendon. The sheath itself is thickened by the growth of
+tuberculous granulation tissue. The bodies are smooth and of a
+dull-white colour, and vary greatly in size and shape. There may be an
+overgrowth of the fatty fringes of the synovial sheath, a condition
+described as "arborescent lipoma."
+
+The _clinical features_ vary with the tendon sheath affected. In the
+common flexor sheath of the hand an hour-glass-shaped swelling is
+formed, bulging above and below the transverse carpal (anterior annular)
+ligament--formerly known as _compound palmar ganglion_. There is little
+or no pain, but the fingers tend to be stiff and weak, and to become
+flexed. On palpation, it is usually possible to displace the contents of
+the sheath from one compartment to the other, and this may yield
+fluctuation, and, what is more characteristic, a peculiar soft crepitant
+sensation from the movement of the melon-seed bodies. In the sheath of
+the peronei or other tendons about the ankle, the swelling is
+sausage-shaped, and is constricted opposite the annular ligament.
+
+The onset and progress of the affection are most insidious, and the
+condition may remain stationary for long periods. It is aggravated by
+use or strain of the tendons involved. In exceptional cases the skin is
+thinned and gives way, resulting in the formation of a sinus.
+
+_Treatment._--In the common flexor sheath of the palm, an attempt may be
+made to cure the condition by removing the contents through a small
+incision and filling the cavity with iodoform glycerine, followed by the
+use of Bier's bandage. If this fails, the distended sheath is laid open,
+the contents removed, the wall scraped, and the wound closed.
+
+A less common form of tuberculous disease is that in which the sheath
+becomes the seat of _a diffuse tuberculous thickening_, not unlike the
+white swelling met with in joints, and with a similar tendency to
+caseation. A painless swelling of an elastic character forms in relation
+to the tendon sheath. It is hour-glass-shaped in the common flexor
+sheath of the palm, elongated or sausage-shaped in the extensors of the
+wrist and in the tendons at the ankle. The tuberculous granulation
+tissue is liable to break down and lead to the formation of a cold
+abscess and sinuses, and in our experience is often associated with
+disease in an adjacent bone or joint. In the peronei tendons, for
+example, it may result from disease of the fibula or of the ankle-joint.
+
+When conservative measures fail, excision of the affected sheath should
+be performed; the whole of the diseased area being exposed by free
+incision of the overlying soft parts, the sheath is carefully isolated
+from the surrounding tissues and is cut across above and below. Any
+tuberculous tissue on the tendon itself is removed with a sharp spoon.
+Associated bone or joint lesions are dealt with at the same time. In the
+after-treatment the functions of the tendons must be preserved by
+voluntary and passive movements.
+
+#Syphilitic Affections of Tendon Sheaths.#--These closely resemble the
+syphilitic affections of the synovial membrane of joints. During the
+secondary period the lesion usually consists in effusion into the
+sheath; gummata are met with during the tertiary period.
+
+Arborescent lipoma has been found in the sheaths of tendons about the
+wrist and ankle, sometimes in a multiple and symmetrical form,
+unattended by symptoms and disappearing under anti-syphilitic treatment.
+
+#Tumours of Tendon Sheaths.#--Innocent tumours, such as _lipoma_,
+_fibroma_, and _myxoma_, are rare. Special mention should be made of the
+_myeloma_ which is met with at the wrist or ankle as an elongated
+swelling of slow development, or over the phalanx of a finger as a small
+rounded swelling. The tumour tissue, when exposed by dissection, is of a
+chocolate or chamois-yellow colour, and consists almost entirely of
+giant cells. The treatment consists in dissecting the tumour tissue off
+the tendons, and this is usually successful in bringing about a
+permanent cure.
+
+All varieties of _sarcoma_ are met with, but their origin from tendon
+sheaths is not associated with special features.
+
+
+
+
+CHAPTER XIX
+
+THE BURSAE
+
+
+Anatomy--Normal and adventitious bursae--Injuries: Bursal
+    haematoma--DISEASES: Infective bursitis; Traumatic or trade
+    bursitis; Bursal hydrops; Solid bursal tumour; Gonorrhoeal and
+    suppurative forms of bursitis; Tuberculous and syphilitic
+    disease--Tumours--_Diseases of individual bursae in the upper and
+    lower extremities_.
+
+A bursa is a closed sac lined by endothelium and containing synovia.
+Some are normally present--for instance, that between the skin and the
+patella, and that between the aponeurosis of the gluteus maximus and the
+great trochanter. _Adventitious bursae_ are developed as a result of
+abnormal pressure--for example, over the tarsal bones in cases of
+club-foot.
+
+#Injuries of Bursae.#--As a result of contusion, especially in bleeders,
+haemorrhage may occur into the cavity of a bursa and give rise to a
+_bursal haematoma_. Such a haematoma may mask a fracture of the bone
+beneath--for example, fracture of the olecranon.
+
+#Diseases of Bursae.#--The lining membrane of bursae resembles that of
+joints and tendon sheaths, and is liable to the same forms of disease.
+
+#Infective bursitis# frequently follows abrasions, scratches, and wounds
+of the skin over the prepatellar or olecranon bursa, and in neglected
+cases the infection transgresses the wall of the bursa and gives rise to
+a spreading cellulitis.
+
+#Traumatic or Trade Bursitis.#--This term may be conveniently applied to
+those affections of bursae which result from repeated slight traumatism
+incident to particular occupations. The most familiar examples of these
+are the enlargement of the prepatellar bursa met with in housemaids--the
+"housemaid's knee" (Fig. 113); the enlargement of the olecranon
+bursa--"miner's elbow"; and of the ischial bursa--"weaver's" or
+"tailor's bottom" (Fig. 116). These affections are characterised by an
+effusion of fluid into the sac of the bursa with thickening of its
+lining membrane. While friction and pressure are the most evident
+factors in their production, it is probable that there is also some
+toxic agent concerned, otherwise these affections would be much more
+common than they are. Of the countless housemaids in whom the
+prepatellar bursa is subjected to friction and pressure, only a small
+proportion become the subjects of housemaid's knee.
+
+_Clinical Features._--As these are best illustrated in the different
+varieties of prepatellar bursitis, it is convenient to take this as the
+type. In a number of cases the inflammation is acute and the patient is
+unable to use the limb; the part is hot, swollen, and tender, and
+fluctuation can be detected in the bursa. In the majority the condition
+is chronic, and the chief feature is the gradual accumulation of fluid
+constituting the _bursal hydrops_ or _hygroma_. When the affection has
+lasted some time, or has frequently relapsed, the wall of the bursa
+becomes thickened by fibrous tissue, which may be deposited irregularly,
+so that septa, bands, or fringes are formed, not unlike those met with
+in arthritis deformans. These fringes may be detached and form loose
+bodies like those met with in joints; less frequently there are
+fibrinous bodies of the melon-seed type, sometimes moulded into circular
+discs like wafers. The presence of irregular thickenings of the wall, or
+of loose bodies, may be recognised on palpation, especially in
+superficial bursae, if the sac is not tensely filled with fluid. The
+thickening of the wall may take place in a uniform and concentric
+fashion, resulting in the formation of a fibrous tumour--_the solid
+bursal tumour_--a small cavity remaining in the centre which serves to
+distinguish it from a new growth or neoplasm.
+
+[Illustration: FIG. 113.--Hydrops of Prepatellar Bursa in a housemaid.]
+
+The _treatment_ varies according to the variety and stage of the
+affection. In recent cases the symptoms subside under rest and the
+application of fomentations. Hydrops may be got rid of by blistering,
+by tapping, or by incision and drainage. When the wall is thickened, the
+most satisfactory treatment is to excise the bursa; the overlying skin
+being reflected in the shape of a horse-shoe flap or being removed along
+with the bursa.
+
+#Other Diseases of Bursae# are associated with _gonorrhoeal infection_,
+and with _rheumatism_, especially that following scarlet fever, and are
+apt to be persistent or to relapse after apparent cure. In the _gouty_
+form, urate of soda is deposited in the wall of the bursa, and may
+result in the formation of chalky tumours, sometimes of considerable
+size (Fig. 114).
+
+[Illustration: FIG. 114.--Section through Bursa over external malleolus,
+showing deposit of urate of soda. (Cf. Fig. 117.)]
+
+_Tuberculous disease_ of bursae closely resembles that of tendon sheaths.
+It may occur as an independent affection, or may be associated with
+disease in an adjacent bone or joint. It is met with chiefly in the
+prepatellar and subdeltoid bursae, or in one of the bursae over the great
+trochanter. The clinical features are those of an indolent hydrops, with
+or without melon-seed bodies, or of uniform thickening of the wall of
+the bursa; the tuberculous granulation tissue may break down into a cold
+abscess, and give rise to sinuses. The best treatment is to excise the
+affected bursa, or, when this is impracticable, to lay it freely open,
+remove the tuberculous tissue with the sharp spoon or knife, and treat
+the cavity by the open method.
+
+_Syphilitic disease_ is rarely recognised except in the form of bursal
+and peri-bursal gummata in front of the knee-joint.
+
+_New growths_ include the fibroma, the myxoma, the myeloma or
+giant-celled tumour, and various forms of sarcoma.
+
+#Diseases of Individual Bursae.#--The _olecranon bursa_ is frequently
+the seat of pyogenic infection and of traumatic or trade bursitis, the
+latter being known as "miner's" or "student's elbow."
+
+[Illustration: FIG. 115.--Tuberculous Disease of Sub-deltoid Bursa.
+
+(From a photograph lent by Sir George T. Beatson.)]
+
+The _sub-deltoid_ or _sub-acromial bursa_, which usually presents a
+single cavity and does not normally communicate with the shoulder-joint,
+is indispensable in abduction and rotation of the humerus. When the arm
+is abducted, the fixed lower part or floor of the bursa is carried under
+the acromion, and the upper part or roof is rolled up in the same
+direction, hence tenderness over the inflamed bursa may disappear when
+the arm is abducted (Dawbarn's sign). It is liable to traumatic
+affections from a fall on the shoulder, pressure, or over-use of the
+limb. Pain, located commonly at the insertion of the deltoid, is a
+constant symptom and is especially annoying at night, the patient being
+unable to get into a comfortable position. Tenderness may be elicited
+over the anatomical limits of the bursa, and is usually most marked over
+the great tuberosity, just external to the inter-tubercular (bicipital)
+groove. When adhesions are present, abduction beyond 10 degrees is
+impossible. Demonstrable effusion is not uncommon, but is disguised by
+the overlying tissues. If left to himself, the patient tends to maintain
+the limb in the "sling position," and resists movements in the direction
+of abduction and rotation. In the treatment of this affection the arm
+should be maintained at a right angle to the body, the arm being rotated
+medially (Codman). When pain does not prevent it, movements of the arm
+and massage are persevered with. In neglected cases, when adhesions have
+formed and the shoulder is fixed, it may be necessary to break down the
+adhesions under an anaesthetic.
+
+The bursa is also liable to infective conditions, such as acute
+rheumatism, gonorrhoea, suppuration, or tubercle. In tuberculous disease
+a large fluctuating swelling may form and acquire the characters of a
+cold abscess (Fig. 115).
+
+The bursa underneath the tendon of the _subscapularis_ muscle when
+inflamed causes alteration in the attitude of the shoulder and
+impairment of its movements.
+
+An adventitious bursa forms over the _acromion_ process in porters and
+others who carry weights on the shoulder, and may be the seat of
+traumatic bursitis.
+
+The bursa under the _tendon of insertion of the biceps_, when the seat
+of disease, is attended with pain and swelling about a finger's breadth
+below the bend of the elbow; there is pain and difficulty in effecting
+the combined movement of flexion and supination, slight limitation of
+extension, and restriction of pronation.
+
+In the lower extremity, a large number of normal and adventitious bursae
+are met with and may be the seat of bursitis. That over the _tuberosity
+of the ischium_, when enlarged as a trade disease, is known as
+"weaver's" or "tailor's bottom." It may form a fluctuating swelling of
+great size, projecting on the buttock and extending down the thigh, and
+causing great inconvenience in sitting (Fig. 116). It sometimes contains
+a number of loose bodies.
+
+There are two bursae over the _great trochanter_, one superficial to, the
+other beneath the aponeurosis of the gluteus maximus; the latter is not
+infrequently infected by tuberculous disease that has spread from the
+trochanter.
+
+The bursa _between the psoas muscle and the capsule of the hip-joint_
+may be the seat of tuberculous disease, and give rise to clinical
+features not unlike those of disease of the hip-joint. The limb is
+flexed, abducted and rotated out; there is a swelling in the upper part
+of Scarpa's triangle, but the movements are not restricted in directions
+which do not entail putting the ilio-psoas muscle on the stretch.
+
+Cartilaginous and partly ossified loose bodies may accumulate in the
+ilio-psoas bursa and distend it, both in a downward direction towards
+the hip-joint, with which it communicates, and upwards, projecting
+towards the abdomen.
+
+The bursa beneath the quadriceps extensor--_subcrural bursa_--usually
+communicates with the knee-joint and shares in its diseases. When shut
+off from the joint it may suffer independently, and when distended with
+fluid forms a horse-shoe swelling above the patella.
+
+In front of the patella and its ligament is the _prepatellar bursa_,
+which may have one, two, or three compartments, usually communicating
+with one another. It is the seat of the affection known as "housemaid's
+knee," which is very common and is sometimes bilateral, and, less
+frequently, of tuberculous disease which usually originates in the
+patella.
+
+[Illustration: FIG. 116.--Great Enlargement of the Ischial Bursa.
+
+(Mr. Scot-Skirving's case.)]
+
+The bursa _between the ligamentum patellae and the tibia_ is rarely the
+seat of disease. When it is, there is pain and tenderness referred to
+the ligament, the patient is unable to extend the limb completely, the
+tuberosity of the tibia is apparently enlarged, and there is a
+fluctuating swelling on either side of the ligament, most marked in the
+extended position of the limb.
+
+Of the numerous bursae in the popliteal space, that _between the
+semi-membranosus and the medial head of the gastrocnemius_ is most
+frequently the seat of disease, which is usually of the nature of a
+simple hydrops, forming a fluctuating egg-or sausage-shaped swelling at
+the medial side of the popliteal space. It is flaccid in the flexed, and
+tense in the extended position. As a rule it causes little
+inconvenience, and may be left alone. Otherwise it should be dissected
+out, and if, as is frequently the case, there is a communication with
+the knee-joint, this should be closed with sutures.
+
+[Illustration: FIG. 117.--Gouty Disease of Bursae in a tailor. The bursal
+tumours were almost entirely composed of urate of soda. (Cf. Fig. 114.)]
+
+An adventitious bursa may form over the _lateral malleolus_, especially
+in tailors, giving rise to the condition known as "tailor's ankle"
+(Fig. 117).
+
+The bursa _between the tendo-calcaneus (Achillis) and the upper part of
+the calcaneus_ may become inflamed--especially as a result of
+post-scarlatinal rheumatism or gonorrhoea. The affection is known as
+Achillo-bursitis. There is severe pain in the region of the insertion of
+the tendo-calcaneus, the movements at the ankle-joint are restricted,
+and the patient may be unable to walk. There is a tender swelling on
+either side of the tendon. When, in spite of palliative treatment, the
+affection persists or relapses, it is best to excise the bursa. The
+tendo-calcaneus is detached from the calcaneus, the bursa dissected out,
+and the tendon replaced. If there is a bony projection from the
+calcaneus, it should be shaved off with the chisel.
+
+The bursa that is sometimes met with on the under aspect of the
+calcaneus--_the subcalcanean bursa_--when inflamed, gives rise to pain
+and tenderness in the sole of the foot. This affection may be associated
+with a spinous projection from the bone, which is capable of being
+recognised in a skiagram. The soft parts of the heel are turned forwards
+as a flap, the bursa is dissected out, and the projection of bone, if
+present, is removed.
+
+The enlargement of adventitious bursae over the head of the first
+metatarsal in hallux valgus; over the tarsus, metatarsus, and digits in
+the different forms of club-foot; over the angular projection in Pott's
+disease of the spine; over the end of the bone in amputation stumps, and
+over hard tumours such as chondroma and osteoma, are described
+elsewhere.
+
+
+
+
+CHAPTER XX
+
+DISEASES OF BONE
+
+
+Anatomy and physiology--Regeneration of bone--Transplantation of bone.
+    DISEASES OF BONE--Definition of terms--Pyogenic diseases:
+    _Acute osteomyelitis and periostitis_; _Chronic and relapsing
+    osteomyelitis_; _Abscess of bone_--Tuberculous disease--Syphilitic
+    disease--Hydatids; Rickets; Osteomalacia--Ostitis deformans of
+    Paget--Osteomyelitis fibrosa--Affections of bones in diseases of
+    the nervous system--Fragilitas ossium--Tumours and cysts of bone.
+
+#Surgical Anatomy.#--During the period of growth, a long bone such as
+the tibia consists of a shaft or _diaphysis_, and two extremities or
+_epiphyses_. So long as growth continues there intervenes between the
+shaft and each of the epiphyses a disc of actively growing
+cartilage--_the epiphysial cartilage_; and at the junction of this
+cartilage with the shaft is a zone of young, vascular, spongy bone known
+as the _metaphysis_ or _epiphysial junction_. The shaft is a cylinder of
+compact bone enclosing the medullary canal, which is filled with yellow
+marrow. The extremities, which include the ossifying junctions, consist
+of spongy bone, the spaces of which are filled with red marrow. The
+articular aspect of the epiphysis is invested with a thick layer of
+hyaline cartilage, known as the _articular cartilage_, which would
+appear to be mainly nourished from the synovia.
+
+The external investment--the _periosteum_--is thick and vascular during
+the period of growth, but becomes thin and less vascular when the
+skeleton has attained maturity. Except where muscles are attached it is
+easily separated from the bone; at the extremities it is intimately
+connected with the epiphysial cartilage and with the epiphysis, and at
+the margin of the latter it becomes continuous with the capsule of the
+adjacent joint. It consists of two layers, an outer fibrous and an inner
+cellular layer; the cells, which are called osteoblasts, are continuous
+with those lining the Haversian canals and the medullary cavity.
+
+The arrangement of the _blood vessels_ determines to some extent the
+incidence of disease in bone. The nutrient artery, after entering the
+medullary canal through a special foramen in the cortex, bifurcates, and
+one main division runs towards each of the extremities, and terminates
+at the ossifying junction in a series of capillary loops projected
+against the epiphysial cartilage. This arrangement favours the lodgment
+of any organisms that may be circulating in the blood, and partly
+accounts for the frequency with which diseases of bacterial origin
+develop in the region of the ossifying junction. The diaphysis is also
+nourished by numerous blood vessels from the periosteum, which penetrate
+the cortex through the Haversian canals and anastomose with those
+derived from the nutrient artery. The epiphyses are nourished by a
+separate system of blood vessels, derived from the arteries which supply
+the adjacent joint. The veins of the marrow are of large calibre and are
+devoid of valves.
+
+The _nerves_ enter the marrow along with the arteries, and, being
+derived from the sympathetic system, are probably chiefly concerned with
+the innervation of the blood vessels, but they are also capable of
+transmitting sensory impulses, as pain is a prominent feature of many
+bone affections.
+
+It has long been believed that _the function of the periosteum_ is to
+form new bone, but this view has been questioned by Sir William Macewen,
+who maintains that its chief function is to limit the formation of new
+bone. His experimental observations appear to show that new bone is
+exclusively formed by the cellular elements or osteoblasts: these are
+found on the surface of the bone, lining the Haversian canals and in the
+marrow. We believe that it will avoid confusion in the study of the
+diseases of bone if the osteoblasts on the surface of the bone are still
+regarded as forming the deeper layer of the periosteum.
+
+The formation of new bone by the osteoblasts may be _defective_ as a
+result of physiological conditions, such as old age and disease of a
+part, and defective formation is often associated with atrophy, or more
+strictly speaking, absorption, of the existing bone, as is well seen in
+the edentulous jaw and in the neck of the femur of a person advanced in
+years. Defective formation associated with atrophy is also illustrated
+in the bones of the lower limbs of persons who are unable to stand or
+walk, and in the distal portion of a bone which is the seat of an
+ununited fracture. The same combination is seen in an exaggerated degree
+in the bones of limbs that are paralysed; in the case of adults, atrophy
+of bone predominates; in children and adolescents, defective formation
+is the more prominent feature, and the affected bones are attenuated,
+smooth on the surface, and abnormally light.
+
+On the other hand, the formation of new bone may be _exaggerated_, the
+osteoblasts being excited to abnormal activity by stimuli of different
+kinds: for example, the secretion of certain glandular organs, such as
+the pituitary and thyreoid; the diluted toxins of certain
+micro-organisms, such as the staphylococcus aureus and the spirochaete of
+syphilis; a condition of hyperaemia, such as that produced artificially
+by the application of a Bier's bandage or that which accompanies a
+chronic leg-ulcer.
+
+The new bone is laid down on the surface, in the Haversian canals, or
+in the cancellous spaces and medullary canal, or in all three
+situations. The new bone on the surface sometimes takes the form of a
+diffuse _encrustation_ of porous or spongy bone as in secondary
+syphilis, sometimes as a uniform increase in the girth of the
+bone--_hyperostosis_, sometimes as a localised heaping up of bone or
+_node_, and sometimes in the form of spicules, spoken of as
+_osteophytes_. When the new bone is laid down in the Haversian canals,
+cancellous spaces and medulla, the bone becomes denser and heavier, and
+is said to be _sclerosed_; in extreme instances this may result in
+obliteration of the medullary canal. Hyperostosis and sclerosis are
+frequently met with in combination, a condition that is well illustrated
+in the femur and tibia in tertiary syphilis; if the subject of this
+condition is confined to bed for several months before his death, the
+sclerosis may be undone, and rarefaction may even proceed beyond the
+normal, the bone becoming lighter and richer in fat, although retaining
+its abnormal girth.
+
+The _function of the epiphysial cartilage_ is to provide for the growth
+of the shaft in length. While all epiphysial cartilages contribute to
+this result, certain of them functionate more actively and for a longer
+period than others. Those at the knee, for example, contribute more to
+the length of limb than do those at the hip or ankle, and they are also
+the last to unite. In the upper limb the more active epiphyses are at
+the shoulder and wrist, and these also are the last to unite.
+
+The activity of the epiphysial cartilage may be modified as a result of
+disease. In rickets, for example, the formation of new bone may take
+place unequally, and may go on more rapidly in one half of the disc than
+in the other, with the result that the axis of the shaft comes to
+deviate from the normal, giving rise to knock-knee or bow-knee. In
+bacterial diseases originating in the marrow, if the epiphysial junction
+is directly involved in the destructive process, its bone-forming
+functions may be retarded or abolished, and the subsequent growth of the
+bone be seriously interfered with. On the other hand, if it is not
+directly involved but is merely influenced by the proximity of an
+infective focus, its bone-forming functions may be stimulated by the
+diluted toxins and the growth of the bone in length exaggerated. In
+paralysed limbs the growth from the epiphyses is usually little short of
+the normal. The result of interference with growth is more injurious in
+the lower than in the upper limb, because, from the functional point of
+view, it is essential that the lower extremities should be approximately
+of equal length. In the forearm or leg, where there are two parallel
+bones, if the growth of one is arrested the continued growth of the
+other results in a deviation of the hand or foot to one side.
+
+In certain diseases, such as rickets and inherited syphilis, and in
+developmental anomalies such as achondroplasia, _dwarfing_ of the
+skeleton results from defective growth of bone at the ossifying
+junctions. Conversely, excessive growth of bone at the ossifying
+junctions results in abnormal height of the skeleton or _giantism_ as a
+result, for example, of increased activity of the pituitary in
+adolescents, and in eunuchs who have been castrated in childhood or
+adolescence; in the latter, union of the epiphyses at the ends of the
+long bones is delayed beyond the usual period at which the skeleton
+attains maturity.
+
+#Regeneration of Bone.#--When bone has been lost or destroyed as a
+result of injury or disease, it is capable of being reproduced, the
+extent to which regeneration takes place varying under different
+conditions. The chief part in the regeneration of bone is played by the
+osteoblasts in the adjacent marrow and in the deeper layer of the
+periosteum. The shaft of a long bone may be reproduced after having been
+destroyed by disease or removed by operation. The flat bones of the
+skull and the bones of the face, which are primarily developed in
+membrane, have little capacity of regeneration; hence, when bone has
+been lost or removed in these situations, there results a permanent
+defect.
+
+Wounds or defects in articular cartilage are repaired by fibrous or
+osseous tissue derived from the subjacent cancellous spaces.
+
+_Transplantation of Bone--Bone-grafting._--Clinical experience is
+conclusive that a portion of bone which has been completely detached
+from its surroundings--for example, a trephine circle, or a flap of bone
+detached with the saw, or the loose fragments in a compound
+fracture--may become, if replaced in position, firmly and permanently
+incorporated with the surrounding bone. Embedded foreign bodies, on the
+other hand, such as ivory pegs or decalcified bone, exhibit, on removal
+after a sufficient interval, evidence of having been eroded, in the
+shape of worm-eaten depressions and perforations, and do not become
+united or fused to the surrounding bone. It follows from this that the
+implanting of living bone is to be preferred to the implanting of dead
+bone or of foreign material. We believe that transplanted living bone
+when placed under favourable conditions survives and becomes
+incorporated with the bone with which it is in contact, and does not
+merely act as a scaffolding. We believe also that the retention of the
+periosteum on the graft is not essential, but, by favouring the
+establishment of vascular connections, it contributes to the survival of
+the graft and the success of the transplantation. Macewen maintains that
+bone grafts "take" better if broken up into small fragments; we regard
+this as unnecessary. Bone grafts yield better functional results when
+they are immovably fixed to the adjacent bone by suture, pegs, or
+plates. As in all grafting procedures, asepsis is essential.
+
+Transplanted bone retains its vitality when embedded in the soft parts,
+but is gradually absorbed and replaced by fibrous tissue.
+
+
+DISEASES OF BONE
+
+The morbid processes met with in bone originate in the same way and lead
+to the same results as do similar processes in other tissues. The
+structural peculiarities of bone, however, and the important changes
+which take place in the skeleton during the period of growth, modify
+certain of the clinical and pathological features.
+
+_Definition of Terms._--Any diseased process that affects the periosteum
+is spoken of as _periostitis_; the term _osteomyelitis_ is employed when
+it is located in the marrow. The term _epiphysitis_ has been applied to
+an inflammatory process in two distinct situations--namely, the
+ossifying nucleus in the epiphysis, and the ossifying junction or
+metaphysis between the epiphysial cartilage and the diaphysis. We shall
+restrict the term to inflammation in the first of these situations.
+Inflammation at the ossifying junction is included under the term
+osteomyelitis.
+
+The term _rarefying ostitis_ is applied to any process that is attended
+with excessive absorption of the framework of a bone, whereby it becomes
+more porous or spongy than it was before, a condition known as
+_osteoporosis_.
+
+The term _caries_ is employed to indicate any diseased process
+associated with crumbling away of the trabecular framework of a bone. It
+may be considered as the equivalent of ulceration or molecular
+destruction in the soft parts. The carious process is preceded by the
+formation of granulation tissue in the marrow or periosteum, which eats
+away and replaces the bone in contact with it. The subsequent
+degeneration and death of the granulation tissue under the necrotic
+influence of bacterial toxins results in disintegration and crumbling
+away of the trabecular framework of the portion of bone affected.
+Clinically, carious bone yields a soft grating sensation under the
+pressure of the probe. The macerated bone presents a rough, eroded
+surface.
+
+The term _dry caries_ (_caries sicca_) is applied to that variety which
+is unattended with suppuration.
+
+_Necrosis_ is the term applied to the death of a tangible portion of
+bone, and the dead portion when separated is called a _sequestrum_. The
+term _exfoliation_ is sometimes employed to indicate the separation or
+throwing off of a superficial sequestrum. The edges and deep surface of
+the sequestrum present a serrated or worm-eaten appearance due to the
+process of erosion by which the dead bone has been separated from the
+living.
+
+
+BACTERIAL DISEASES
+
+The most important diseases in this group are the pyogenic, the
+tuberculous, and the syphilitic.
+
+PYOGENIC DISEASES OF BONE.--These diseases result from
+infection with pyogenic organisms, and two varieties or types are
+recognised according to whether the organisms concerned reach their seat
+of action by way of the blood-stream, or through an infection of the
+soft parts in contact with the bone.
+
+
+INFECTIONS THROUGH THE BLOOD-STREAM
+
+#Diseases caused by the Staphylococcus Aureus.#--As the majority of
+pyogenic diseases are due to infection with the staphylococcus aureus,
+these will be described first.
+
+#Acute osteomyelitis# is a suppurative process beginning in the marrow
+and tending to spread to the periosteum. The disease is common in
+children, but is rare after the skeleton has attained maturity. Boys are
+affected more often than girls, in the proportion of three to one,
+probably because they are more liable to exposure, to injury, and to
+violent exertion.
+
+_Etiology._--Staphylococci gain access to the blood-stream in various
+ways, it may be through the skin or through a mucous surface.
+
+Such conditions as, for example, a blow, some extra exertion such as a
+long walk, or exposure to cold, as in wading, may act as localising
+factors.
+
+The long bones are chiefly affected, and the commonest sites are: either
+end of the tibia and the lower end of the femur; the other bones of the
+skeleton are affected in rare instances.
+
+_Pathology._--The disease commences and is most intense in the marrow of
+the ossifying junction at one end of the diaphysis; it may commence at
+both ends simultaneously--_bipolar osteomyelitis_; or, commencing at one
+end, may spread to the other.
+
+The changes observed are those of intense engorgement of the marrow,
+going on to greenish-yellow purulent infiltration. Where the process is
+most advanced--that is, at the ossifying junction--there are evidences
+of absorption of the framework of the bone; the marrow spaces and
+Haversian canals undergo enlargement and become filled with
+greenish-yellow pus. This rarefaction of the spongy bone is the earliest
+change seen with the X-rays.
+
+The process may remain localised to the ossifying junction, but usually
+spreads along the medullary canal for a varying distance, and also
+extends to the periosteum by way of the enlarged Haversian canals. The
+pus accumulates under the periosteum and lifts it up from the bone. The
+extent of spread in the medullary canal and beneath the periosteum is in
+close correspondence. The periosteum of the diaphysis is easily
+separated--hence the facility with which the pus spreads along the
+shaft; but in the region of the ossifying junction it is raised with
+difficulty because of its intimate connection with the epiphysial
+cartilage. Less frequently there is more than one collection of pus
+under the periosteum, each being derived from a focus of suppuration in
+the subjacent marrow. The pus perforates the periosteum, and makes its
+way to the surface by the easiest anatomical route, and discharges
+externally, forming one or more sinuses through which fresh infection
+may take place. The infection may spread to the adjacent joint, either
+directly through the epiphysis and articular cartilage, or along the
+deep layer of the periosteum and its continuation--the capsular
+ligament. When the epiphysis is intra-articular, as, for example, in the
+head of the femur, the pus when it reaches the surface of the bone
+necessarily erupts directly into the joint.
+
+While the occurrence of purely periosteal suppuration is regarded as
+possible, we are of opinion that the embolic form of staphylococcal
+osteomyelitis always originates in the marrow.
+
+The portion of the diaphysis which has sustained the action of the
+concentrated toxins has its vitality further impaired as a result of the
+stripping of the periosteum and thrombosis of the blood vessels of the
+marrow, so that _necrosis_ of bone is one of the most striking results
+of the disease, and as this takes place rapidly, that is, in a day or
+two, the term _acute necrosis_, formerly applied to the disease, was
+amply justified.
+
+When there is marked rarefaction of the bone at the ossifying junction,
+the epiphysis is liable to be separated--_epiphysiolysis_. The
+separation usually takes place through the young bone of the ossifying
+junction, and the surfaces of the diaphysis and epiphysis are opposed to
+each other by irregular eroded surfaces bathed in pus. The separated
+epiphysis may be kept in place by the periosteum, but when this has been
+detached by the formation of pus beneath it, the epiphysis is liable to
+be displaced by muscular action or by some movement of the limb, or it
+is the diaphysis that is displaced, for example, the lower end of the
+diaphysis of the femur may be projected into the popliteal space.
+
+The epiphysial cartilage usually continues its bone-forming functions,
+but when it has been seriously damaged or displaced, the further growth
+of the bone in length may be interfered with. Sometimes the separated
+and displaced epiphysis dies and constitutes a sequestrum.
+
+The adjacent joint may become filled at an early stage with a serous
+effusion, which may be sterile. When the cocci gain access to the joint,
+the lesion assumes the characters of a purulent arthritis, which, from
+its frequency during the earlier years of life, has been called _the
+acute arthritis of infants_.
+
+Separation of an epiphysis nearly always results in infection and
+destruction of the adjacent joint.
+
+Osteomyelitis is rare in the bones of the carpus and tarsus, and the
+associated joints are usually infected from the outset. In flat bones,
+such as the skull, the scapula, or the ilium, suppuration usually occurs
+on both aspects of the bone as well as in the marrow.
+
+_Clinical Features._--The constitutional symptoms, which are due to the
+associated toxaemia, vary considerably in different cases. In mild cases
+they may be so slight as to escape recognition. In exceptionally severe
+cases the patient may succumb before there are obvious signs of the
+localisation of the staphylococci in the bone marrow. In average cases
+the temperature rises rapidly with a rigor and runs an irregular course
+with morning remissions, there is marked general illness accompanied by
+headache, vomiting, and sometimes delirium.
+
+The local manifestations are pain and tenderness in relation to one of
+the long bones; the pain may be so severe as to prevent sleep and to
+cause the child to cry out. Tenderness on pressure over the bone is the
+most valuable diagnostic sign. At a later stage there is an ill-defined
+swelling in the region of the ossifying junction, with oedema of the
+overlying skin and dilatation of the superficial veins.
+
+The swelling appears earlier and is more definite in superficial bones
+such as the tibia, than in those more deeply placed such as the upper
+end of the femur. It may be less evident to the eye than to the fingers,
+and is best appreciated by gently stroking the bone from the middle of
+its shaft towards the end. The maximum thickening and tenderness usually
+correspond to the junction of the diaphysis with the epiphysis, and the
+swelling tails off gradually along the shaft. As time goes on there is
+redness of the skin, especially over a superficial bone, such as the
+tibia, the swelling becomes softer, and gives evidence of fluctuation.
+This stage may be reached at the end of twenty-four hours, or not for
+some days.
+
+Suppuration spreads towards the surface, until, some days later, the
+skin sloughs and pus escapes, after which the fever usually remits and
+the pain and other symptoms are relieved. The pus may contain blood and
+droplets of fat derived from the marrow, and in some cases minute
+particles of bone are present also. The presence of fat and bony
+particles in the pus confirms the medullary origin of the suppuration.
+
+If an incision is made, the periosteum is found to be raised from the
+bone; the extent of the bare bone will be found to correspond fairly
+accurately with the extent of the lesion in the marrow.
+
+_Local Complications._--The adjacent joint may exhibit symptoms which
+vary from those of a simple effusion to those of a purulent _arthritis_.
+The joint symptoms may count for little in the clinical picture, or, as
+in the case of the hip, may so predominate as to overshadow those of the
+bone lesion from which they originated.
+
+_Separation and displacement of the epiphysis_ usually reveals itself by
+an alteration in the attitude of the limb; it is nearly always
+associated with suppuration in the adjacent joint.
+
+When _pathological fracture_ of the shaft occurs, as it may do, from
+some muscular effort or strain, it is attended with the usual signs of
+fracture.
+
+_Dislocation_ of the adjacent joint has been chiefly observed at the
+hip; it may result from effusion into the joint and stretching of the
+ligaments, or may be the sequel of a purulent arthritis; the signs of
+dislocation are not so obvious as might be expected, but it is attended
+with an alteration in the attitude of the limb, and the displacement of
+the head of the bone is readily shown in a skiagram.
+
+_General Complications._--In some cases a _multiplicity of lesions_ in
+the bones and joints imparts to the disease the features of pyaemia. The
+occurrence of endocarditis, as indicated by alterations in the heart
+sounds and the development of murmurs, may cause widespread infective
+embolism, and metastatic suppurations in the kidneys, heart-wall, and
+lungs, as well as in other bones and joints than those primarily
+affected. The secondary suppurations are liable to be overlooked unless
+sought for, as they are rarely attended with much pain.
+
+In these multiple forms of osteomyelitis the toxaemic symptoms
+predominate; the patient is dull and listless, or he may be restless and
+talkative, or actually delirious. The tongue is dry and coated, the lips
+and teeth are covered with sordes, the motions are loose and offensive,
+and may be passed involuntarily. The temperature is remittent and
+irregular, the pulse small and rapid, and the urine may contain blood
+and albumen. Sometimes the skin shows erythematous and purpuric rashes,
+and the patient may cry out as in meningitis. The post-mortem
+appearances are those of pyaemia.
+
+_Differential Diagnosis._--Acute osteomyelitis is to be diagnosed from
+infections of the soft parts, such as erysipelas and cellulitis, and, in
+the case of the tibia, from erythema nodosum. Tenderness localised to
+the ossifying junction is the most valuable diagnostic sign of
+osteomyelitis.
+
+When there is early and pronounced general intoxication, there is likely
+to be confusion with other acute febrile illnesses, such as scarlet
+fever. In all febrile conditions in children and adolescents, the
+ossifying junctions of the long bones should be examined for areas of
+pain and tenderness.
+
+Osteomyelitis has many features in common with acute articular
+rheumatism, and some authorities believe them to be different forms of
+the same disease (Kocher). In acute rheumatism, however, the joint
+symptoms predominate, there is an absence of suppuration, and the pains
+and temperature yield to salicylates.
+
+The _prognosis_ varies with the type of the disease, with its
+location--the vertebrae, skull, pelvis, and lower jaw being specially
+unfavourable--with the multiplicity of the lesions, and with the
+development of endocarditis and internal metastases.
+
+_Treatment._--This is carried out on the same lines as in other pyogenic
+infections.
+
+In the earliest stages of the disease, the induction of hyperaemia is
+indicated, and should be employed until the diagnosis is definitely
+established, and in the meantime preparations for operation should be
+made. An incision is made down to and through the periosteum, and
+whether pus is found or not, the bone should be opened in the vicinity
+of the ossifying junction by means of a drill, gouge, or trephine. If
+pus is found, the opening in the bone is extended along the shaft as far
+as the periosteum has been separated, and the infected marrow is removed
+with the spoon. The cavity is then lightly packed with rubber dam, or,
+as recommended by Bier, the skin edges are brought together by sutures
+which are loosely tied to afford sufficient space between them for the
+exit of discharge, and the hyperaemic treatment is continued.
+
+When there is widespread suppuration in the marrow, and the shaft is
+extensively bared of periosteum and appears likely to die, it may be
+resected straight away or after an interval of a day or two. Early
+resection of the shaft is also indicated if the opening of the medullary
+canal is not followed by relief of symptoms. In the leg and forearm, the
+unaffected bone maintains the length and contour of the limb; in the
+case of the femur and humerus, extension with weight and pulley along
+with some form of moulded gutter splint is employed with a similar
+object.
+
+Amputation of the limb is reserved for grave cases, in which life is
+endangered by toxaemia, which is attributed to the primary lesion. It may
+be called for later if the limb is likely to be useless, as, for
+example, when the whole shaft of the bone is dead without the formation
+of a new case, when the epiphyses are separated and displaced, and the
+joints are disorganised.
+
+Flat bones, such as the skull or ilium, must be trephined and the pus
+cleared out from both aspects of the bone. In the vertebrae, operative
+interference is usually restricted to opening and draining the
+associated abscess.
+
+#Nature's Effort at Repair.#--_In cases which are left to nature_, and
+in which necrosis of bone has occurred, those portions of the periosteum
+and marrow which have retained their vitality resume their osteogenetic
+functions, often to an exaggerated degree. Where the periosteum has been
+lifted up by an accumulation of pus, or is in contact with bone that is
+dead, it proceeds to form new bone with great activity, so that the dead
+shaft becomes surrounded by a sheath or case of new bone, known as the
+_involucrum_ (Fig. 118). Where the periosteum has been perforated by pus
+making its way to the surface, there are defects or holes in the
+involucrum, called _cloacae_. As these correspond more or less in
+position to the sinuses in the skin, in passing a probe down one of the
+sinuses it usually passes through a cloaca and strikes the dead bone
+lying in the interior. If the periosteum has been extensively
+destroyed, new bone may only be formed in patches, or not at all. The
+dead bone is separated from the living by the agency of granulation
+tissue with its usual complements of phagocytes and osteoclasts, so that
+the sequestrum presents along its margins and on its deep surface a
+pitted, grooved, and worm-eaten appearance, except on the periosteal
+aspect, which is unaltered. Ultimately the dead bone becomes loose and
+lies in a cavity a little larger than itself; the wall of the cavity is
+formed by the new case, lined with granulation tissue. The separation of
+the sequestrum takes place more rapidly in the spongy bone of the
+ossifying junction than in the compact bone of the shaft.
+
+When foci of suppuration have been scattered up and down the medullary
+cavity, and the bone has died in patches, several sequestra may be
+included by the new case; each portion of dead bone is slowly separated,
+and comes to lie in a cavity lined by granulations.
+
+Even at a distance from the actual necrosis there is formation of new
+bone by the marrow; the medullary canal is often obliterated, and the
+bone becomes heavier and denser--sclerosis; and the new bone which is
+deposited on the original shaft results in an increase in the girth of
+the bone--hyperostosis.
+
+[Illustration: FIG. 118.--Shaft of Femur after Acute Osteomyelitis. The
+shaft has undergone extensive necrosis, and a shell of new bone has been
+formed by the periosteum.]
+
+_Pathological fracture_ of the shaft may occur at the site of necrosis,
+when the new case is incapable of resisting the strain put upon it, and
+is most frequently met with in the shaft of the femur. Short of
+fracture, there may be bending or curving of the new case, and this
+results in deformity and shortening of the limb (Fig. 119).
+
+The _extrusion of a sequestrum_ may occur, provided there is a cloaca
+large enough to allow of its escape, but the surgeon has usually to
+interfere by performing the operation of sequestrectomy. Displacement or
+partial extrusion of the dead bone may cause complications, as when a
+sequestrum derived from the trigone of the femur perforates the
+popliteal artery or the cavity of the knee-joint, or a sequestrum of the
+pelvis perforates the wall of the urinary bladder.
+
+The extent to which bone which has been lost is reproduced varies in
+different parts of the skeleton: while the long bones, the scapula, the
+mandible, and other bones which are developed in cartilage are almost
+completely re-formed, bones which are entirely developed in membrane,
+such as the flat bones of the skull and the maxilla, are not reproduced.
+
+[Illustration: FIG. 119.--Femur and Tibia showing results of Acute
+Osteomyelitis affecting Trigone of Femur; sequestrum partly surrounded
+by new case; backward displacement of lower epiphysis and implication of
+knee-joint.]
+
+It may be instructive to describe _the X-ray appearances of a long bone
+that has passed through an attack of acute osteomyelitis_ severe enough
+to have caused necrosis of part of the diaphysis. The shadow of the dead
+bone is seen in the position of the original shaft which it represents;
+it is of the same shape and density as the original shaft, while its
+margins present an irregular contour from the erosion concerned in its
+separation. The sequestrum is separated from the living bone by a clear
+zone which corresponds to the layer of granulations lining the cavity in
+which it lies. This clear zone separating the shadow of the dead bone
+from that of the living bone by which it is surrounded is conclusive
+evidence of a sequestrum. The medullary canal in the vicinity of the
+sequestrum being obliterated, is represented by a shadow of varying
+density, continuous with that of the surrounding bone. The shadow of the
+new case or involucrum with its wavy contour is also in evidence, with
+its openings or cloacae, and is mainly responsible for the increase in
+the diameter of the bone.
+
+The skiagram may also show separation and displacement of the adjacent
+epiphysis and destruction of the articular surfaces or dislocation of
+the joint.
+
+_Sequelae of Acute Suppurative Osteomyelitis._--The commonest sequel is
+the presence of a sequestrum with one or more discharging sinuses; owing
+to the abundant formation of scar tissue these sinuses have rigid edges
+which are usually depressed and adherent to the bone.
+
+_The Recognition and Removal of Sequestra._--So long as there is dead
+bone there will be suppuration from the granulations lining the cavity
+in which it lies, and a discharge of pus from the sinuses, so that the
+mere persistence of discharge after an attack of osteomyelitis, is
+presumptive evidence of the occurrence of necrosis. Where there are one
+or more sinuses, the passage of a probe which strikes bare bone affords
+corroboration of the view that the bone has perished. When the dead bone
+has been separated from the living, the X-rays yield the most exact
+information.
+
+The traditional practice is to wait until the dead bone is entirely
+separated before undertaking an operation for its removal, from fear, on
+the one hand, of leaving portions behind which may keep up the
+discharge, and, on the other, of removing more bone than is necessary.
+This practice need not be adhered to, as by operating at an earlier
+stage healing is greatly hastened. If it is decided to wait for
+separation of the dead bone, drainage should be improved, and the
+infective element combated by the induction of hyperaemia.
+
+_The operation_ for the removal of the dead bone (_sequestrectomy_)
+consists in opening up the periosteum and the new case sufficiently to
+allow of the removal of all the dead bone, including the most minute
+sequestra. The limb having been rendered bloodless, existing sinuses are
+enlarged, but if these are inconveniently situated--for example, in the
+centre of the popliteal space in necrosis of the femoral trigone--it is
+better to make a fresh wound down to the bone on that aspect of the
+limb which affords best access, and which entails the least injury of
+the soft parts. The periosteum, which is thick and easily separable, is
+raised from the new case with an elevator, and with the chisel or gouge
+enough of the new bone is taken away to allow of the removal of the
+sequestrum. Care must be taken not to leave behind any fragment of dead
+bone, as this will interfere with healing, and may determine a relapse
+of suppuration.
+
+The dead bone having been removed, the lining granulations are scraped
+away with a spoon, and the cavity is disinfected.
+
+There are different ways of dealing with a _bone cavity_. It may be
+packed with gauze (impregnated with "bipp" or with iodoform), which is
+changed at intervals until healing takes place from the bottom; it may
+be filled with a flap of bone and periosteum raised from the vicinity,
+or with bone grafts; or the wall of bone on one side of the cavity may
+be chiselled through at its base, so that it can be brought into contact
+with the opposite wall. The method of filling bone cavities devised by
+Mosetig-Moorhof, consists in disinfecting and drying the cavity by a
+current of hot air, and filling it with a mixture of powdered iodoform
+(60 parts) and oil of sesame and spermaceti (each 40 parts), which is
+fluid at a temperature of 112 F.; the soft parts are then brought
+together without drainage. As the cavity fills up with new bone the
+iodoform is gradually absorbed. Iodoform gives a dark shadow with the
+X-rays, so that the process of its absorption can be followed in
+skiagrams taken at intervals.
+
+These procedures may be carried out at the same time as the sequestrum
+is removed, or after an interval. In all of them, asepsis is essential
+for success.
+
+The _deformities_ resulting from osteomyelitis are more marked the
+earlier in life the disease occurs. Even under favourable conditions,
+and with the continuous effort at reconstruction of the bone by Nature's
+method, the return to normal is often far from perfect, and there
+usually remains a variable amount of hyperostosis and sclerosis and
+sometimes curving of the bone. Under less favourable conditions, the
+late results of osteomyelitis may be more serious. _Shortening_ is not
+uncommon from interference with growth at the ossifying junction.
+_Exaggerated growth_ in the length of a bone is rare, and has been
+observed chiefly in the bones of the leg. Where there are two parallel
+bones--as in the leg, for example--the growth of the diseased bone may
+be impaired, and the other continuing its normal growth becomes
+disproportionately long; less frequently the growth of the diseased
+bone is exaggerated, and it becomes the longer of the two. In either
+case, the longer bone becomes curved. An _obliquity_ of the bone may
+result when one half of the epiphysial cartilage is destroyed and the
+other half continues to form bone, giving rise to such deformities as
+knock-knee and club-hand.
+
+Deformity may also result from vicious union of a pathological fracture,
+permanent displacement of an epiphysis, contracture, ankylosis, or
+dislocation of the adjacent joint.
+
+#Relapsing Osteomyelitis.#--As the term indicates, the various forms of
+relapsing osteomyelitis date back to an antecedent attack, and their
+occurrence depends on the capacity of staphylococci to lie latent in the
+marrow.
+
+Relapse may take place within a few months of the original attack, or
+not for many years. Cases are sometimes met with in which relapses recur
+at regular intervals for several years, the tendency, however, being for
+the attacks to become milder as the virulence of the organisms becomes
+more and more attenuated.
+
+_Clinical Features._--Osteomyelitis in a patient over twenty-five is
+nearly always of the relapsing variety. In some cases the bone becomes
+enlarged, with pain and tenderness on pressure; in others there are the
+usual phenomena which attend suppuration, but the pus is slow in coming
+to the surface, and the constitutional symptoms are slight. The pus may
+escape by new channels, or one of the old sinuses may re-open.
+Radiograms usually furnish useful information as to the condition of the
+bone, both as it is altered by the original attack and by the changes
+that attend the relapse of the infective process.
+
+_Treatment._--In cases of thickening of the bone with persistent and
+severe pain, if relief is not afforded by the repeated application of
+blisters, the thickened periosteum should be incised, and the bone
+opened up with the chisel or trephine. In cases attended with
+suppuration, the swelling is incised and drained, and if there is a
+sequestrum, it must be removed.
+
+#Circumscribed Abscess of Bone--"Brodie's Abscess."#--The most important
+form of relapsing osteomyelitis is the circumscribed abscess of bone
+first described by Benjamin Brodie. It is usually met with in young
+adults, but we have met with it in patients over fifty. Several years
+may intervene between the original attack of osteomyelitis and the onset
+of symptoms of abscess.
+
+_Morbid Anatomy._[7]--The abscess is nearly always situated in the
+central axis of the bone in the region of the ossifying junction,
+although cases are occasionally met with in which it lies nearer the
+middle of the shaft. In exceptional cases there is more than one abscess
+(Fig. 120). The tibia is the bone most commonly affected, but the lower
+end of the femur, or either end of the humerus, may be the seat of the
+abscess. In the quiescent stage the lesion is represented by a small
+cavity in the bone, filled with clear serum, and lined by a fibrous
+membrane which is engaged in forming bone. Around the cavity the bone is
+sclerosed, and the medullary canal is obliterated. When the infection
+becomes active, the contents of the cavity are transformed into a
+greenish-yellow pus from which the staphylococcus can be isolated, and
+the cavity is lined by a thin film of granulation tissue which erodes
+the surrounding bone and so causes the abscess to increase in size. If
+the erosion proceeds uniformly, the cavity is spherical or oval; if it
+is more active at some points than others, diverticula or tunnels are
+formed, and one of these may finally erupt through the shell of the bone
+or into an adjacent joint. Small irregular sequestra are occasionally
+found within the abscess cavity. In long-standing cases it is common to
+find extensive obliteration of the medullary canal, and a considerable
+increase in the girth of the bone.
+
+[7] Alexis Thomson, _Edin. Med. Journ._, 1906.
+
+[Illustration: FIG. 120.--Segment of Tibia resected for Brodie's
+Abscess. The specimen shows two separate abscesses in the centre of the
+shaft, the lower one quiescent, the upper one active and increasing in
+size.]
+
+The size of the abscess ranges from that of a cherry to that of a
+walnut, but specimens in museums show that, if left to Nature, the
+abscess may attain much greater dimensions.
+
+The affected bone is not only thicker and heavier than normal, but may
+also be curved or otherwise deformed as a result of the original attack
+of osteomyelitis.
+
+The _clinical features_ are almost exclusively local. Pain, due to
+tension within the abscess, is the dominant symptom. At first it is
+vague and difficult to localise, later it is referred to the interior of
+the bone, and is described as "boring." It is aggravated by use of the
+limb, and there are often, especially during the night, exacerbations in
+which the pain becomes excruciating. In the early stages there are
+periods of days or weeks during which the symptoms abate, but as the
+abscess increases these become shorter, until the patient is hardly ever
+free from pain. Localised tenderness can almost always be elicited by
+percussion, or by compressing the bone between the fingers and thumb.
+The pain induced by the traction of muscles attached to the bone, or by
+the weight of the body, may interfere with the function of the limb, and
+in the lower extremity cause a limp in walking. The limb may be disabled
+from _involvement of the adjacent joint_, in which there may be an
+intermittent hydrops which comes and goes coincidently with
+exacerbations of pain; or the abscess may perforate the joint and set up
+an acute arthritis.
+
+The _diagnosis_ of Brodie's abscess from other affections met with at
+the ends of long bones, and particularly from tuberculosis, syphilis,
+and new growths, is made by a consideration of the previous history,
+especially with reference to an antecedent attack of osteomyelitis. When
+the adjacent joint is implicated, the surgeon may be misled by the
+patient referring all the symptoms to the joint.
+
+The X-ray picture is usually diagnostic chiefly because all the lesions
+which are liable to be confused with Brodie's abscess--gumma, tubercle,
+myeloma, chondroma, and sarcoma--give a well-marked central clear area;
+the sclerosis around Brodie's abscess gives a dense shadow in which the
+central clear area is either not seen at all or only faintly (Fig. 121).
+
+_Treatment._--If an abscess is suspected, there should be no hesitation
+in exploring the interior of the bone. It is exposed by a suitable
+incision; the periosteum is reflected and the bone is opened up by a
+trephine or chisel, and the presence of an abscess may be at once
+indicated by the escape of pus. If, owing to the small size of the
+abscess or the density of the bone surrounding it, the pus is not
+reached by this procedure, the bone should be drilled in different
+directions.
+
+[Illustration: FIG. 121.--Radiogram of Brodie's Abscess in Lower End of
+Tibia.]
+
+#Other Forms of Acute Osteomyelitis.#--Among the less severe forms of
+osteomyelitis resulting from the action of attenuated organisms are the
+_serous_ variety, in which an effusion of serous fluid forms under the
+periosteum; and _growth fever_, in which the child complains of vague
+evanescent pains (growing pains), and of feeling tired and disinclined
+to play; there may be some rise of temperature in the evening.
+
+Infection with the _staphylococcus albus_, the _streptococcus_, or the
+_pneumococcus_ also causes a mild form of osteomyelitis which may go on
+to suppuration.
+
+_Necrosis without suppuration_, described by Paget under the name "quiet
+necrosis," is a rare disease, and would appear to be associated with an
+attenuated form of staphylococcal infection (Tavel). It occurs in
+adults, being met with up to the age of fifty or sixty, and is
+characterised by the insidious development of a swelling which involves
+a considerable extent of a long bone. The pain varies in intensity, and
+may be continuous or intermittent, and there is tenderness on pressure.
+The shaft is increased in girth as a result of its being surrounded by a
+new case of bone. The resemblance to sarcoma may be very close, but the
+swelling is not as defined as in sarcoma, nor does it ever assume the
+characteristic "leg of mutton" shape. In both diseases there is a
+tendency to pathological fracture. It is difficult also in the absence
+of skiagrams to differentiate the condition from syphilitic and from
+tuberculous disease. If the diagnosis is not established after
+examination with the X-rays, an exploratory incision should be made; if
+dead bone is found, it is removed.
+
+In typhoid fever the bone marrow is liable to be invaded by _the typhoid
+bacillus_, which may set up osteomyelitis soon after its lodgment, or it
+may lie latent for a considerable period before doing so. The lesions
+may be single or multiple, they involve the marrow or the periosteum or
+both, and they may or may not be attended with suppuration. They are
+most commonly met with in the tibia and in the ribs at the
+costo-chondral junctions.
+
+The bone lesions usually occur during the seventh or eighth week of the
+fever, but have been known to occur much later. The chief complaint is
+of vague pains, at first referred to several bones, later becoming
+localised in one; they are aggravated by movement, or by handling the
+bone, and are worst at night. There is redness and oedema of the
+overlying soft parts, and swelling with vague fluctuation, and on
+incision there escapes a yellow creamy pus, or a brown syrupy fluid
+containing the typhoid bacillus in pure culture. Necrosis is
+exceptional.
+
+When the abscess develops slowly, the condition resembles tuberculous
+disease, from which it may be diagnosed by the history of typhoid fever,
+and by obtaining a positive Widal reaction.
+
+The prognosis is favourable, but recovery is apt to be slow, and relapse
+is not uncommon.
+
+It is usually sufficient to incise the periosteum, but when the disease
+occurs in a rib it may be necessary to resect a portion of bone.
+
+#Pyogenic Osteomyelitis due to Spread of Infection from the Soft
+Parts.#--There still remain those forms of osteomyelitis which result
+from infection through a wound involving the bone--for example, compound
+fractures, gun-shot injuries, osteotomies, amputations, resections, or
+operations for un-united fracture. In all of these the marrow is exposed
+to infection by such organisms as are present in the wound. A similar
+form of osteomyelitis may occur apart from a wound--for example,
+infection may spread to the jaws from lesions of the mouth; to the
+skull, from lesions of the scalp or of the cranial bones
+themselves--such as a syphilitic gumma or a sarcoma which has fungated
+externally; or to the petrous temporal, from suppuration in the middle
+ear.
+
+The most common is an osteomyelitis commencing in the marrow exposed in
+a wound infected with pyogenic organisms. In amputation stumps,
+fungating granulations protrude from the sawn end of the bone, and if
+necrosis takes place, the sequestrum is annular, affecting the
+cross-section of the bone at the saw-line; or tubular, extending up the
+shaft, and tapering off above. The periosteum is more easily detached,
+is thicker than normal, and is actively engaged in forming bone. In the
+macerated specimen, the new bone presents a characteristic coral-like
+appearance, and may be perforated by cloacae (Fig. 122).
+
+[Illustration: FIG. 122.--Tubular Sequestrum resulting from Septic
+Osteomyelitis in Amputation Stump.]
+
+Like other pyogenic infections, it may terminate in pyaemia, as a result
+of septic phlebitis in the marrow.
+
+The _clinical features_ of osteomyelitis in _an amputation stump_ are
+those of ordinary pyogenic infection; the involvement of the bone may be
+suspected from the clinical course, the absence of improvement from
+measures directed towards overcoming the sepsis in the soft parts, and
+the persistence of suppuration in spite of free drainage, but it is not
+recognised unless the bone is exposed by opening up the stump or the
+changes in the bone are shown by the X-rays. The first change is due to
+the deposit of new bone on the periosteal surface; later, there is the
+shadow of the sequestrum.
+
+Healing does not take place until the sequestrum is extruded or removed
+by operation.
+
+_In compound fractures_, if a fragment dies and forms a sequestrum, it
+is apt to be walled in by new bone; the sinuses continue to discharge
+until the sequestrum is removed. Even after healing has taken place,
+relapse is liable to occur, especially in gun-shot injuries. Months or
+years afterwards, the bone may become painful and tender. The symptoms
+may subside under rest and elevation of the limb and the application of
+a compress, or an abscess forms and bursts with comparatively little
+suffering. The contents may be clear yellow serum or watery pus;
+sometimes a small spicule of bone is discharged. Valuable information,
+both for diagnosis and treatment, is afforded by skiagrams.
+
+[Illustration: FIG. 123.--New Periosteal Bone on surface of Femur from
+Amputation Stump. Osteomyelitis supervened on the amputation, and
+resulted in necrosis at the sawn section of the bone. (Anatomical
+Museum, University of Edinburgh.)]
+
+
+TUBERCULOUS DISEASE
+
+The tuberculous diseases of bone result from infection of the marrow or
+periosteum by tubercle bacilli conveyed through the arteries; it is
+exceedingly rare for tubercle to appear in bone as a primary infection,
+the bacilli being usually derived from some pre-existing focus in the
+bronchial glands or elsewhere. According to the observations of John
+Fraser, 60 per cent. of the cases of bone and joint tubercle in children
+are due to the bovine bacillus, 37 per cent. to the human variety, and
+in 3 per cent. both types are present.
+
+Tuberculous disease in bone is characterised by its insidious onset and
+slow progress, and by the frequency with which it is associated with
+disease of the adjacent joint.
+
+#Periosteal tuberculosis# is met with in the ribs, sternum, vertebral
+column, skull, and less frequently in the long bones of the limbs. It
+may originate in the periosteum, or may spread thence from the marrow,
+or from synovial membrane.
+
+_In superficial bones_, such as the sternum, the formation of
+tuberculous granulation tissue in the deeper layer of the periosteum,
+and its subsequent caseation and liquefaction, is attended by the
+insidious development of a doughy swelling, which is not as a rule
+painful, although tender on pressure. While the swelling often remains
+quiescent for some time, it tends to increase in size, to become boggy
+or fluctuating, and to assume the characters of a cold abscess. The pus
+perforates the fibrous layer of the periosteum, invading and infecting
+the overlying soft parts, its spread being influenced by the anatomical
+arrangement of the tissues. The size of the abscess affords no
+indication of the extent of the bone lesion from which it originates. As
+the abscess reaches the surface, the skin becomes of a dusky red or
+livid colour, is gradually thinned out, and finally sloughs, forming a
+sinus. A probe passed into the sinus strikes carious bone. Small
+sequestra may be found embedded in the granulation tissue. The sinus
+persists as long as any active tubercle remains in the tissues, and is
+apt to form an avenue for pyogenic infection.
+
+_In deeply seated bones_, such as the upper end of the femur, the
+formation of a cold abscess in the soft parts is often the first
+evidence of the disease.
+
+_Diagnosis._--Before the stage of cold abscess is reached, the localised
+swelling is to be differentiated from a gumma, from chronic forms of
+staphylococcal osteomyelitis, from enlarged bursa or ganglion, from
+sub-periosteal lipoma, and from sarcoma. Most difficulty is met with in
+relation to periosteal sarcoma, which must be differentiated either by
+the X-ray appearances or by an exploratory incision.
+
+_X-ray appearances in periosteal tubercle_: the surface of the cortical
+bone in the area of disease is roughened and irregular by erosion, and
+in the vicinity there may be a deposit of new bone on the surface,
+particularly if a sinus is present and mixed infection has occurred; in
+_syphilis_ the shadow of the bone is denser as a result of sclerosis,
+and there is usually more new bone on the surface--hyperostosis; in
+_periosteal sarcoma_ there is greater erosion and consequently greater
+irregularity in the contour of the cortical bone, and frequently there
+is evidence of formation of bone in the form of characteristic spicules
+projecting from the surface at a right angle.
+
+The early recognition of periosteal lesions in the articular ends of
+bones is of importance, as the disease, if left to itself, is liable to
+spread to the adjacent joint.
+
+The _treatment_ is that of tuberculous lesions in general; if
+conservative measures fail, the choice lies between the injection of
+iodoform, and removal of the infected tissues with the sharp spoon. In
+the ribs it is more satisfactory to remove the diseased portion of bone
+along with the wall of the associated abscess or sinus. If all the
+tubercle has been removed and there is no pyogenic infection, the wound
+is stitched up with the object of obtaining primary union; otherwise it
+is treated by the open method.
+
+#Tuberculous Osteomyelitis.#--Tuberculous lesions in the marrow occur as
+isolated or as multiple foci of granulation tissue, which replace the
+marrow and erode the trabeculae of bone in the vicinity (Fig. 124). The
+individual focus varies in size from a pea to a walnut. The changes that
+ensue resemble in character those in other tissues, and the extent of
+the destruction varies according to the way in which the tubercle
+bacillus and the marrow interact upon one another. The granulation
+tissue may undergo caseation and liquefaction, or may become
+encapsulated by fibrous tissue--"encysted tubercle."
+
+[Illustration: FIG. 124.--Tuberculous Osteomyelitis of Os Magnum,
+excised from a boy aet. 8. Note well-defined caseous focus, with several
+minute foci in surrounding marrow.]
+
+Sometimes the tuberculous granulation tissue spreads in the marrow,
+assuming the characters of a diffuse infiltration--diffuse tuberculous
+osteomyelitis. The trabecular framework of the bone undergoes erosion
+and absorption--rarefying ostitis--and either disappears altogether or
+only irregular fragments or sequestra of microscopic dimensions remain
+in the area affected. Less frequently the trabecular framework is added
+to by the formation of new bone, resulting in a remarkable degree of
+sclerosis, and if, following upon this, there is caseation of the
+tubercle and death of the affected portion of bone, there results a
+sequestrum often of considerable size and characteristic shape, which,
+because of the sclerosis and surrounding endarteritis, is exceedingly
+slow in separating. When the sequestrum involves an articular surface it
+is often wedge-shaped; in other situations it is rounded or truncated
+and lies in the long axis of the medullary canal (Fig. 125). Finally,
+the sequestrum lies loose in a cavity lined by tuberculous granulation
+tissue, and is readily identified in a radiogram. This type of sclerosis
+preceding death of the bone is highly characteristic of tuberculosis.
+
+[Illustration: FIG. 125.--Tuberculous Disease of Child's Tibia,
+showing sequestrum in medullary cavity, and increase in girth from
+excess of new bone.]
+
+_Clinical Features._--As a rule, it is only in superficially placed
+bones, such as the tibia, ulna, clavicle, mandible, or phalanges, that
+tuberculous disease in the marrow gives rise to signs sufficiently
+definite to allow of its clinical recognition. In the vertebrae, or in
+the bones of deeply seated joints, such as the hip or shoulder, the
+existence of tuberculous lesions in the marrow can only be inferred from
+indirect signs--such, for example, as rigidity and curvature in the case
+of the spine, or from the symptoms of grave and persistent joint-disease
+in the case of the hip or shoulder.
+
+With few exceptions, tuberculous disease in the interior of a bone does
+not reveal its presence until by extension it reaches one or other of
+the surfaces of the bone. In the shaft of a long bone its eruption on
+the periosteal surface is usually followed by the formation of a cold
+abscess in the overlying soft parts. When situated in the articular ends
+of bones, the disease more often erupts in relation to the reflection of
+the synovial membrane or directly on the articular surface--in either
+case giving rise to disease of the joint (Fig. 156).
+
+[Illustration: Fig. 126.--Diffuse Tuberculous Osteomyelitis of Right
+Tibia.
+
+(Photograph lent by Sir H. J. Stiles.)]
+
+#Diffuse Tuberculous Osteomyelitis in the shaft of a long bone# is
+comparatively rare, and has been observed chiefly in the tibia and the
+ulna in children (Fig. 126). It commences at the growing extremity of
+the diaphysis, and spreads along the medulla to a variable extent; it is
+attended by the formation of vascular and porous bone on the surface,
+which causes thickening of the diaphysis; this is most marked at the
+ossifying junction and tapers off along the shaft. The infection not
+only spreads along the medulla, but it invades the spongy bone
+surrounding this, and then the cortical bone, and is only prevented from
+reaching the soft parts by the new bone formed by the periosteum. The
+bone is replaced by granulation tissue, and disappears, or part of it
+may become sclerosed and in time form a sequestrum. In the macerated
+specimen, the sequestrum appears small in proportion to the large cavity
+in which it lies. All these changes are revealed in a good skiagram,
+which not only confirms the diagnosis, but, in many instances,
+demonstrates the extent of the disease, the presence or absence of a
+sequestrum, and the amount of new bone on the surface. Finally the
+periosteum gives way, and an abscess forms in the soft parts; and if
+left to itself ruptures externally, leaving a sinus. The most
+satisfactory _treatment_ is to resect sub-periosteally the diseased
+portion of the diaphysis.
+
+_In cancellous bones, such as those of the tarsus_, there is a similar
+caseous infiltration in the marrow, and this may be attended with the
+formation of a sequestrum either in the interior of the bone or
+involving its outer shell, as shown in Fig. 127. The situation and
+extent of the disease are shown in X-ray photographs. After the
+tuberculous granulation tissue erupts through the cortex of the bone, it
+gives rise to a cold abscess or infects adjacent joints or tendon
+sheaths.
+
+[Illustration: FIG. 127.--Advanced Tuberculous Disease in region of
+Ankle. The ankle-joint is ankylosed, and there is a large sequestrum in
+the calcaneus.
+
+(Specimen in Anatomical Museum, University of Edinburgh.)]
+
+If an exact diagnosis is made at an early stage of the disease--and this
+is often possible with the aid of X-rays--the affected bone is excised
+sub-periosteally or its interior is cleared out with the sharp spoon and
+gouge, the latter procedure being preferred in the case of the
+_calcaneus_ to conserve the stability of the heel. When several bones
+and joints are simultaneously affected, and there are sinuses with
+mixed infection, amputation is usually indicated, especially in adults.
+
+#Tuberculous dactylitis# is the name applied to a diffuse form of the
+disease as it affects the phalanges, metacarpal or metatarsal bones. The
+lesion presents, on a small scale, all the anatomical changes that have
+been described as occurring in the medulla of the tibia or ulna, and
+they are easily followed in skiagrams. A periosteal type of dactylitis
+is also met with.
+
+The _clinical features_ are those of a spindle-shaped swelling of a
+finger or toe, indolent, painless, and interfering but little with the
+function of the digit. Recovery may eventually occur without
+suppuration, but it is common to have the formation of a cold abscess,
+which bursts and forms one or more sinuses. It may be difficult to
+differentiate tuberculous dactylitis from the enlargement of the
+phalanges in inherited syphilis (syphilitic dactylitis), especially when
+the tuberculous lesion occurs in a child who is the subject of inherited
+syphilis.
+
+[Illustration: FIG. 128.--Tuberculous Dactylitis.]
+
+In the syphilitic lesion, skiagrams usually show a more abundant
+formation of new bone, but in many cases the doubt is only cleared up by
+observing the results of the tuberculin test or the effects of
+anti-syphilitic treatment.
+
+Sarcoma of a phalanx or metacarpal bone may closely resemble a
+dactylitis both clinically and in skiagrams, but it is rare.
+
+_Treatment._--Recovery under conservative measures is not uncommon, and
+the functional results are usually better than those following upon
+operative treatment, although in either case the affected finger is
+liable to be dwarfed (Fig. 129). The finger should be immobilised in a
+splint, and a Bier's bandage applied to the upper arm. Operative
+interference is indicated if a cold abscess develops, if there is a
+persistent sinus, or if a sequestrum has formed, a point upon which
+information is obtained by examination with the X-rays. When a toe is
+affected, amputation is the best treatment, but in the case of a finger
+it is rarely called for. In the case of a metacarpal or metatarsal bone,
+sub-periosteal resection is the procedure of choice, saving the
+articular ends if possible.
+
+[Illustration: FIG. 129.--Shortening of Middle Finger of Adult, the
+result of Tuberculous Dactylitis in childhood.]
+
+
+SYPHILITIC DISEASE
+
+Syphilitic affections of bone may be met with at any period of the
+disease, but the graver forms occur in the tertiary stage of acquired
+and inherited syphilis. The virus is carried by the blood-stream to all
+parts of the skeleton, but the local development of the disease appears
+to be influenced by a predisposition on the part of individual bones.
+
+Syphilitic diseases of bone are much less common in practice than those
+due to pyogenic and tuberculous infectious, and they show a marked
+predilection for the tibia, sternum, and skull. They differ from
+tuberculous affections in the frequency with which they attack the
+shafts of bones rather than the articular ends, and in the comparative
+rarity of joint complications.
+
+_Evanescent periostitis_ is met with in acquired syphilis during the
+period of the early skin eruptions. The patient complains, especially at
+night, of pains over the frontal bone, ribs, sternum, tibiae, or ulnae.
+Localised tenderness is elicited on pressure, and there is slight
+swelling, which, however, rarely amounts to what may be described as a
+_periosteal node_.
+
+In the later stages of acquired syphilis, _gummatous periostitis and
+osteomyelitis_ occur, and are characterised by the formation in the
+periosteum and marrow of circumscribed gummata or of a diffuse gummatous
+infiltration. The framework of the bone is rarefied in the area
+immediately involved, and sclerosed in the parts beyond. If the
+gummatous tissue degenerates and breaks down, and especially if the
+overlying skin is perforated and septic infection is superadded, the
+bone disintegrates and exhibits the condition known as _syphilitic
+caries_; sometimes a portion of bone has its blood supply so far
+interfered with that it dies--_syphilitic necrosis_. Syphilitic
+sequestra are heavier and denser than normal bone, because sclerosis
+usually precedes death of the bone. The bones especially affected by
+gummatous disease are: the skull, the septum of the nose, the nasal
+bones, palate, sternum, femur, tibia, and the bones of the forearm.
+
+_In the bones of the skull_, gummata may form in the peri-cranium,
+diploe, or dura mater. An isolated gumma forms a firm elastic swelling,
+shading off into the surroundings. In the macerated bone there is a
+depression or an actual perforation of the calvaria; multiple gummata
+tend to fuse with one another at their margins, giving the appearance of
+a combination of circles: these sometimes surround an area of bone and
+cut it off from its blood supply (Fig. 130). If the overlying skin is
+destroyed and septic infection superadded, such an isolated area of bone
+is apt to die and furnish a sequestrum; the separation of the dead bone
+is extremely slow, partly from the want of vascularity in the sclerosed
+bone round about, and partly from the density of the sequestrum. In
+exceptional cases the necrosis involves the entire vertical plate of the
+frontal bone. Pus is formed between the bone and the dura (suppurative
+pachymeningitis), and this may be followed by cerebral abscess or by
+pyaemia. Gummatous disease in the wall of the orbit may cause
+displacement of the eye and paralysis of the ocular muscles.
+
+[Illustration: FIG. 130.--Syphilitic Disease of Skull, showing a
+sequestrum in process of separation.]
+
+On the inner surface of the skull, the formation of gummatous tissue may
+cause pressure on the brain and give rise to intense pain in the head,
+Jacksonian epilepsy, or paralysis, the symptoms varying with the seat
+and extent of the disease. The cranial nerves may be pressed upon at the
+base, especially at their points of exit, and this gives rise to
+symptoms of irritation or paralysis in the area of distribution of the
+nerves affected.
+
+_In the septum of the nose, the nasal bones, and the hard palate_,
+gummatous disease causes ulceration, which, beginning in the mucous
+membrane, spreads to the bones, and being complicated with septic
+infection leads to caries and necrosis. In the nose, the disease is
+attended with stinking discharge (ozoena), the extrusion of portions of
+dead bone, and subsequently with deformity characterised by loss of the
+bridge of the nose; in the palate, it is common to have a perforation,
+so that the air escapes through the nose in speaking, giving to the
+voice a characteristic nasal tone.
+
+_Syphilitic disease of the tibia_ may be taken as the type of the
+affection as it occurs _in the long bones_. Gummatous disease in the
+periosteum may be localised and result in the formation of a
+well-defined node, or the whole shaft may become the seat of an
+irregular nodular enlargement (Fig. 132). If the bone is macerated, it
+is found to be heavier and bulkier than normal; there is diffuse
+sclerosis with obliteration of the medullary canal, and the surface is
+uneven from heaping up of new bone--hyperostosis (Fig. 131). If a
+periosteal gumma breaks down and invades the skin, a syphilitic ulcer is
+formed with carious bone at the bottom. A central gumma may eat away the
+surrounding bone to such an extent that the shaft undergoes pathological
+fracture. In the rare cases in which it attacks the articular end of a
+long bone, gummatous disease may implicate the adjacent joint and give
+rise to syphilitic arthritis.
+
+[Illustration: FIG. 131.--Syphilitic Hyperostosis and Sclerosis of
+Tibia, on section and on surface view.]
+
+_Clinical Features._--There is severe boring pain--as if a gimlet were
+being driven into the bone. It is worst at night, preventing sleep, and
+has been ascribed to compression of the nerves in the narrowed Haversian
+canals.
+
+The _periosteal gumma_ appears as a smooth, circumscribed swelling which
+is soft and elastic in the centre and firm at the margins, and shades
+off into the surrounding bone. The gumma may be completely absorbed or
+it may give place to a hard node. In some cases the gumma softens in the
+centre, the skin becomes adherent, thin, and red, and finally gives way.
+The opening in the skin persists as a sinus, or develops into a typical
+ulcer with irregular, crescentic margins; in either case a probe reveals
+the presence of carious bone or of a sequestrum. The health may be
+impaired as a result of mixed infection, and the absorption of toxins
+and waxy degeneration in the viscera may ultimately be induced.
+
+A _central gumma_ in a long bone may not reveal its presence until it
+erupts through the shell and reaches the periosteal surface or invades
+an adjacent joint. Sometimes the first manifestation is a fracture of
+the bone produced by slight violence.
+
+In radiograms the appearance of syphilitic bones is usually
+characteristic. When there is hyperostosis and sclerosis, the shaft
+appears denser and broader than normal, and the contour is uneven or
+wavy. When there is a central gumma, the shadow is interrupted by a
+rounded clear area, like that of a chondroma or myeloma, but there is
+sclerosis round about.
+
+_Diagnosis._--The conditions most liable to be mistaken for syphilitic
+disease of bone are chronic staphylococcal osteomyelitis, tuberculosis,
+and sarcoma; and the diagnosis is to be made by the history and progress
+of the disease, the result of examination with the X-rays, and the
+results of specific tests and treatment.
+
+_Treatment._--The general health is to be improved by open air, by
+nourishing food, and by the administration of cod-liver oil, iron, and
+arsenic. Anti-syphilitic remedies should be given, and if they are
+administered before there is any destruction of tissue, the benefit
+derived from them is usually marked.
+
+Radiograms show the rapid absorption of the new bone both on the surface
+and in the marrow, and are of value in establishing the therapeutic
+diagnosis.
+
+In certain cases, and particularly when there are destructive changes in
+the bone complicated with pyogenic infection, specific remedies have
+little effect. In cases of persistent or relapsing gummatous disease
+with ulceration of skin, it is often necessary to remove the diseased
+soft parts with the sharp spoon and scissors, and to gouge or chisel
+away the unhealthy bone, on the same lines as in tuberculous disease.
+When hyperostosis and sclerosis of the bone is attended with severe pain
+which does not yield to blistering, the periosteum may be incised and
+the sclerosed bone perforated with a drill or trephine.
+
+#Lesions of Bone in Inherited Syphilis.#--_Craniotabes_, in which the
+flat bones of the skull undergo absorption in patches, was formerly
+regarded as syphilitic, but it is now known to result from prolonged
+malnutrition from any cause. _Bossing of the skull_ resulting in the
+formation of Parrot's nodes is also being withdrawn from the category of
+syphilitic affections. The lesions in infancy--epiphysitis, bossing of
+the skull, and craniotabes--have been referred to in the chapter on
+inherited syphilis.
+
+_Epiphysitis or Syphilitic Perichondritis._--The first of these terms is
+misleading, because the lesion involves the ossifying junction and the
+shaft of the bone, and the epiphysis only indirectly. The young bone is
+replaced by granulation tissue, so that large clear areas are seen with
+the X-rays. The symptoms are referred to the joint, because it is there
+that the muscles are inserted and drag on the perichondrium when
+movement occurs; swelling is most marked in the vicinity of the joint,
+and it may be added to by effusion into the synovial cavity. The baby,
+usually under six months, is noticed to be feverish and fretful and to
+cry when touched. The mother discovers that the pain is caused by moving
+a particular limb, usually the arm, as the humerus, radius, and ulna are
+the bones most commonly affected; the limb, moreover, hangs useless at
+the side as if paralysed, and the condition was formerly described as
+_syphilitic pseudo-paralysis_.
+
+The lesions met with later correspond to those of the tertiary period of
+the acquired disease, but as they affect bones which are still actively
+growing, the effects are more striking. Gummatous disease may come and
+go over periods of many years, with the result that the external
+appearance and architectural arrangement of a long bone come to be
+profoundly altered. In the tibia, for example, the shaft is bowed
+forward in a gentle curve, which is compared to the curve of a
+sabre--"sabre-blade" deformity (Fig. 132). The diffuse thickening all
+round the bone obscures the sharp margins so that the bone becomes
+circular in section and the anterior and mesial edges are blunted, and
+the comparison to a cucumber is deserved. In some cases the tibia is
+actually increased in length as well as in girth.
+
+[Illustration: FIG. 132.--Sabre-blade Deformity of Left Tibia in
+Inherited Syphilis.
+
+(From a photograph lent by Sir George T. Beatson.)]
+
+The contrast between the grossly enlarged and misshapen tibia and the
+normal or even attenuated fibula is a striking one.
+
+_Treatment_ is carried out on lines similar to those recommended in the
+acquired disease. When curving of the tibia causes disability in
+walking, the bone may be straightened by a cuneiform resection.
+
+_Syphilitic dactylitis_ is met with chiefly in children. It may affect
+any of the fingers or toes, but is commonest in the first phalanx of the
+index-finger or of the thumb. Several fingers may be attacked at the
+same time or in succession. The lesion consists in a gummatous
+infiltration of the soft parts surrounding the phalanx, or a gummatous
+osteomyelitis, but there is practically no tendency to break down and
+discharge, or to the formation of a sequestrum as is so common in
+tuberculous dactylitis.
+
+The finger becomes the seat of a swelling, which is more evident on the
+dorsal aspect, and, according to the distribution and extent of the
+disease, it is acorn-shaped, fusiform, or cylindrical. It is firm and
+elastic, and usually painless. The movements are impaired, especially if
+the joints are involved. In its early stages the disease is amenable to
+anti-syphilitic treatment, and complete recovery is the rule.
+
+
+HYDATID DISEASE
+
+This rare disease results from the lodgment of the embryos of the taenia
+echinoccus, which are conveyed to the marrow by the blood-stream. The
+cysts are small, usually about the size of a pin-head, and they are
+present in enormous numbers scattered throughout the marrow. The parts
+of the skeleton most often affected are the articular ends of the long
+bones, the bodies of the vertebrae, and the pelvis.
+
+As the cysts increase in number and in size, the framework of the bone
+is gradually absorbed, and there result excavations or cavities. The
+marrow and spongy bone first disappear, the compact tissue then becomes
+thin, and pathological fracture may result. The bone becomes expanded,
+and the cysts may escape through perforations into the surrounding
+cellular tissue, and when thus freed from confinement may attain
+considerable dimensions. Suppuration from superadded pyogenic infection
+may be attended with extensive necrosis, and lead to disorganisation of
+the adjacent joint.
+
+_Clinical Features._--The patient complains of deep-seated pains. In
+superficial bones, such as the tibia, there is enlargement, and it may
+be possible to recognise egg-shell crackling, or unequal consistence of
+the bone, which is hard in some parts, and doughy and elastic in others.
+The disease may pursue an indolent course during months or years until
+some complication occurs, such as suppuration or fracture. With the
+occurrence of suppuration the disease becomes more active, and abscesses
+may form in the soft parts and in the adjacent joint. In the vertebral
+column, hydatids give rise to angular deformity and paraplegia. In the
+pelvis, there is usually great enlargement of the bones, and when
+suppuration occurs it is apt to infect the hip-joint and to terminate
+fatally.
+
+Examination with the X-rays shows the characteristic excavations of the
+bone caused by the cysts. The disease is liable to be mistaken for
+central tumour, gumma, tuberculosis, or abscess of bone.
+
+The _treatment_ consists in thorough eradication of the parasite by
+operation. The bone is laid open and scraped or resected according to
+the extent of the disease, and the raw surfaces swabbed with 1 per cent.
+formalin. In advanced cases complicated with spontaneous fracture or
+with suppuration, amputation affords the best chance of recovery.
+
+The lesions in the bones resulting from _actinomycosis_ and from
+_mycetoma_, have been described with these diseases.
+
+
+CONSTITUTIONAL DISEASES ATTENDED WITH LESIONS IN THE BONES
+
+These include rickets, scurvy-rickets, osteomalacia, ostitis deformans,
+osteomyelitis fibrosa, fragilitas ossium, and diseases of the nervous
+system.
+
+
+RICKETS
+
+Rickets or rachitis is a constitutional disease associated with
+disturbance of nutrition, and attended with changes in the skeleton.
+The disease is most common and most severe among the children of the
+poorer classes in large cities, who are improperly fed and are brought
+up in unhealthy surroundings. There is evidence that the most important
+factors in the causation of rickets are ill-health of the mother during
+pregnancy, and the administration to the child after its birth of food
+which is defective in animal fat, proteids, and salts of lime, or which
+contains these in such a form that they are not readily assimilated. The
+occurrence of the disease is favoured, and its features are aggravated,
+by imperfect oxygenation of the blood as the result of a deficiency of
+fresh air and sunlight, want of exercise, and by other conditions which
+prevail in the slums of large towns.
+
+_Pathological Anatomy._--The most striking feature is the softness
+(malacia) of the bones, due to excessive absorption of osseous tissue,
+and the formation of an imperfectly calcified tissue at the sites of
+ossification. The affected bones lose their rigidity, so that they are
+bent under the weight of the body, by the traction of muscles, and by
+other mechanical forces.
+
+The _periosteum_ is thick and vascular, and when detached carries with
+it plates and spicules of soft porous bone. The new bone may be so
+abundant that it forms a thick crust on the surface, and in the flat
+bones of the skull this may be heaped up in the form of bosses or ridges
+resembling those ascribed to inherited syphilis.
+
+In the epiphysial cartilages and at the ossifying junctions, all the
+processes concerned in ossification, excepting the deposition of lime
+salts, occur to an exaggerated degree. The cartilage of the epiphysial
+disc proliferates actively and irregularly, so that it becomes softer,
+thicker, and wider, and gives rise to a visible swelling, best seen at
+the lower end of the radius and lower end of the tibia, and at the
+costo-chondral junctions where the series of beaded swellings is known
+as the "rickety rosary."
+
+The ossifying zone is increased in depth; the marrow is abnormally
+vascular; and the new bone that is formed is imperfectly calcified. The
+result is that the bones may never attain their normal length, and they
+remain stunted throughout life as in rickety dwarfs (Fig. 133), or the
+shafts may grow unequally and come to deviate from their normal axes as
+in knock-knee and bow-knee.
+
+[Illustration: FIG. 133.--Skeleton of Rickety Dwarf, known as
+"Bowed Joseph," leader of the Meal Riots in Edinburgh, who died in 1780.
+
+(Anatomical Museum, University of Edinburgh.)]
+
+These changes are well brought out in skiagrams; instead of the
+well-defined narrow line which represents the epiphysial cartilage,
+there is an ill-defined, blurred zone of considerable depth.
+
+In the shafts of the long bones, owing to the excessive absorption of
+bone, the cortex becomes porous, the spongy bone is rarefied, and the
+bones readily bend or break under mechanical influences. When the
+disease is arrested, a process of repair sets in which often results in
+the bones becoming denser and heavier than normal. In the flat bones of
+the skull, the absorption may result in the entire disappearance of
+areas of bone, leaving a membrane which dimples like thin cardboard
+under the pressure of the finger--a condition known as _craniotabes_.
+
+_Changes in the Skeleton before the Child is able to walk._--The
+fontanelles remain open until the end of the second year or longer, and
+the frontal and parietal eminences are unduly prominent. There is
+sometimes hydrocephalus, and the head is characteristically enlarged.
+The jaws are altered so that while the upper jaw is contracted into the
+shape of a #V#, the lower jaw is square instead of rounded in outline,
+and the teeth do not oppose one another. In the _thorax_, the chief
+feature may be the beading at the costo-chondral junctions, principally
+of the fifth and sixth ribs or its walls may be contracted,
+particularly if respiration is interfered with as a result of bronchial
+catarrh or adenoids. The contraction may take the form of a vertical
+groove on each side, or of a horizontal groove at the level of the upper
+end of the xiphi-sternum; when the sternum and cartilages form a
+projection in front, the deformity is known as "pigeon-breast."
+
+The _spine_ may be curved backwards--_kyphosis_--throughout its
+whole extent or only in one part; or it may be curved to one
+side--_scoliosis_.
+
+In the _limbs_, the prominent features are the deficient growth in
+length of the long bones, the enlargements at the epiphysial junctions,
+and the bending, and occasional greenstick fracture, of the shafts. The
+degree of enlargement of the epiphysial junctions is directly
+proportionate to the amount of movement to which the bone is subjected
+(John Thomson). The curves at this stage depend on the attitude of the
+child while sitting or being carried--for example, the arm bones become
+bent in children who paddle about the floor with the aid of their arms;
+and in a child who lies on its back with the lower limbs everted, the
+weight of the limb may lead to curvature of the neck of the femur--coxa
+vara. The clavicle or humerus may sustain greenstick fracture from the
+child being lifted by the arms; the femur, by a fall. From the extreme
+laxity of the ligaments, the joints can be moved beyond the normal
+limits, and the child is often observed to twist its limbs into abnormal
+attitudes.
+
+_In Children who have walked._--In these children the most important
+deformities occur in the spine, pelvis, and lower extremities, and
+result for the most part from yielding of the softened bones under the
+weight of the body. Scoliosis is the usual type of spinal curvature, and
+in extreme cases it may lead to a pronounced form of hump-back. The
+pelvis may remain small (_justo-minor pelvis_), or it may be contracted
+in the sagittal plane (_flat pelvis_); when the bones are unusually
+soft, the acetabular portions are pushed inwards by the femora bearing
+the weight of the body, and the pelvis assumes the shape of a trefoil,
+as in the malacia of women. The shaft of the femur is curved forwards
+and laterally; the bones of the leg laterally as in bow-leg, or
+forwards, or forwards and laterally just above the ankle. The
+deformities at the knee (genu valgum, genu varum, and genu recurvatum),
+and at the hip (coxa vara), will be described in the volume dealing with
+the Extremities.
+
+The majority of cases seen in surgical practice suffer from the
+deformities resulting from rickets rather than from the active disease.
+The examination of a large series of children at different ages shows
+that the deformities become less and less frequent with each year. Those
+who recover may ultimately show no trace of rickets, and this is
+especially true of children who grow at the average rate; in those,
+however, in whom growth is retarded, especially from the fifth to the
+seventh year, the deformities are apt to be permanent. It may be noted
+that the scoliosis due to rickets has little tendency towards recovery.
+
+_Treatment._--The treatment of the disease consists in regulating the
+diet, improving the surroundings, and preventing deformity. Phosphorus
+in doses of 100th grain may be given dissolved in cod-liver oil, and
+preparations of iron and lime may be added with advantage. To avoid
+those postures which predispose to deformities, the child should lie as
+much as possible. In the well-to-do classes this is readily accomplished
+by the aid of a nurse and the use of a perambulator. In hospital
+out-patients the child is kept off its feet by the use of a light wooden
+splint applied to the lateral aspect of each lower extremity, and
+extending from the pelvis to 6 inches beyond the sole.
+
+When deformities are already present, the treatment depends upon whether
+or not there is any prospect of the bone straightening naturally. Under
+five years of age this may, as a rule, be confidently expected; the
+child should be kept off its feet, and the limbs bathed and massaged. In
+children of five or six and upwards, the prospect of natural
+straightening is a diminishing one, and it is more satisfactory to
+correct the deformity by operation. In rickety curvature of the spine,
+the child should lie on a firm mattress, or, to allow of its being taken
+into the open air, upon a double Thomas' splint extending from the
+occiput to the heels; the muscles acting on the trunk should be braced
+up by massage and appropriate exercises.
+
+#Late Rickets# or #Rachitis Adolescentium# is met with at any age from
+nine to seventeen, and is generally believed to be due to a
+recrudescence of rickets which had been present in childhood. The
+disease is not attended with any disturbance of the general health; the
+pathological changes are the same as in infantile rickets, but are for
+the most part confined to the ossifying junctions, especially those
+which are most active during adolescence, for example at the knee-joint.
+The patient is easily tired, complains of pain in the bones, and, unless
+care is taken, deformity is liable to ensue. There can be no doubt that
+adolescent rickets plays an important part in the production of the
+deformities which occur at or near puberty, especially knock-knee and
+bow-knee.
+
+#Scurvy-Rickets# or #Infantile Scurvy#.--This disease, described by
+Barlow and Cheadle, is met with in infants under two years who have been
+brought up upon sterilised or condensed milk and other proprietary
+foods, and is most common in the well-to-do classes. The haemorrhages,
+which are so characteristic of the disease, are usually preceded for
+some weeks by a cachectic condition, with listlessness and debility and
+disinclination for movement. Very commonly the child ceases to move one
+of his lower limbs--pseudo-paralysis--and screams if it is touched; a
+swelling is found over one of the bones, usually the femur, accompanied
+by exquisite tenderness; the skin is tense and shiny, and there may be
+some oedema. These symptoms are due to a sub-periosteal haemorrhage, and
+associated with this there may be crepitus from separation of an
+epiphysis, rarely from fracture of the shaft of the bone. X-ray
+photographs show enlargement of the bone, the periosteum being raised
+from the shaft and new bone formed in relation to it. Haemorrhages also
+occur into the skin, presenting the appearance of bruises, into the
+orbit and conjunctiva, and from the mucous membranes.
+
+The _treatment_ consists in correcting the errors in diet. The infant
+should have a wet nurse or a plentiful supply of cow's milk in its
+natural state. Anti-scorbutics in the form of orange, lemon, or grape
+juice, and of potatoes bruised down in milk, may be given.
+
+#Osteomalacia.#--The term osteomalacia includes a group of conditions,
+closely allied to rickets, in which the bones of adults become soft and
+yielding, so that they are unduly liable to bend or break.
+
+One form occurs in _pregnant and puerperal women_, affecting most
+commonly the pelvis and lumbar vertebrae, but sometimes the entire
+skeleton. The lime salts are absorbed, the bones lose their rigidity and
+bend under the weight of the body and other mechanical influences, with
+the result that gross deformities are produced, particularly in the
+pelvis, the lumbar spine, and the hip-joints.
+
+_Neuropathic_ forms occur in certain chronic diseases of the brain and
+cord; in some cases the bones lose their lime salts and bend, in others
+they become brittle.
+
+_Osteomalacia associated with New Growths in the Skeleton._--When
+_secondary cancer_ is widely distributed throughout the skeleton, it is
+associated with softening of the bones, as a result of which they
+readily bend or break, and after death are easily cut with a knife. In
+the disease known as _multiple myeloma_, the interior of the ribs,
+sternum, and bodies of the vertebrae is occupied by a reddish gelatinous
+pulp, the structure of which resembles sarcoma; the bones are reduced to
+a mere shell, and may break on the slightest pressure; the urine
+contains albumose, a substance resembling albumen but coagulating at a
+comparatively low temperature (140 F.), and the coagulum is
+re-dissolved on boiling, and it is readily precipitated by hydrochloric
+acid (Bence-Jones).
+
+#Ostitis Deformans--Paget's Disease of Bone.#--This rare disease was
+first described by Sir James Paget in 1877. In the early stages, the
+marrow is transformed into a vascular connective tissue; its bone-eating
+functions are exaggerated, and the framework of the bone becomes
+rarefied, so that it bends under pressure as in osteomalacia. In course
+of time, however, new bone is formed in great abundance; it is at first
+devoid of lime salts, but later becomes calcified, so that the bones
+regain their rigidity. This formation of new bone is much in excess of
+the normal, the bones become large and bulky, their surfaces rough and
+uneven, their texture sclerosed in parts, and the medullary canal is
+frequently obliterated. These changes are well brought out in X-ray
+photographs. The curving of the long bones, which is such a striking
+feature of the disease, may be associated with actual lengthening, and
+the changes are sometimes remarkably symmetrical (Fig. 135). The bones
+forming the cranium may be enormously thickened, the sutures are
+obliterated, the distinction into tables and diploe is lost, and, while
+the general texture is finely porous, there may be areas as dense as
+ivory (Fig. 134).
+
+[Illustration: FIG. 134.--Changes in the Skull resulting from Ostitis
+Deformans.
+
+(Anatomical Museum, University of Edinburgh.)]
+
+_Clinical Features._--The disease is usually met with in persons over
+fifty years of age. It is insidious in its onset, and, the patient's
+attention may be first attracted by the occurrence of vague pains in the
+back or limbs; by the enlargement and bending of such bones as the tibia
+or femur; or by a gradual increase in the size of the head,
+necessitating the wearing of larger hats. When the condition is fully
+developed, the attitude and general appearance are eminently
+characteristic. The height is diminished, and, owing to the curving of
+the lower limbs and spine, the arms appear unnaturally long; the head
+and upper part of the spine are bent forwards; the legs are held apart,
+slightly flexed at the knees, and are rotated out as well as curved; the
+whole appearance suggests that of one of the large anthropoid apes. The
+muscles of the limbs may waste to such an extent as to leave the large,
+curved, misshapen bones covered only by the skin (Fig. 135). In the
+majority of cases the bones of the lower extremities are much earlier
+and more severely affected than those of the upper extremity, but the
+capacity of walking is usually maintained even in the presence of great
+deformity. In a case observed by Byrom Bramwell, the patient suffered
+from a succession of fractures over a period of years.
+
+[Illustration: FIG. 135.--Cadaver, illustrating the alterations in the
+Lower Limbs resulting from Ostitis Deformans.]
+
+The disease may last for an indefinite period, the general health
+remaining long unaffected. In a considerable number of the recorded
+cases one of the bones became the seat of sarcoma.
+
+#Osteomyelitis Fibrosa.#--This comparatively rare disease, which was
+first described by Recklinghausen, presents many interesting features.
+Because of its causing deformities of the bones and an undue liability
+to fracture, and being chiefly met with in adolescents, it is regarded
+by some authors as a juvenile form of Paget's disease. It may be
+diffused throughout the skeleton--we have seen it in the skull and in
+the bones of the extremities--or it may be confined to a single bone,
+usually the femur, or, what is more remarkable, the condition may affect
+a portion only of the shaft of a long bone and be sharply defined from
+the normal bone in contact with it.
+
+[Illustration: FIG. 136.--Osteomyelitis Fibrosa affecting Femora in a
+man aet. 19. The curving of the bones is due to multiple fractures.]
+
+On longitudinal section of a long bone during the active stage of the
+disease, the marrow is seen to be replaced by a vascular young
+connective tissue which encroaches on the surrounding spongy bone,
+reducing it to the slenderest proportions; the formation of bone from
+the periosteum does not keep pace with the absorption and replacement
+going on in the interior, and the cortex may be reduced to a thin shell
+of imperfectly calcified bone which can be cut with a knife. The young
+connective tissue which replaces the marrow is not unlike that seen in
+osteomalacia; it is highly vascular and may show haemorrhages of various
+date; there are abundant giant cells of the myeloma type, and
+degeneration and liquefaction of tissue may result in the formation of
+cysts, which, when they constitute a prominent feature, are responsible
+for the name--_osteomyelitis fibrosa cystica_--sometimes applied to the
+condition.
+
+It would appear that most of the recorded cases of _cysts of bone_ owe
+their origin to this disease, while the abundance of giant cells with
+occasional islands of cartilage in the wall of such cysts is responsible
+for the view formerly held that they owed their origin to the
+liquefaction of a solid tumour, such as a myeloma, a chondroma, or even
+a sarcoma. Although the tissue elements in this disease resemble those
+of a new growth arising in the marrow, they differ in their arrangement
+and in their method of growth; there is no tendency to erupt through the
+cortex of the bone, to invade the soft parts, or to give rise to
+secondary growths.
+
+_Clinical Features._--The onset of the disease is insidious, and
+attention is usually first directed to it by the occurrence of fracture
+of the shaft of one of the long bones--usually the femur--from violence
+that would be insufficient to break a healthy bone. Apart from fracture,
+the great increase in the size of one of the long bones and its uneven
+contour are sufficiently remarkable to suggest examination with the
+X-rays, by means of which the condition is at once recognised. A
+systematic examination of the other long bones will often reveal the
+presence of the disease at a stage before the bone is altered
+externally.
+
+Symmetrical bossing of the skull was present in the case shown in
+Figs. 136 and 137, and there were also scattered patches of brown
+pigmentation of the skin of the face, neck, and trunk, similar to those
+met with in generalised neuro-fibromatosis. Apart from fracture, the
+disease is recognised by the thickening and usually also by the curving
+of the shafts of the long bones. It is easy to understand the curvature
+of bones that have passed through a soft stage and also of those that
+have been broken and badly united, but it is difficult to account for
+the curvatures that have no such cause; for example, we have seen
+marked curve of the radius in a forearm of which the ulna was quite
+straight. The curvature probably resulted from exaggerated growth in
+length.
+
+[Illustration: FIG. 137.--Radiogram of Upper End of Femur showing
+appearances in Osteomyelitis Fibrosa.]
+
+The X-ray appearances vary with the stage of the malady, not estimated
+in time, for the condition is chronic and may become stationary, but
+according to whether it is progressive or undergoing repair. The shadow
+of the bone presents a poor contrast to the soft parts, and no trace of
+its original architecture; in extreme cases the shadow of the femur
+resembles an unevenly filled sausage (Fig. 137); there is no cortical
+layer, the interior shows no trabecular structure, and some of the many
+clear areas are probably cysts. The condition extends right up to the
+articular cartilage, or, in the case of adolescent bones, up to the
+epiphysial cartilage.
+
+_Prognosis._--The condition does not appear to affect the general
+health. The future is concerned with the local conditions, and,
+especially in the case of the femur, with its liability to fracture; so
+far as we know there is no time limit to this.
+
+_Treatment_ is confined to protecting the affected bone--usually the
+femur--from injury. Operative treatment may be required for lameness due
+to a badly united fracture.
+
+#Neuropathic Atrophy of Bone.#--The conditions included under this
+heading occur in association with diseases of the nervous system.
+
+Most importance attaches to the fragility of the bones met with in
+general paralysis of the insane, locomotor ataxia, and other chronic
+diseases of the brain and spinal cord. The bones are liable to be
+fractured by forces which would be insufficient to break a healthy bone.
+In _locomotor ataxia_ the fractures affect especially the bones of the
+lower extremity, and may occur before there are any definite nerve
+symptoms, but they are more often met with in the ataxic stage, when the
+abrupt and uncontrolled movements of the limbs may play a part in their
+causation. They may be unattended with pain, and may fail to unite; when
+repair does take place, it is sometimes attended with an excessive
+formation of callus. Joint lesions of the nature of Charcot's disease
+may occur simultaneously with the alterations in the bones. In
+_syringomyelia_ pathological fracture is not so frequent as in locomotor
+ataxia; it is more likely to occur in the bones of the upper extremity,
+and especially in the humerus. In some cases of _epilepsy_ the bones
+break when the patient falls in a fit, and there is usually an
+exaggerated amount of comminution.
+
+In these affections the bones present no histological or chemical
+alterations, and the X-ray shadow does not differ from the normal. It is
+maintained, therefore, that the disposition to fracture does not depend
+upon a fragility of the bone, but on the loss of the muscular sense and
+of common sensation in the bones, as a result of which there is an
+inability properly to throw the muscles into action and dispose the
+limbs so as to place them under the most favourable conditions to meet
+external violence.
+
+#Osteogenesis Imperfecta#, #Fragilitas Ossium#, or #Congenital
+Osteopsathyrosis#.--These terms are used to describe a condition in
+which an undue fragility of the bones dates from intra-uterine life. It
+may occur in several members of the same family. In severe cases,
+intra-uterine fractures occur, and during parturition fresh fractures
+are almost sure to be produced, so that at birth there is a combination
+of recent fractures and old fractures united and partly united, with
+bendings and thickenings of the bones. Large areas of the cranial vault
+may remain membranous.
+
+After birth the predisposition to fracture continues, the bones are
+easily broken, the fractures are attended with little or no pain, the
+crepitus is soft, and although union may take place, it may be delayed
+and be attended with excess of callus. Cases have been observed in which
+a child has sustained over a hundred fractures.
+
+The bones show a feeble shadow with the X-rays, and appear thin and
+atrophied; the medullary canal is increased at the expense of the
+cortex.
+
+In young infants in whom multiple fractures occur the prognosis as to
+life is unfavourable, and no satisfactory treatment of the disease has
+been formulated. If the patient survives, the tendency to fracture
+gradually disappears.
+
+#Hypertrophic Pulmonary Osteo-Arthropathy.#--This condition, which was
+described by Marie in 1890, is secondary to disease in the chest, such
+as chronic phthisis, empyema, bronchiectasis, or sarcoma of the lung.
+There is symmetrical enlargement and deformity of the hands and feet;
+the shafts of the bones are thickened, and the soft tissues of the
+terminal segments of the digits hypertrophied. The fingers come to
+resemble drum-sticks, and the thumb the clapper of a bell. The nails are
+convex, and incurved at their free ends, suggesting a resemblance to the
+beak of a parrot. There is also enlargement of the lower ends of the
+bones of the forearm and leg, and effusion into the wrist and
+ankle-joints. Skiagrams of the hands and feet show a deposit of new bone
+along the shafts of the phalanges.
+
+
+TUMOURS OF BONE
+
+New growths which originate in the skeleton are spoken of as _primary
+tumours_; those which invade the bones, either by metastasis from other
+parts of the body or by spread from adjacent tissues, as _secondary_. A
+tumour of bone may grow from the cellular elements of the periosteum,
+the marrow, or the epiphysial cartilage.
+
+Primary tumours are of the connective-tissue type, and are usually
+solitary, although certain forms, such as the chondroma, may be multiple
+from the outset.
+
+_Periosteal tumours_ are at first situated on one side of the bone, but
+as they grow they tend to surround it completely. Innocent periosteal
+tumours retain the outer fibrous layer as a capsule. Malignant tumours
+tend to perforate the periosteal capsule and invade the soft parts.
+
+_Central_ or _medullary tumours_ as they increase in size replace the
+surrounding bone, and simultaneously new bone is formed on the surface;
+as this is in its turn absorbed, further bone is formed beneath the
+periosteum, so that in time the bone is increased in girth, and is said
+to be "expanded" by the growth in its interior.
+
+#Primary Tumours--Osteoma.#--When the tumour projects from the surface
+of a bone it is called an _exostosis_. When growing from bones developed
+in membrane, such as the flat bones of the skull, it is usually dense
+like ivory, and the term _ivory exostosis_ is employed. When derived
+from hyaline cartilage--for example, at the ends of the long bones--it
+is known as a _cartilaginous exostosis_. This is invested with a cap of
+cartilage from which it continues to grow until the skeleton attains
+maturity.
+
+An exostosis forms a rounded or mushroom-shaped tumour of limited size,
+which may be either sessile or pedunculated, and its surface is smooth
+or nodulated (Figs. 138 and 139). A cartilaginous exostosis in the
+vicinity of a joint may be invested with a synovial sac or bursa--the
+so-called _exostosis bursata_. The bursa may be derived from the
+synovial membrane of the adjacent joint with which its cavity sometimes
+communicates, or it may be of adventitious origin; when it is the seat
+of bursitis and becomes distended with fluid, it may mask the underlying
+exostosis, which then requires a radiogram for its demonstration.
+
+[Illustration: FIG. 138.--Radiogram of Right Knee showing Multiple
+Exostoses.]
+
+_Clinically_, the osteoma forms a hard, indolent tumour attached to a
+bone. The symptoms to which it gives rise depend on its situation. In
+the vicinity of a joint, it may interfere with movement; on the medial
+side of the knee it may incapacitate the patient from riding. When
+growing from the dorsum of the terminal phalanx of the great
+toe--_subungual exostosis_--it displaces the nail, and may project
+through its matrix at the point of the toe, while the soft parts over it
+may be ulcerated from pressure (Fig. 107). It incapacitates the patient
+from wearing a boot. When it presses on a nerve-trunk it causes pains
+and cramps. In the orbit it displaces the eyeball; in the nasal fossae
+and in the external auditory meatus it causes obstruction, which may be
+attended with ulceration and discharge. In the skull it may project
+from the outer table, forming a smooth rounded swelling, or it may
+project from the inner table and press upon the brain.
+
+The diagnosis is to be made by the slow growth of the tumour, its
+hardness, and by the shadow which it presents with the X-rays (Fig. 138).
+
+An osteoma which does not cause symptoms may be left alone, as it ceases
+to grow when the skeleton is mature and has no tendency to change its
+benign character. If causing symptoms, it is removed by dividing the
+neck or base of the tumour with a chisel, care being taken to remove the
+whole of the overlying cartilage. The dense varieties met with in the
+bones of the skull present greater difficulties; if it is necessary to
+remove them, the base or neck of the tumour is perforated in many
+directions with highly tempered drills rotated by some form of engine,
+and the division is completed with the chisel.
+
+[Illustration: FIG. 139.--Multiple Exotoses of both limbs.
+
+(Photograph lent by Sir George T. Beatson.)]
+
+#Multiple Exostoses.#--This disease, which, by custom, is still placed
+in the category of tumours, is to be regarded as a disorder of growth,
+dating from intra-uterine life and probably due to a disturbance in the
+function of the glands of internal secretion, the thyreoid being the one
+which is most likely to be at fault (Arthur Keith). The disorder of
+growth is confined to those elements of the skeleton where a core of
+bone formed in cartilage comes to be encased in a sheath of bone formed
+beneath the periosteum. To indicate this abnormality the name
+_diaphysial aclasis_ has been employed by Arthur Keith at the suggestion
+of Morley Roberts.
+
+Bones formed entirely in cartilage are exempt, namely, the tarsal and
+carpal bones, the epiphyses of the long bones, the sternum, and the
+bodies of the vertebrae. Bones formed entirely in membrane, that is,
+those of the face and of the cranial vault, are also exempt. The
+disorder mainly affects the ossifying junctions of the long bones of the
+extremities, the vertebral border of the scapula, and the cristal border
+of the ilium.
+
+_Clinically_ the disease is attended with the gradual and painless
+development during childhood or adolescence of a number of tumours or
+irregular projections of bone, at the ends of the long bones, the
+vertebral border of the scapula, and the cristal border of the ilium.
+They exhibit a rough symmetry; they rarely attain any size; and they
+usually cease growing when the skeleton attains maturity--the conversion
+of cartilage into bone being then completed. While they originate from
+the ossifying junctions of the long bones, they tend, as the shaft
+increases in length, to project from the surface of the bone at some
+distance from the ossifying junction and to "point" away from it. They
+may cause symptoms by "locking" the adjacent joint or by pressing upon
+nerve-trunks or blood vessels.
+
+In a considerable proportion of cases, the disturbance of growth is
+further manifested by dwarfing of the long bones; these are not only
+deficient in length but are sometimes also curved and misshapen, which
+accounts for the condition being occasionally confused with the
+disturbances of growth resulting from rickets. In about one-third of the
+recorded cases there is a dislocation of the head of the radius on one
+or on both sides, a result of unequal growth between the bones of the
+forearm.
+
+[Illustration: FIG. 140.--Multiple Cartilaginous Exostoses in a
+man aet. 27. The scapular tumour projecting above the right clavicle has
+taken on active growth and pressed injuriously on the cords of the
+brachial plexus.]
+
+In early adult life, one of the tumours, instead of undergoing
+ossification, may take on active growth and exhibit the features of a
+chondro-sarcoma, pressing injuriously upon adjacent structures (Fig. 140)
+and giving rise later to metastases in the lungs.
+
+The _X-ray appearances_ of the bones affected are of a striking
+character; apart from the outgrowths of bone or "tumours" there is
+evident a widespread alteration in the internal architecture of the
+bones, which suggests analogies with other disturbances of ossification
+such as achondroplasia and osteomyelitis fibrosa. The condition is one
+that runs in families, sometimes through several generations; we have
+more than once seen a father and son together in the hospital
+waiting-room.
+
+As regards _treatment_, there is no indication for surgical interference
+except when one or other tumour is a source of disability as by pressing
+upon a nerve-trunk or by locking a joint, in which case it is easily
+removed by chiselling through its neck.
+
+[Illustration: FIG. 141.--Multiple Cartilaginous Exostoses in a
+man aet. 27, the same as in Fig. 140.]
+
+_Diffuse Osteoma, Leontiasis Ossea._--This rare affection was described
+by Virchow, and named leontiasis ossea because of the disfigurement to
+which it gives rise. It usually commences in adolescence as a diffuse
+overgrowth first of one and then of both maxillae; these bones are
+enlarged in all directions and project on the face, and the nasal fossae
+and the maxillary and frontal sinuses become filled up with bone, which
+encroaches also on the orbital cavities. In addition to the hideous
+deformity, the patient suffers from blocking of the nose, loss of smell,
+and protrusion of the eyes, sometimes followed by loss of sight. The
+condition is liable to spread to the zygomatic and frontal bones, the
+vault of the skull, and to the mandible. The base of the skull is not
+affected. The disease is of slow progress and may become arrested; life
+may be prolonged for many years, or may be terminated by brain
+complications or by intercurrent affections. In certain cases it is
+possible to remove some of the more disfiguring of the bony masses.
+
+A less aggressive form, confined to the maxilla on one side, is
+sometimes met with, and, in a case of this variety under our own
+observation, the disfigurement, which was the only subject of complaint,
+was removed, after reflecting the soft parts, by paring away the excess
+of bone; this is easily done as the bone is spongy, and at an early
+stage, imperfectly calcified.
+
+A remarkable form of _unilateral hypertrophy and diffuse osteoma of the
+skull_, following the distribution of the fifth nerve, has seen
+described by Jonathan Hutchinson and Alexis Thomson.
+
+#Chondroma.#--Cartilaginous tumours, apart from those giving rise to
+multiple exostoses, grow from the long bones and from the scapula,
+ilium, ribs, or jaws. They usually project from the surface of the bone,
+and may attain an enormous size; sometimes they grow in the interior of
+a bone, the so-called _enchondroma_.
+
+The hyaline cartilage composing the tumour frequently undergoes
+myxomatous degeneration, resulting in the formation of a glairy,
+semi-fluid jelly, and if this change takes place throughout the tumour
+it comes to resemble a cyst. On the other hand, the cartilage may
+undergo calcification or ossification. The most important transition of
+all is that into sarcoma, the so-called _malignant chondroma_ or
+_chondro-sarcoma_, which is associated with rapid increase in size,
+and parts of the tumour may be carried off in the blood-stream and give
+rise to secondary growths, especially in the lungs.
+
+Cases have been met with in which certain parts of the skeleton--only
+those developed in cartilage--were so uniformly permeated with cartilage
+that the condition has been described as a "chondromatosis" and is
+regarded as dating from an early period of foetal life. Unlike the
+condition known as multiple cartilaginous exostoses, it is a malignant
+disease.
+
+[Illustration: FIG. 142.--Multiple Chondromas of Phalanges and
+Metacarpals in a boy aet. 10 (cf. Fig. 143).]
+
+The chondroma is met with as a slowly growing tumour which is specially
+common in the bones of the hand, often in a multiple form (Figs. 142 and
+144). The surface is smooth or lobulated, and in consistence the tumour
+may be dense and elastic like normal cartilage, or may present areas of
+softening, or of bony hardness. The skin moves freely over it, except in
+relation to the bones of the fingers, where it may become adherent and
+ulcerate, simulating the appearance of a malignant tumour. Large tumours
+growing from the bones of the extremities may implicate the main
+vessels and nerves, either surrounding them or pressing on them.
+
+Portions of a chondroma, which have undergone calcification or
+ossification, throw a dark shadow with the X-rays; unaltered cartilage
+and myxomatous tissue appear as clear areas.
+
+[Illustration: FIG. 143.--Skiagram of Multiple Chondromas shown
+in Fig. 142.]
+
+_Treatment._--It is necessary to remove the whole tumour, and in
+chondromas growing from the surface of the bone, especially if they are
+pedunculated, this is comparatively easy. When a bone, such as the
+scapula or mandible, is involved, it is better to excise the bone, or at
+least the part of it which bears the tumour. In the case of central
+tumours the shell of bone is removed over an area sufficient to allow of
+the enucleation of the tumour, or the affected portion of bone is
+resected. Should there be evidence of malignancy, such as increased rate
+of growth, a tube of radium should be inserted, and in advanced cases
+with destruction of tissue, amputation may be called for.
+
+[Illustration: FIG. 144.--Multiple Chondromas in Hand of boy aet. 8]
+
+In multiple chondromas of the hand in young subjects, it was formerly
+the custom to amputate the limb; an attempt should be made to avoid this
+by shelling out the larger tumours individually, and persevering with
+the application of the X-rays or of radium to inhibit the growth of the
+smaller ones.
+
+Chondromas springing from the pelvic bones usually arise in the region
+of the sacro-iliac joint; they project into the pelvis and press on the
+bladder and rectum, and on the sciatic and obturator nerves; sometimes
+also on the iliac veins, causing oedema of the legs. They are liable to
+take on malignant characters, and rarely lend themselves to complete
+removal by operation.
+
+#Fibroma# is met with chiefly as a periosteal growth in relation to the
+mouth and pharynx, the _simple epulis_ of the alveolar margin and the
+_naso-pharyngeal polypus_ being the most common examples. We have met
+with a fibroma in the interior of the lower end of the femur of an
+adult, causing expansion of the bone with decided increase in girth and
+liability to pathological fracture; it is possible that this represents
+the cured stage of osteomyelitis fibrosa.
+
+_Myxoma_, _lipoma_, and _angioma_ of bone are all rare.
+
+#Myeloma.#--The myeloid tumour, which is sometimes classified with the
+sarcomas, contains as its chief elements large giant cells, like those
+normally present in the marrow. On section these tumours present a
+brownish-red or chocolate colour, and, being highly vascular, are liable
+to haemorrhages, and therefore also to pigmentation, and to the formation
+of blood cysts. Sometimes the arterial vessels are so dilated as to
+impart to the tumour an aneurysmal pulsation and bruit. The enlargement
+or "expansion" of the bone results in the cortex being represented by a
+thin shell of bone, which may crackle on pressure--parchment or
+egg-shell crackling.
+
+The myeloma is most often met with between the ages of twenty-five and
+forty in the upper end of the tibia or lower end of the femur. It grows
+slowly and causes little pain, and may long escape recognition unless an
+examination is made with the X-rays. Although these tumours have been
+known to give rise to metastases, they are, as a rule, innocent and are
+to be treated as such. When located in the shaft of a long bone,
+pathological fracture is liable to occur.
+
+_Diagnosis and X-ray Appearances of Myeloma._--The early diagnosis of
+myeloma is made with the aid of the X-rays: the typical appearance is
+that of a rounded or oval clear area bounded by a shell of bone of
+diminishing thickness (Fig. 145). The inflammatory lesions at the ends
+of the long bones--tubercle, syphilitic gumma, and Brodie's abscess,
+that resemble myeloma, are all attended with the formation of new bone
+in greater or lesser amount. The myeloma is also to be diagnosed from
+chondroma, from sarcoma, and from osteomyelitis fibrosa cystica.
+
+[Illustration: FIG. 145.--Radiogram of Myeloma of Humerus.
+
+(Mr. J. W. Struthers' case.)]
+
+_Treatment._--In early cases the cortex is opened up to give free access
+to the tumour tissue, which is scraped out with the spoon. Bloodgood
+advises the use of Esmarch's tourniquet, and that the curetting be
+followed by painting with pure carbolic acid and then rinsing with
+alcohol; a rod of bone is inserted to fill the gap. In advanced cases
+the segment of bone is resected and a portion of the tibia or fibula
+from the other limb inserted into the gap; a tube of radium should also
+be introduced.
+
+The coexistence of diffuse myelomatosis of the skeleton and albumosuria
+(Bence-Jones) is referred to on p. 474. Myeloma occurs in the jaws,
+taking origin in the marrow or from the periosteum of the alveolar
+process, and is described elsewhere.
+
+#Sarcoma# and #endothelioma# are the commonest tumours of bone, and
+present wide variations in structure and in clinical features.
+Structurally, two main groups may be differentiated: (1) the soft,
+rapidly growing cellular tumours, and (2) those containing fully formed
+fibrous tissue, cartilage, or bone.
+
+(1) The _soft cellular tumours_ are composed mainly of spindle or round
+cells; they grow from the marrow of the spongy ends or from the
+periosteum of the long bones, the diploe of the skull, the pelvis,
+vertebrae, and jaws. As they grow they may cause little alteration in the
+contour of the bone, but they eat away its framework and replace it, so
+that the continuity of the bone is maintained only by tumour tissue, and
+pathological fracture is a frequent result. The small round-celled
+sarcomas are among the most malignant tumours of bone, growing with
+great rapidity, and at an early stage giving rise to secondary growths.
+
+(2) The second group includes the _fibro-_, _osteo-_, and
+_chondro-sarcomas_, and combinations of these; in all of them fully
+formed tissues or attempts at fully formed tissues predominate over the
+cellular elements. They grow chiefly from the deeper layer of the
+periosteum, and at first form a projection on the surface, but later
+tend to surround the bone (Fig. 150), and to invade its interior,
+filling up the marrow spaces with a white, bone-like substance; in the
+flat bones of the skull they may traverse the diploe and erupt on the
+inner table. The tumour tissue next the shaft consists of a dense,
+white, homogeneous material, from which there radiate into the softer
+parts of the tumour, spicules, needles, and plates, often exhibiting a
+fan-like arrangement (Fig. 151). The peripheral portion consists of soft
+sarcomatous tissue, which invades the overlying soft parts. The
+articular cartilage long resists destruction. The ossifying sarcoma is
+met with most often in the femur and tibia, less frequently in the
+humerus, skull, pelvis, and jaws. In the long bones it may grow from the
+shaft, while the chondro-sarcoma more often originates at the
+extremities. Sometimes they are multiple, several tumours appearing
+simultaneously or one after another. Secondary growths are met with
+chiefly in the lungs, metastasis taking place by way of the veins.
+
+[Illustration: FIG. 146.--Periosteal Sarcoma of Femur in a young
+subject.]
+
+[Illustration: FIG. 147.--Periosteal Sarcoma of Humerus, after
+maceration.
+
+(Anatomical Museum, University of Edinburgh.)]
+
+_Clinical Features._--Sarcoma is usually met with before the age of
+thirty, and is comparatively common in children. Males suffer oftener
+than females, in the proportion of two to one.
+
+In _periosteal sarcoma_ the presence of a swelling is usually the first
+symptom; the tumour is fusiform, firm, and regular in outline, and when
+it occurs near the end of a long bone the limb frequently assumes a
+characteristic "leg of mutton" shape (Fig. 146). The surface may be
+uniform or bossed, the consistence varies at different parts, and the
+swelling gradually tapers off along the shaft. On firm pressure, fine
+crepitation may be felt from crushing of the delicate framework of new
+bone.
+
+[Illustration: FIG. 148.--Chondro-Sarcoma of Scapula in a man aet. 63;
+removal of the scapula was followed two years later by metastases and
+death.]
+
+In _central sarcoma_ pain is the first symptom, and it is usually
+constant, dull, and aching; is not obviously increased by use of the
+limb, but is often worse at night. Swelling occurs late, and is due to
+expansion of the bone; it is fusiform or globular, and is at first
+densely hard, but in time there may be parchment-like or egg-shell
+crackling from yielding of the thin shell. The swelling may pulsate, and
+a bruit may be heard over it. In advanced cases it may be impossible to
+differentiate between a periosteal and a central tumour, either
+clinically or after the specimen has been laid open.
+
+Pathological fracture is more common in central tumours, and sometimes
+is the first sign that calls attention to the condition. Consolidation
+rarely takes place, although there is often an attempt at union by the
+formation of cartilaginous callus.
+
+[Illustration: FIG. 149.--Central Sarcoma of Lower End of Femur,
+invading the knee-joint.
+
+(Museum of Royal College of Surgeons, Edinburgh.)]
+
+[Illustration: FIG. 150.--Osseous Shell of Osteo-Sarcoma of Upper Third
+of Femur, after maceration.]
+
+The soft parts over the tumour for a long time preserve their normal
+appearance; or they become oedematous, and the subcutaneous venous
+network is evident through the skin. Elevation of the temperature over
+the tumour, which may amount to two degrees or more, is a point of
+diagnostic significance, as it suggests an inflammatory lesion.
+
+The adjacent joint usually remains intact, although its movements may be
+impaired by the bulk of the tumour or by effusion into the cavity.
+
+Enlargement of the neighbouring lymph glands does not necessarily imply
+that they have become infected with sarcoma for the enlargement may
+disappear after removal of the primary growth; actual infection of the
+glands, however, does sometimes occur, and in them the histological
+structure of the parent tumour is reproduced.
+
+To obtain a reasonable prospect of cure, the _diagnosis_ must be made at
+an early stage. Great reliance is to be placed on information gained by
+examination with the X-rays.
+
+[Illustration: FIG. 151.--Radiogram of Osteo-Sarcoma of Upper Third
+of Femur.]
+
+_X-ray Appearances._--In periosteal tumours that do not ossify, there is
+merely erosion of bone, and the shadow is not unlike that given by
+caries; in ossifying tumours, the arrangement of the new bone on the
+surface is characteristic, and when it takes the form of spicules at
+right angles to the shaft, it is pathognomic.
+
+In soft central tumours, there is disappearance of bone shadow in the
+area of the tumour, while above and below or around this, the shadow is
+that of normal bone right up to the clear area. In many respects the
+X-ray appearances resemble those of myeloma. In tumours in which there
+is a considerable amount of imperfectly formed new bone, this gives a
+shadow which barely replaces that of the original bone, in parts it may
+even add to it--the resulting picture differing widely in different
+cases; but it is usually possible to differentiate it from that caused
+by bacterial infections of the bone and from lesions of the adjacent
+joint.
+
+[Illustration: FIG. 152.--Radiogram of Chondro-Sarcoma of Upper End of
+Humerus in a woman aet. 29.]
+
+Skiagraphy is not only of assistance in differentiating new growths from
+other diseases of bone, but may also yield information as to the
+situation and nature of the tumour, which may have important bearings on
+its treatment by operation.
+
+When fracture of a long bone takes place in an adolescent or young adult
+from comparatively slight violence, disease of the bone should be
+suspected and an X-ray examination made.
+
+In difficult cases the final appeal is to exploratory incision and
+microscopical examination of a portion of the tumour; this should be
+done when the major operation has been arranged for, the surgeon waiting
+until the examination is completed.
+
+The _prognosis_ varies widely. In general, it may be said that
+periosteal tumours are less favourable than central ones, because they
+are more liable to give rise to metastases. Permanent cures are
+unfortunately the exception.
+
+_Treatment._--When one of the bones of a limb is involved, the usual
+practice has been to perform amputation well above the growth, and this
+may still be recommended as a routine procedure. There are reasons,
+however, which may be urged against its continuance. High amputation is
+unnecessary in the more benign sarcomas, and in the more malignant forms
+is usually unavailing to prevent a fatal issue either from local
+recurrence or from metastases in the lungs or elsewhere. Following
+the lead of Mikulicz, a considerable number of permanent cures have been
+obtained by resecting the portion of bone which is the seat of the
+tumour, and substituting for it a corresponding portion from the tibia
+or fibula of the other limb. In a cellular sarcoma of the humerus of a
+boy we resected the shaft and inserted his fibula ten years ago, and he
+shows no sign of recurrence. When resection is impracticable, a
+subcapsular enucleation is performed, followed by the insertion of
+radium.
+
+#Pulsating Haematoma# or #Aneurysm of Bone#.--A limited number of these
+are innocent cavernous tumours dating from a congenital angioma. The
+majority would appear to be the result of changes in a sarcoma,
+endothelioma, or myeloma. The tumour tissue largely disappears, while
+the vessels and vascular spaces undergo a remarkable development. The
+tumour may come to be represented by one large blood-containing space
+communicating with the arteries of the limb; the walls of the space
+consist of the remains of the original tumour, plus a shell of bone of
+varying thickness. The most common seats of the condition are the lower
+end of the femur, the upper end of the tibia, and the bones of the
+pelvis.
+
+The _clinical features_ are those of a pulsating tumour of slow
+development, and as in true aneurysm, the pulsation and bruit disappear
+on compression of the main artery. The origin of the tumour from bone
+may be revealed by the presence of egg-shell crackling, and by
+examination with the X-rays.
+
+If the condition is believed to be innocent, the treatment is the same
+as for aneurysm--preferably by ligation of the main artery; if
+malignant, it is the same as for sarcoma.
+
+#Secondary Tumours of Bone.#--These embrace two groups of new growth,
+those which give rise to secondary growths in the marrow of bones and
+those which spread to bone by direct continuity.
+
+_Metastatic Tumours._--Excepting certain cancers which give rise to
+metastases by lymphatic permeation (Handley), the common metastases
+arising in the bone-marrow reach their destination through the
+blood-stream.
+
+[Illustration: FIG. 153.--Epitheliomatous Ulcer of Leg with direct
+extension to Tibia.
+
+(Lord Lister's specimen. Anatomical Museum, University of Edinburgh.)]
+
+Secondary cancer is a comparatively common disease, and, as in
+metastases in other tissues, the secondary growths resemble the parent
+tumour. The soft forms grow rapidly, and eat away the bone, without
+altering its shape or form. In slowly growing forms there may be
+considerable formation of imperfectly formed bone, often deficient in
+lime salts; this condition may be widely diffused throughout the
+skeleton, and, as it is associated with softening and bending of the
+bones, it is known as _cancerous osteomalacia_. Secondary cancer of bone
+is attended with pain, or it suddenly attracts notice by the occurrence
+of pathological fracture--as, for example, in the shaft of the femur or
+humerus. In the vertebrae, it is attended with a painful form of
+paraplegia, which may involve the lower or all four extremities. On the
+other hand, the disease may show itself clinically as a tumour of bone,
+which may attain a considerable size, and may be mistaken for a sarcoma,
+unless the existence of the primary cancer is discovered.
+
+The cancers most liable to give rise to metastasis in bone are those of
+the breast, liver, uterus, prostate, colon, and rectum; hyper-nephroma
+of the kidney may also give rise to metastases in bone.
+
+_Secondary tumours derived from the thyreoid gland_ require special
+mention, because they are peculiar in that neither the primary growth in
+the thyreoid nor the secondary growth in the bones is necessarily
+malignant. They are therefore amenable to operative treatment.
+
+_Secondary sarcoma_, whether derived from a primary growth in the bone
+or in the soft parts, is much rarer than secondary cancer. Its removal
+by operation is usually contra-indicated, but we have known of cases
+terminating fatally in which the _section_ revealed only one metastasis,
+the removal of which would have benefited the patient.
+
+In all of these conditions, examination of the bones with the X-rays
+gives valuable information and often disclose unsuspected metastases.
+
+_Cancer of Bone resulting from Direct Extension from Soft Parts._--In
+this group there are also two clinical types. The first is met with in
+relation to _epithelioma of a mucous surface_--for example, the palate,
+tongue, gums, antrum, frontal sinus, auditory meatus, or middle ear.
+They will be described under these special regions.
+
+The second type is met with in relation to _epithelioma occurring in a
+sinus_, the sequel of suppurative osteomyelitis, compound fracture, or
+tuberculous disease. The patient has usually had a discharging sinus for
+a great number of years: we have known it to last as many as fifty. The
+epithelioma originates at the skin orifice of the sinus, and spreads to
+the bone and into its interior, where the progress of the cancer is
+resisted by dense bone, which obliterates the medullary canal. Although
+its progress is slow, the infiltration of the bone is usually more
+extensive than appears externally. It is recognised clinically by the
+characteristic cauliflower growth at the orifice of the sinus, and by
+the offensive nature of the discharge. A similar epithelioma may arise
+in connection with a _chronic ulcer of the leg_. The cancer may infect
+the femoral lymph glands. The operative treatment is influenced by the
+extent of the disease in the soft parts overlying the bone, and consists
+in wide removal of the diseased tissues and resection of the bone, or in
+amputation.
+
+#Cysts of Bone.#--With the exception of hydatid cysts, cysts in the
+interior of bone are the result of the liquefaction of solid tissue;
+this may be that of chondroma, myeloma, or sarcoma, but more commonly of
+the marrow in osteomyelitis fibrosa.
+
+
+
+
+CHAPTER XXI
+
+DISEASES OF JOINTS
+
+
+Definition of terms--Ankylosis. DISEASES: Errors of
+    development--Bacterial diseases: _Pyogenic_; _Gonorrhoeal_;
+    _Tuberculous_; _Syphilitic_; _Acute rheumatism_--Diseases
+    associated with certain constitutional conditions: _Gout_; _Chronic
+    articular rheumatism_; _Arthritis deformans_;
+    _Haemophilia_--Diseases associated with affections of the nervous
+    system: _Neuro-arthropathies_; _Charcot's disease_--Hysterical or
+    mimetic affections of joints--Tumours and cysts--Loose bodies.
+
+#Definition of Terms.#--The term _synovitis_ is applied to any reaction
+which affects the synovial membrane of a joint. It is usually associated
+with effusion of fluid, and this may be serous, sero-fibrinous, or
+purulent. As the term synovitis merely refers to the tissue involved, it
+should always be used with an adjective--such as gouty, gonorrhoeal, or
+tuberculous--which indicates its pathological nature.
+
+The terms _hydrops_, _hydrarthrosis_, and _chronic serous synovitis_ are
+synonymous, and are employed when a serous effusion into the joint is
+the prominent clinical feature. Hydrops may occur apart from
+disease--for example, in the knee-joint from repeated sprains, or when
+there is a loose body in the joint--but is met with chiefly in the
+chronic forms of synovitis which result from gonorrhoea, tuberculosis,
+syphilis, arthritis deformans, or arthropathies of nerve origin.
+
+_Arthritis_ is the term applied when not only the synovial membrane but
+the articular surfaces, and it may be also the ends of the bones, are
+involved, and it is necessary to prefix a qualifying adjective which
+indicates its nature. When effusion is present, it may be serous, as in
+arthritis deformans, or sero-fibrinous or purulent, as in certain forms
+of pyogenic and tuberculous arthritis. Wasting of the muscles,
+especially the extensors, in the vicinity of the joint is a constant
+accompaniment of arthritis. On account of the involvement of the
+articular surfaces, arthritis is apt to be followed by ankylosis.
+
+The term _empyema_ is sometimes employed to indicate that the cavity of
+the joint contains pus. This is observed chiefly in chronic disease of
+pyogenic or tuberculous origin, and is usually attended with the
+formation of abscesses outside the joint.
+
+_Ulceration of cartilage_ and _caries of the articular surfaces_ are
+common accompaniments of the more serious and progressive forms of joint
+disease, especially those of bacterial origin. The destruction of
+cartilage may be secondary to disease of the synovial membrane or of the
+subjacent bone. When the disease begins as a synovitis, the synovial
+membrane spreads over the articular surface, fuses with the cartilage
+and eats into it, causing defects or holes which are spoken of as
+ulcers. When the disease begins in the bone, the marrow is converted
+into granulation tissue, which eats into the cartilage and separates it
+from the bone. Following on the destruction of the cartilage, the
+articular surface of the bone undergoes disintegration, a condition
+spoken of as _caries of the articular surface_. The occurrence of
+ulceration of cartilage and of articular caries is attended with the
+clinical signs of fixation of the joint from involuntary muscular
+contraction, wasting of muscles, and starting pains. These _starting
+pains_ are the result of sudden involuntary movements of the joint. They
+occur most frequently as the patient is dropping off to sleep; the
+muscles becoming relaxed, the sensitive ulcerated surfaces jar on one
+another, which causes sudden reflex contraction of the muscles, and the
+resulting movement being attended with severe pain, wakens the patient
+with a start. Advanced articular caries is usually associated with some
+abnormal attitude and with shortening of the limb. It may be possible to
+feel the bony surfaces grate upon one another. When all its constituent
+elements are damaged or destroyed, a joint is said to be _disorganised_.
+Should recovery take place, repair is usually attended with union of the
+opposing articular surfaces either by fibrous tissue or by bone.
+
+#Conditions of Impaired Mobility of Joints.#--There are four conditions
+of impaired mobility in joints: rigidity, contracture, ankylosis, and
+locking. _Rigidity_ is the fixation of a joint by involuntary
+contraction of muscles, and is of value as a sign of disease in
+deep-seated joints, such as the hip. It disappears under anaesthesia.
+
+_Contracture_ is the term applied when the fixation is due to permanent
+shortening of the soft parts around a joint--muscles, tendons,
+ligaments, fasciae, or skin. As the structures on the flexor aspect are
+more liable to undergo such shortening, contracture is nearly always
+associated with flexion. Contracture may result from disease of the
+joint, or from conditions outside it--for example, disease in one of
+the adjacent bones, or lesions of the nerves.
+
+_Ankylosis_ is the term applied when impaired mobility results from
+changes involving the articular surfaces. It is frequently combined with
+contracture. Three anatomical varieties of ankylosis are
+recognised--(a) The _fibrous_, in which there are adhesions between
+the opposing surfaces, which may be in the form of loose isolated bands
+of fibrous tissue, or may bind the bones so closely together as to
+obliterate the cavity of the joint. The resulting stiffness, therefore,
+varies from a mere restriction of the normal range of movement, up to a
+close union of the bones which prevents movement. Fibrous ankylosis may
+follow upon injury, especially dislocation or fracture implicating a
+joint, or it may result from any form of arthritis. (b) _Cartilaginous
+ankylosis_ implies the fusion of two apposed cartilaginous surfaces. It
+is often found between the patella and the trochlear surface of the
+femur in tuberculous disease of the knee. The fusion of the
+cartilaginous surfaces is preceded by the spreading of a vascular
+connective tissue, derived from the synovial membrane, over the
+articular cartilage. Clinically, it is associated with absolute
+immobility, (c) _Bony ankylosis_ or _synostosis_ is an osseous union
+between articulating surfaces (Figs. 154 and 155). It may follow upon
+fibrous or cartilaginous ankylosis, or may result from the fusion of two
+articular surfaces which have lost their cartilage and become covered
+with granulations. In the majority of cases it is to be regarded as a
+reparative process, presenting analogies with the union of fracture.
+
+[Illustration: FIG. 154.--Osseous Ankylosis of Femur and Tibia in
+position of flexion.]
+
+The term _arthritis ossificans_ has been applied by Joseph Griffiths to
+a condition in which the articular surfaces become fused without evident
+cause.
+
+The occurrence of ankylosis in a joint before the skeleton has attained
+maturity does not appear to impair the growth in length of the bones
+affected; ankylosis of the temporo-maxillary joints, however, greatly
+impairs the growth of the mandible. When there is arrest of growth
+accompanying ankylosis, it usually depends on changes in the ossifying
+junctions caused by the original disease.
+
+To differentiate by manipulation between muscular fixation and
+ankylosis, it may be necessary to anaesthetise the patient. The nature
+and extent of ankylosis may be learned by skiagraphy; in osseous
+ankylosis the shadow of the two bones is a continuous one. In fibrous as
+contrasted with osseous ankylosis mobility may be elicited, although
+only to a limited extent; while in osseous ankylosis the joint is
+rigidly fixed, and attempts to move it are painless.
+
+[Illustration: FIG. 155.--Osseous Ankylosis of Knee in the flexed
+position following upon Tuberculous Arthritis.
+
+(Anatomical Museum, University of Edinburgh.)]
+
+The _treatment_ is influenced by the nature of the original lesion, the
+variety of the ankylosis, and the attitude of the joint. When there is
+restriction of movement due to fibrous adhesions, these may be elongated
+or ruptured. Elongation of the adhesions may be effected by
+manipulations, exercises, and the use of special forms of
+apparatus--such as the application of weights to the limb. It may be
+necessary to administer an anaesthetic before rupturing strong fibrous
+adhesions, and this procedure must be carried out with caution, in view
+of such risks as fracture of the bone--which is often rarefied--or
+separation of an epiphysis. There is also the risk of fat embolism, and
+of re-starting the original disease. The giving way of adhesions may be
+attended with an audible crack; and the procedure is often followed by
+considerable pain and effusion into the joint, which necessitate rest
+for some days before exercises and manipulations can be resumed.
+
+_Operative treatment_ may be called for in cases in which the bones are
+closely bound to one another by fibrous or by osseous tissue.
+
+_Arthrolysis_, which consists in opening the joint and dividing the
+fibrous adhesions, is almost inevitably followed by their reunion.
+
+_Arthroplasty._--Murphy of Chicago devised this operation for restoring
+movement to an ankylosed joint. It consists in transplanting between the
+bones a flap of fat-bearing tissue, from which a bursal cavity lined
+with endothelium and containing a fluid rich in mucin is ultimately
+formed.
+
+Arthroplasty is most successful in ankylosis following upon injury; when
+the ankylosis results from some infective condition such as tuberculosis
+or gonorrhoea, it is liable to result in failure either because of a
+fresh outbreak of the infection or because the ankylosis recurs.
+
+When arthroplasty is impracticable, and a movable joint is desired--for
+example at the elbow--a considerable amount of bone, and it may be also
+of periosteum and capsular ligament, is resected to allow of the
+formation of a false joint.
+
+When bony ankylosis has occurred with the joint in an undesirable
+attitude--for example flexion at the hip or knee--it can sometimes be
+remedied by osteotomy or by a wedge-shaped resection of the bone, with
+or without such additional division of the contracted soft parts as will
+permit of the limb being placed in the attitude desired.
+
+Bony ankylosis of the joints of a finger, whether the result of injury
+or disease, is difficult to remedy by any operative procedure, for while
+it is possible to restore mobility, the new joint is apt to be
+flail-like.
+
+_Locking._--A joint is said to lock when its movements are abruptly
+arrested by the coming together of bony outgrowths around the joint. It
+is best illustrated in arthritis deformans of the hip in which new bone
+formed round the rim of the acetabulum mechanically arrests the
+excursions of the head of the femur. The new bone, which limits the
+movements, is readily demonstrated in skiagrams; it may be removed by
+operative means. Locking of joints is more often met with as a result of
+injuries, especially in fractures occurring in the region of the elbow.
+In certain injuries of the semilunar menisci of the knee, also, the
+joint is liable to a variety of locking, which differs, however, in many
+respects from that described above.
+
+#Errors of Development.#--These include congenital dislocations and
+other deformities of intra-uterine origin, such as abnormal laxity of
+joints, absence, displacement, or defective growth of one or other of
+the essential constituents of a joint. The more important of these are
+described along with the surgery of the Extremities.
+
+
+DISEASES OF JOINTS
+
+#Bacterial Diseases.#--In most bacterial diseases the organisms are
+carried to the joint in the blood-stream, and they lodge either in the
+synovial membrane or in one of the bones, whence the disease
+subsequently spreads to the other structures of the joint. Organisms may
+also be introduced through accidental wounds. It has been shown
+experimentally that joints are among the most susceptible parts of the
+body to infection, and this would appear to be due to the viscid
+character of the synovial fluid, which protects organisms from
+bactericidal agents in the tissues and fluids.
+
+
+PYOGENIC DISEASES
+
+The commoner pyogenic diseases are the result of infection of one or
+other of the joint structures with _staphylococci_ or _streptococci_,
+which may be demonstrated in the exudate in the joint and in the
+substance of the synovial membrane. The mode of infection is the same as
+in the pyogenic diseases of bone, the metastasis occurring most
+frequently from the mucous membrane of the pharynx (J. B. Murphy). The
+localisation of the infection in a particular joint is determined by
+injury, exposure to cold, antecedent disease of the joint, or other
+factors, the nature of which is not always apparent.
+
+The effects on the joint vary in severity. In the milder forms, there is
+engorgement and infiltration of the synovial membrane, and an effusion
+into the cavity of the joint of serous fluid mixed with flakes of
+fibrin--_serous synovitis_. In more severe infections the exudate
+consists of pus mixed with fibrin, and, it may be, red blood
+corpuscles--_purulent_ or _suppurative synovitis_; the synovial membrane
+and the ligaments are softened, and the surface of the membrane presents
+granulations resembling those on an ulcer; foci of suppuration may
+develop in the peri-articular cellular tissue and result in abscesses.
+In _acute arthritis_, all the structures of the joint are involved; the
+articular cartilage is invaded by granulation tissue derived from the
+synovial membrane, and from the marrow of the subjacent bone; it
+presents a worm-eaten or ulcerated appearance, or it may undergo
+necrosis and separate, exposing the subjacent bone and leading to
+disintegration of the osseous trabeculae--_caries_. With the destruction
+of the ligaments, the stability of the joint is lost, and it becomes
+disorganised.
+
+The _clinical features_ vary with the extent of the infection. When
+this is confined to the synovial and peri-synovial tissues--_acute
+serous_ and _purulent synovitis_--there is the usual general reaction,
+associated with pyrexia and great pain in the joint. The part is hot and
+swollen, the swelling assuming the shape of the distended synovial sac,
+fluctuation can usually be elicited, and the joint is held in the flexed
+position.
+
+When the joint is infected by extension from the surrounding cellular
+tissue, the joint lesion may not be recognised at an early stage because
+of the swollen condition of the limb, and because there are already
+symptoms of toxaemia. We have observed a case in which both the hip and
+knee joints were infected from the cellular tissue.
+
+If the infection involves all the joint structures--_acute
+arthritis_--the general and local phenomena are intensified, the
+temperature rises quickly, often with a rigor, and remains high; the
+patient looks ill, and is either unable to sleep or the sleep is
+disturbed by starting pains. The joint is held rigid in the flexed
+position, and the least attempt at movement causes severe pain; the
+slightest jar--even the shaking of the bed--may cause agony. The joint
+is hot, tensely distended, and there may be oedema of the peri-articular
+tissues or of the limb as a whole. If the pus perforates the joint
+capsule, there are signs of abscess or of diffuse suppuration in the
+cellular tissue. The final disorganisation of the joint is indicated by
+abnormal mobility and grating of the articular surfaces, or by
+spontaneous displacement of the bones, and this may amount to
+dislocation. In the acute arthritis of infants, the epiphysis concerned
+may be separated and displaced.
+
+When the _joint is infected through an external wound_, the anatomical
+features are similar to those observed when the infection has reached
+the joint by the blood-stream, but the destructive changes tend to be
+more severe and are more likely to result in disorganisation.
+
+The _terminations_ vary with the gravity of the infection and with the
+stage at which treatment is instituted. In the milder forms recovery is
+the rule, with more or less complete restoration of function. In more
+severe forms the joint may be permanently damaged as a result of fibrous
+or bony ankylosis, or from displacement or dislocation. From changes in
+the peri-articular structures there may be contracture in an undesirable
+position, and in young subjects the growth of the limb may be interfered
+with. The persistence of sinuses is usually due to disease in one or
+other of the adjacent bones. In the most severe forms, and especially
+when several joints are involved, death may result from toxaemia.
+
+The _treatment_ is carried out on the same principles as in other
+pyogenic infections. The limb is immobilised in such an attitude that
+should stiffness occur there will be the least interference with
+function. Extension by weight and pulley is the most valuable means of
+allaying muscular spasm and relieving intra-articular tension and of
+counteracting the tendency to flexion; as much as 15 or 20 pounds may be
+required to relieve the pain.
+
+The induction of hyperaemia is sometimes remarkably efficacious in
+relieving pain and in arresting the progress of the infection. If the
+fluid in the joint is in sufficient quantity to cause tension, if it
+persists, or if there is reason to suspect that it is purulent, it
+should be withdrawn without delay; an exploring syringe usually
+suffices, the skin being punctured with a tenotomy knife, and, as
+practised by Murphy, 5 to 15 c.c. of a 2 per cent. solution of formalin
+in glycerin are injected and the wound is closed. In virulent infections
+the injection may be repeated in twenty-four hours. Drainage by tube or
+otherwise is to be condemned (Murphy). A vaccine may be prepared from
+the fluid in the joint and injected into the subcutaneous cellular
+tissue.
+
+Suppuration in the peri-articular soft parts or in one of the adjacent
+bones must be looked for and dealt with.
+
+When convalescence is established, attention is directed to the
+restoration of the functions of the limb, and to the prevention of
+stiffness and deformity by movements and massage, and the use of hot-air
+and other baths.
+
+At a later stage, and especially in neglected cases, operative and other
+measures may be required for deformity or ankylosis.
+
+
+#Metastatic Forms of Pyogenic Infection#
+
+In #pyaemia#, one or more joints may fill with pus without marked
+symptoms or signs, and if the pus is aspirated without delay the joint
+often recovers without impairment of function.
+
+In #typhoid fever#, joint lesions result from infection with the typhoid
+bacillus alone or along with pyogenic organisms, and run their course
+with or without suppuration; there is again a remarkable absence of
+symptoms, and attention may only be called to the condition by the
+occurrence of dislocation.
+
+Joint lesions are comparatively common in #scarlet fever#, and were
+formerly described as scarlatinal rheumatism. The most frequent clinical
+type is that of a serous synovitis, occurring within a week or ten days
+from the onset of the fever. Its favourite seat is in the hand and
+wrist, the sheaths of the extensor tendons as well as the synovial
+membrane of the joints being involved. It does not tend to migrate to
+other joints, and rarely lasts longer than a few days. It is probably
+due to the specific virus of scarlet fever.
+
+At a later stage, especially in children and in cases in which the
+throat lesion is severe, an arthritis is sometimes observed that is
+believed to be a metastasis from the throat; it may be acute and
+suppurative, affect several joints, and exhibit a septicaemic or pyaemic
+character.
+
+The joints of the lower extremity are especially apt to suffer; the
+child is seriously ill, is delirious at night, develops bed-sores over
+the sacrum and, it may happen that, not being expected to recover, the
+legs are allowed to assume contracture deformities with ankylosis or
+dislocation at the hip and flexion ankylosis at the knees; should the
+child survive, the degree of crippling may be pitiable in the extreme;
+prolonged orthopaedic treatment and a series of operations--arthroplasty,
+osteotomies, and resections--may be required to restore even a limited
+capacity of locomotion.
+
+#Pneumococcal affections of joints#, the result of infection with the
+pneumococcus of Fraenkel, are being met with in increasing numbers. The
+local lesion varies from a _synovitis_ with infiltration of the synovial
+membrane and effusion of serum or pus, to an _acute arthritis_ with
+erosion of cartilage, caries of the articular surfaces, and
+disorganisation of the joint. The knee is most frequently affected, but
+several joints may suffer at the same time. In most cases the joint
+affection makes its appearance a few days after the commencement of a
+pneumonia, but in a number of instances, especially among children, the
+lung is not specially involved, and the condition is an indication of a
+generalised pneumococcal infection, which may manifest itself by
+endocarditis, empyema, meningitis, or peritonitis, and frequently has a
+fatal termination. The differential diagnosis from other forms of
+pyogenic infection is established by bacteriological examination of the
+fluid withdrawn from the joint. The treatment is carried out on the same
+lines as in other pyogenic infections, considerable reliance being
+placed on the use of autogenous vaccines.
+
+In #measles#, #diphtheria#, #smallpox#, #influenza#, and #dysentery#,
+similar joint lesions may occur.
+
+The joint lesions which accompany #acute rheumatism# or "rheumatic
+fever" are believed to be due to a diplococcus. In the course of a
+general illness in which there is moderate pyrexia and profuse sweating,
+some of the larger joints, and not infrequently the smaller ones also,
+become swollen and extremely sensitive, so that the sufferer lies in bed
+helpless, dreading the slightest movement. From day to day fresh joints
+are attacked, while those first affected subside, often with great
+rapidity. Affections of the heart-valves and of the pericardium are
+commonly present. On recovery from the acute illness, it may be found
+that the joints have entirely recovered, but in a small proportion of
+cases certain of them remain stiff and pass into the crippled condition
+described under chronic rheumatism. There is no call for operative
+interference.
+
+#Gonococcal Affections of Joints.#--These include all forms of joint
+lesion occurring in association with gonorrhoeal urethritis,
+vulvo-vaginitis, or gonorrhoeal ophthalmia. They may develop at any stage
+of the urethritis, but are most frequently met with from the eighteenth
+to the twenty-second day after the primary infection, when the organisms
+have reached the posterior urethra; they have been observed, however,
+after the discharge has ceased. There is no connection between the
+severity of the gonorrhoea and the incidence of joint disease. In women,
+the gonorrhoeal nature of the discharge must be established by
+bacteriological examination.
+
+As a complication of ophthalmia, the joint lesions are met with in
+infants, and occur more commonly towards the end of the second or during
+the third week.
+
+The gonococcus is carried to the joint in the blood-stream and is first
+deposited in the synovial membrane, in the tissues of which it can
+usually be found; it may be impossible to find it in the exudate within
+the joint. The joint lesions may be the only evidence of metastasis, or
+they may be part of a general infection involving the endocardium,
+pleura, and tendon sheaths.
+
+The joints most frequently affected are the knee, elbow, ankle, wrist,
+and fingers. Usually two or more joints are affected.
+
+Several clinical types are differentiated. (1) A _dry poly-arthritis_
+met with in the joints and tendon sheaths of the wrist and hand,
+formerly described as gonorrhoeal rheumatism, which in some cases is
+trifling and evanescent, and in others is persistent and progressive,
+and results in stiffness of the affected joints and permanent crippling
+of the hand and fingers.
+
+(2) The commonest type is a _chronic synovitis_ or _hydrops_, in which
+the joint--very often the knee--becomes filled with a serous or
+sero-fibrinous exudate. There are no reactive changes in the synovial
+membrane, cellular tissue, or skin, nor is there any fever or
+disturbance of health. The movements are free except in so far as they
+are restricted by the amount of fluid in the joint. It usually subsides
+in two or three weeks under rest, but tends to relapse.
+
+(3) An _acute synovitis_ with peri-articular phlegmon is most often met
+with in the elbow, but it occurs also in the knee and ankle. There is a
+sudden onset of severe pain and swelling in and around the joint, with
+considerable fever and disturbance of health. The slightest movement
+causes pain, and the part is sensitive to touch. The skin is hot and
+tense, and in the case of the elbow may be red and fiery as in
+erysipelas.
+
+The deposit of fibrin on the synovial membrane and on the articular
+surfaces may lead to the formation of adhesions, sometimes in the form
+of isolated bands, sometimes in the form of a close fibrous union
+between the bones.
+
+(4) A _suppurative arthritis_, like that caused by ordinary pus
+microbes, may be the result of gonococcal infection alone or of a mixed
+infection. Usually only one joint is affected, but the condition may be
+multiple. The articular cartilages are destroyed, the ends of the bones
+are covered with granulations, extra-articular abscesses form, and
+complete osseous ankylosis results.
+
+The _diagnosis_ is often missed because the possibility of gonorrhoea is
+not suspected.
+
+The denial of the disease by the patient is not always to be relied
+upon, especially in the case of women, as they may be ignorant of its
+presence. The chief points in the differential diagnosis from acute
+articular rheumatism are, that the gonorrhoeal affection is more often
+confined to one or two joints, has little tendency to wander from joint
+to joint, and its progress is not appreciably influenced by salicylates,
+although these drugs may relieve pain. The conclusive point is the
+recognition of a gonorrhoeal discharge or of threads in the urine.
+
+The disease may persist or may relapse, and the patient may be laid up
+for weeks or months, and may finally be crippled in one or in several
+joints.
+
+The _treatment_--besides that of the urethral disease or of the
+ophthalmia--consists in rest until all pain and sensitiveness have
+disappeared. The pain is relieved by salicylates, but most benefit
+follows weight extension, the induction of hyperaemia by the rubber
+bandage and hot-air baths; if the joint is greatly distended, the fluid
+may be withdrawn by a needle and syringe. Detoxicated vaccines should be
+given from the first, and in afebrile cases the injection of a foreign
+protein, such as anti-typhoid vaccine, is beneficial (Harrison).
+
+Murphy has found benefit from the introduction into the joint, in the
+early stages, of from 5 to 15 c.c. of a 2 per cent. solution of formalin
+in glycerin. This may be repeated within a week, the patient being kept
+in bed with light weight extension. In the chronic hydrops the fluid is
+withdrawn, and about an ounce of a 1 per cent. solution of protargol
+injected; the patient should be warned of the marked reaction which
+follows.
+
+After all symptoms have settled down, but not till then, for fear of
+exciting relapse or metastasis, the joint is massaged and exercised.
+Stiffness from adhesions is most intractable, and may, in spite of every
+attention, terminate in ankylosis even in cases where there has been no
+suppuration. Forcible breaking down of adhesions under anaesthesia is
+not recommended, as it is followed by great suffering and the adhesions
+re-form. Operation for ankylosis--arthroplasty--should not be
+undertaken, as the ankylosis recurs.
+
+
+TUBERCULOUS DISEASE
+
+Tuberculous disease of joints results from bacillary infection through
+the arteries. The disease may commence in the synovial membrane or in
+the marrow of one of the adjacent bones, and the relative frequency of
+these two seats of infection has been the subject of considerable
+difference of opinion. The traditional view of Konig is that in the knee
+and most of the larger joints the disease arises in the bone and in the
+synovial membrane in about equal proportion, and that in the hip the
+number of cases beginning in the bones is about five times greater than
+that originating in the membrane. This estimate, so far as the actual
+frequency of bone lesions is concerned, has been generally accepted, but
+recent observers, notably John Fraser, do not accept the presence of
+bone lesions as necessarily proving that the disease commenced in the
+bones; he maintains, and we think with good grounds, that in many cases
+the disease having commenced in the synovial membrane, slowly spreads to
+the bone by way of the blood vessels and lymphatics, and gives rise to
+lesions in the marrow.
+
+#Morbid Anatomy.#--Tuberculous disease in the articular end of a long
+bone may give rise to _reactive changes_ in the adjacent joint,
+characterised by effusion and by the extension of the synovial membrane
+over the articular surfaces. This may result in the formation of
+adhesions which obliterate the cavity of the joint or divide it into
+compartments. These lesions are comparatively common, and are not
+necessarily due to actual tuberculous infection of the joint.
+
+The _infection of the joint_ by tubercle originating in the adjacent
+bone may take place at the periphery, the osseous focus reaching the
+surface of the bone at the site of reflection of the synovial membrane,
+and the infection which begins at this point then spreads to the rest of
+the membrane. Or it may take place in the central area, by the
+projection of tuberculous granulation tissue into the joint following
+upon erosion of the cartilage (Fig. 156).
+
+[Illustration: FIG. 156.--Section of Upper End of Fibula, showing
+caseating focus in marrow, erupting on articular surface and infecting
+joint.]
+
+_Changes in the Synovial Membrane._--In the majority of cases there is a
+_diffuse thickening of the synovial membrane_, due to the formation of
+granulation tissue, or of young connective tissue, in its substance.
+This new tissue is arranged in two layers--the outer composed of fully
+formed connective or fibrous tissue, the inner of embryonic tissue,
+usually permeated with miliary tubercles. On opening the joint, these
+tubercles may be seen on the surface of the membrane, or the surface may
+be covered with a layer of fibrinous or caseating tissue. Where there is
+greater resistance on the part of the tissues, there is active formation
+of young connective tissue which circumscribes or encapsulates the
+tubercles, so that they remain embedded in the substance of the
+membrane, and are only seen on cutting into it.
+
+The thickened synovial membrane is projected into the cavity of the
+joint, filling up its pouches and recesses, and spreading over the
+surface of the articular cartilage "like ivy growing on a wall."
+Wherever the synovial tissue covers the cartilage it becomes adherent to
+and fused with it. The morbid process may be arrested at this stage, and
+fibrous adhesions form between the opposing articular surfaces, or it
+may progress, in which case further changes occur, resulting in
+destruction of the articular cartilage and exposure of the subjacent
+bone.
+
+In rare instances the synovial membrane presents nodular masses or
+lumps, resembling the tuberculous tumours met with in the brain; they
+project into the cavity of the joint, are often pedunculated, and may
+give rise to the symptoms of loose body. The fringes of synovial
+membrane may also undergo a remarkable development, like that observed
+in arthritis deformans, and described as arborescent lipoma. Both these
+types are almost exclusively met with in the knee.
+
+_The Contents of Tuberculous Joints._--In a large proportion of cases of
+synovial tuberculosis the joint is entirely filled up by the diffuse
+thickening of the synovial membrane. In a small number there is an
+abundant serous exudate, and with this there may be a considerable
+formation of fibrin, covering the surface of the membrane and floating
+in the fluid as flakes or masses; under the influence of movement it may
+assume the shape of melon-seed bodies. More rarely the joint contains
+pus, and the surface of the synovial membrane resembles the wall of a
+cold abscess.
+
+_Ulceration and Necrosis of Cartilage._--The synovial tissue covering
+the cartilage causes pitting and perforation of the cartilage and makes
+its way through it, and often spreads widely between it and the
+subjacent bone; the cartilage may be detached in portions of
+considerable size. It may be similarly ulcerated or detached as a result
+of disease in the bone.
+
+_Caries of Articular Surfaces._--Tuberculous infiltration of the marrow
+in the surface cancelli breaks up the spongy framework of the bone into
+minute irregular fragments, so that it disintegrates or crumbles
+away--caries. When there is an absence of caseation and suppuration, the
+condition is called _caries sicca_.
+
+The pressure of the articular surfaces against one another favours the
+progress of ulceration of cartilage and of articular caries. These
+processes are usually more advanced in the areas most exposed to
+pressure--for example, in the hip-joint, on the superior aspect of the
+head of the femur, and on the posterior and upper segment of the
+acetabulum.
+
+The occurrence of _pathological dislocation_ is due to softening and
+stretching of the ligaments which normally retain the bones in position,
+and to some factor causing displacement, which may be the accumulation
+of fluid or of granulations in the joint, the involuntary contraction of
+muscles, or some movement or twist of the limb. The occurrence of
+dislocation is also favoured by destructive changes in the bones.
+
+_Peri-articular tubercle and abscess_ may result from the spread of
+disease from the bone or joint into the surrounding tissues, either
+directly or by way of the lymphatics. A peri-articular abscess may
+spread in several directions, sometimes invading tendon sheaths or
+bursae, and finally reaching the skin surface by tortuous sinuses.
+
+Reactive changes in the vicinity of tuberculous joints are of common
+occurrence, and play a considerable part in the production of what is
+clinically known as _white swelling_. New connective tissue forms in the
+peri-articular fat and between muscles and tendons. It may be tough and
+fibrous, or soft, vascular, and oedematous, and the peri-articular fat
+becomes swollen and gelatinous, constituting a layer of considerable
+thickness. The fat disappears and is replaced by a mucoid effusion
+between the fibrous bundles of connective tissue. This is what was
+formerly known as _gelatinous degeneration_ of the synovial membrane. In
+the case of the wrist the newly formed connective tissue may fix the
+tendons in their sheaths, interfering with the movements of the fingers.
+In relation to the bones also there may be reactive changes, resulting
+in the formation of spicules of new bone on the periosteal surfaces and
+at the attachment of the capsular and other ligaments; these are only
+met with where pyogenic infection has been superadded.
+
+_Terminations and Sequelae._--A natural process of cure may occur at any
+stage, the tuberculous tissue being replaced by scar tissue. Recovery is
+apt to be attended with impairment of movement due to adhesions,
+ankylosis, or contracture of the peri-articular structures. Caseous foci
+in the interior of the bones may become encapsulated, and a cure be thus
+effected, or they may be the cause of a relapse of the disease at a
+later date. Interference with growth is comparatively common, and may
+involve only the epiphysial junctions in the immediate vicinity of the
+joint affected, or those of all the bones of the limb. This is well seen
+in adults who have suffered from severe disease of the hip in
+childhood--the entire limb, including the foot, being shorter and
+smaller than the corresponding parts of the opposite side.
+
+Atrophic conditions are also met with, the bones undergoing fatty
+atrophy, so that in extreme cases they may be cut with a knife or be
+easily fractured. These atrophic conditions are most marked in bedridden
+patients, and are largely due to disuse of the limb; they are recovered
+from if it is able to resume its functions.
+
+#Clinical Features.#--These vary with the different anatomical forms of
+the disease, and with the joint affected.
+
+Sometimes the disease is ushered in by a febrile attack attended with
+pains in several joints--described by John Duncan as _tuberculous
+arthritic fever_. This is liable to be mistaken for rheumatic fever,
+from which, however, it differs in that there is no real migration from
+joint to joint; there is an absence of sweating and of cardiac
+complications; and no benefit follows the administration of salicylates.
+
+In exceptional cases, tuberculous joint disease follows an acute course
+resembling that of the pyogenic arthritis of infants. This has been
+observed in children, especially in the knee, the lesion being in the
+synovial membrane, and attended with an accumulation of pus in the
+joint. If promptly treated by incision and drainage, recovery is rapid,
+and free movement of the joint, may be preserved.
+
+The onset and early stages of tuberculous disease, however, are more
+often insidious, and are attended with so few symptoms that the disease
+may have obtained a considerable hold before it attracts notice. It is
+not uncommon for patients or their friends to attribute the condition to
+injury, as it often first attracts attention after some slight trauma or
+excessive use of the limb. The symptoms usually subside under rest, only
+to relapse again with use of the limb.
+
+The initial local symptoms may be due to the presence of a focus in the
+neighbouring bone, perhaps causing neuralgic pains in the joint, or
+weakness, tiredness, stiffness, and inability to use the limb, these
+symptoms improving with rest and being aggravated by exertion.
+
+It is rarely possible by external examination to recognise deep-seated
+osseous foci in the vicinity of joints; but if they are near the surface
+in a superficial bone--such as the head of the tibia--there may be local
+thickening of the periosteum, oedema, pain, and tenderness on pressure
+and on percussion.
+
+_X-ray Appearances of Tuberculous Joints._--Gross lesions such as
+caseous foci in the marrow of the adjacent bone show as clear areas with
+an ill-defined margin; a sclerosed focus gives a denser shadow than the
+surrounding bone, and a sequestrum presents a dark shadow of irregular
+contour, and a clear interval between it and the surrounding bone.
+
+Caries of the articular surface imparts a woolly appearance or irregular
+contour in place of the well-defined outline of the articular end of the
+bone. In bony ankylosis the shadow of the two bones is a continuous one,
+the joint interval having been filled up. The minor changes are best
+appreciated on comparison with the normal joint of the other limb.
+
+_Wasting of muscles_ is a constant accompaniment of tuberculous joint
+disease. It is to be attributed partly to want of use, but chiefly to
+reflex interference with the trophic innervation of the muscles. It is
+specially well seen in the extensor and adductor muscles of the thigh in
+disease of the knee, and in the deltoid in disease of the shoulder. The
+muscles become soft and flaccid, they exhibit tremors on attempted
+movement, and their excitability to the faradic current is diminished.
+The muscular tissue may be largely replaced by fat.
+
+_Impairment of the normal movements_ is one of the most valuable
+diagnostic signs, particularly in deeply seated joints such as the
+shoulder, hip, and spine. It is due to a protective contraction of the
+muscles around the joint, designed to prevent movement. This muscular
+fixation disappears under anaesthesia.
+
+_Abnormal attitudes of the limb_ occur earlier, and are more pronounced
+in cases in which pain and other irritative symptoms of articular
+disease are well marked, and are best illustrated by the attitudes
+assumed in disease of the hip. They are due to reflex or involuntary
+contraction of the muscles acting on the joint, with the object of
+placing it in the attitude of greatest ease; they also disappear under
+anaesthesia. With the lapse of time they not only become exaggerated, but
+may become permanent from ankylosis or from contracture of the soft
+parts round the joint.
+
+_Startings at night_ are to be regarded as an indication that there is
+progressive disease involving the articular surfaces.
+
+_The formation of extra-articular abscess_ may take place early, or it
+may not occur till long after the disease has subsided. The abscess may
+develop so insidiously that it does not attract attention until it has
+attained considerable size, especially when associated with disease of
+the spine, pelvis, or hip. The position of the abscess in relation to
+different joints is fairly constant and is determined by the anatomical
+relationships of the capsule and synovial membrane to the surrounding
+tissues. The bursae and tendon sheaths in the vicinity may influence the
+direction of spread of the abscess and the situation of resulting
+sinuses. When the abscess is allowed to burst, or is opened and becomes
+infected with pyogenic bacteria, there is not only the risk of
+aggravation of the disease and persistent suppuration, but there is a
+greater liability to general tuberculosis.
+
+The sinuses may be so tortuous that a probe cannot be passed to the
+primary focus of disease, and their course and disposition can only be
+demonstrated by injecting the sinuses with an emulsion of bismuth and
+taking X-ray photographs.
+
+Tuberculous infection of the lymph glands of the limb is exceptional,
+but may follow upon infection of the skin around the orifice of a sinus.
+
+A slight rise of temperature in the evening may be induced in quiescent
+joint lesions by injury or by movement of the joint under anaesthesia, or
+by the fatigue of a railway journey. When sinuses have formed and become
+infected with pyogenic bacteria, there may be a diurnal variation in the
+temperature of the type known as hectic fever (Fig. 11).
+
+_Relative Frequency of Tuberculous Disease in Different
+Joints._--Hospital statistics show that joints are affected in the
+following order of frequency: Spine, knee, hip, ankle and tarsus, elbow,
+wrist, shoulder. The hip and spine are most often affected in childhood
+and youth, the shoulder and wrist in adults; the knee, ankle, and elbow
+show little age preference.
+
+_Clinical Variations of Tuberculous Joint Disease._--The above
+description applies to tuberculous joint disease in general; it must be
+modified to include special manifestations or varieties.
+
+When the main incidence of the infection affects the synovial membrane,
+the clinical picture may assume the form of a _hydrops_, or of an
+_empyema_ in which the joint is filled with pus. More common than either
+of these is the well-known _white swelling_ or _tumor albus_ (Wiseman,
+1676) which is the clinical manifestation of diffuse thickening of the
+synovial membrane along with mucoid degeneration of the peri-synovial
+cellular tissue. It is well seen in joints which are superficial--such
+as the knee, ankle, elbow, and wrist. The swelling, which is the first
+and most prominent clinical feature, develops gradually and painlessly,
+obliterating the bony prominences by filling up the natural hollows. It
+appears greater to the eye than is borne out by measurement, being
+thrown into relief by the wasting of the muscles above and below the
+joint. In the early stage the swelling is elastic, doughy, and
+non-sensitive, and corresponds to the superficial area of the synovial
+membrane involved, and there is comparatively little complaint on the
+part of the patient, because the articular surfaces and ligaments are
+still intact. There may be a feeling of weight in the limb, and in the
+case of the knee and ankle the patient tires on walking and drags the
+leg with more or less of a limp. Movements of the joint are permitted,
+but are limited in range. The disability is increased by use and
+exertion, but, for a time at least, it improves under rest.
+
+If the disease is not arrested, there follow the symptoms and signs of
+involvement of the articular surfaces.
+
+_Influence of Tuberculous Joint Disease on the General
+Health._--Experience shows that the early stages of tuberculous joint
+disease are compatible with the appearance of good health. As a rule,
+however, and especially if there is mixed infection, the health suffers,
+the appetite is impaired, the patient is easily tired, and there may be
+some loss of weight.
+
+#Treatment.#--In addition to the general treatment of tuberculosis,
+local measures are employed. These may be described under two heads--the
+conservative and the operative.
+
+_Conservative treatment_ is almost always to be employed in the first
+instance, as by it a larger proportion of cures is obtained with a
+smaller mortality and with better functional results than by operation.
+
+_Treatment by rest_ implies the immobilisation of the diseased limb
+until pain and tenderness have disappeared. The attitude in which the
+limb is immobilised should be that in which, in the event of subsequent
+stiffness, it will be most serviceable to the patient. Immobilisation
+may be secured by bandages, splints, extension, or other apparatus.
+_Extension_ with weight and pulley is of value in securing rest,
+especially in disease of the hip or knee; it eliminates muscular spasm,
+relieves pain and startings at night, and prevents abnormal attitudes of
+the limb. If, when the patient first comes under observation, the limb
+is in a deformed attitude which does not readily yield to extension, the
+deformity should be corrected under an anaesthetic.
+
+_The induction of hyperaemia_ is often helpful, the rubber bandage or the
+hot-air chamber being employed for an hour or so morning and evening.
+
+_Injection of Iodoform._--This is carried out on the same lines as have
+been described for tuberculous abscess. After the fluid contents of the
+joint are withdrawn, the iodoform is injected; and this may require to
+be repeated in a month or six weeks.
+
+After the injection of iodoform there is usually considerable reaction,
+attended with fever (101 F.), headache, and malaise, and considerable
+pain and swelling of the joint. In some cases there is sickness, and
+there may be blood pigment in the urine. The severity of these phenomena
+diminishes with each subsequent injection.
+
+The use of Scott's dressing and of blisters and of the actual cautery
+has largely gone out of fashion, but the cautery may still be employed
+with benefit for the relief of pain in cases in which ulceration of
+cartilage is a prominent feature.
+
+The application of the X-rays has proved beneficial in synovial lesions
+in superficial joints such as the wrist or elbow; prolonged exposures
+are made at fortnightly intervals, and on account of the cicatricial
+contraction which attends upon recovery, the joint must be kept in good
+position.
+
+Conservative treatment is only abandoned if improvement does not show
+itself after a thorough trial, or if the disease relapses after apparent
+cure.
+
+_Operative Treatment._--Other things being equal, operation is more
+often indicated in adults than in children, because after the age of
+twenty there is less prospect of recovery under conservative treatment,
+there is more tendency for the disease to relapse and to invade the
+internal organs, and there is no fear of interfering with the growth of
+the bones. The state of the general health may necessitate operation as
+the most rapid method of removing the disease. The social status of the
+patient must also be taken into account; the bread-winner, under
+existing social conditions, may be unable to give up his work for a
+sufficient time to give conservative measures a fair trial.
+
+The _local conditions_ which decide for or against operation are
+differently regarded by different surgeons, but it may be said in
+general terms that operative interference is indicated in cases in which
+the disease continues to progress in spite of a fair trial of
+conservative measures; in cases unsuited for conservative
+treatment--that is to say, where there are severe bone lesions.
+Operative interference is indicated also when the functional result will
+be better than that likely to be obtained by conservative measures, as
+is often the case in the knee and elbow. Cold abscesses should, if
+possible, be dealt with before operating on the joint.
+
+In many cases the extent of the operation can only be decided after
+exploration. The aim is to remove all the disease with the least
+impairment of function and the minimum sacrifice of healthy tissue. The
+more open the method of operating the better, so that all parts of the
+joint may be available for inspection. The methods of Kocher, which
+permit of dislocating the joint, are specially to be recommended, as
+this procedure affords the freest possible access. Diseased synovial
+membrane is removed with the scissors or knife. If the cartilages are
+sound, and if a movable joint is aimed at, they may be left; but if
+ankylosis is desired, they must be removed. Localised disease of the
+cartilage should be removed with the spoon or gouge, and the bone
+beneath investigated. If the articular surface is extensively diseased,
+a thin slice of bone should be removed, and if foci in the marrow are
+then revealed, it is better to gouge them out than to remove further
+slices of bone, as this involves sacrifice of the cortex and periosteum.
+
+Operative treatment of deformities resulting from tuberculous joint
+disease has almost entirely replaced reduction by force; the contracted
+soft parts are divided, and the bone is resected.
+
+_Amputation_ for tuberculous joint disease has become one of the rare
+operations of surgery, and is only justified when less radical measures
+have failed and the condition of the limb is affecting the general
+health. Amputation is more frequently called for in persons past middle
+life who are the subjects of pulmonary tuberculosis.
+
+
+SYPHILITIC DISEASE
+
+Syphilitic affections of joints are comparatively rare. As in
+tuberculosis, the disease may be first located in the synovial membrane,
+or it may spread to the joint from one of the bones.
+
+In #acquired syphilis#, at an early stage and before the skin eruptions
+appear, one of the large joints, such as the shoulder or knee, may be
+the seat of pain--_arthralgia_--which is worse at night. In the
+secondary stage, a _synovitis_ with serous effusion is not uncommon, and
+may affect several joints. Syphilitic _hydrops_ is met with almost
+exclusively in the knee; it is frequently bilateral, and is insidious in
+its onset and progress, the patient usually being able to go about.
+
+In the _tertiary stage_ the joint lesions are persistent and
+destructive, and result from the formation of gummata, either in the
+deeper layers of the synovial membrane or in the adjacent bone or
+periosteum.
+
+_Peri-synovial_ and _peri-bursal gummata_ are met with in relation to
+the knee-joint of middle-aged adults, especially women. They are usually
+multiple, develop slowly, and are rarely sensitive or painful. One or
+more of the gummata may break down and give rise to tertiary ulcers. The
+co-existence of indolent swellings, ulcers, and depressed scars in the
+vicinity of the knee is characteristic of tertiary syphilis.
+
+The disease spreads throughout the capsule and synovial membrane, which
+becomes diffusely thickened and infiltrated with granulation tissue
+which eats into and replaces the articular cartilage. Clinically, the
+condition resembles tuberculous disease of the synovial membrane, for
+which it is probably frequently mistaken, but in the syphilitic
+affection the swelling is nodular and uneven, and the subjective
+symptoms are slight, mobility is little impaired, and yet the deformity
+is considerable.
+
+_Syphilitic osteo-arthritis_ results from a gumma in the periosteum or
+marrow of one of the adjacent bones. There is gradual enlargement of one
+of the bones, the patient complains of pains, which are worst at night.
+The disease may extend to the synovial membrane and be attended with
+effusion into the joint, or it may erupt on the periosteal surface and
+invade the skin, forming one or more sinuses. The further progress is
+complicated by the occurrence of pyogenic infection leading to necrosis
+of bone, in the knee-joint, for example, the patella or one of the
+condyles of the femur or tibia, may furnish a sequestrum. In such cases,
+anti-syphilitic treatment must be supplemented by operation for the
+removal of the diseased tissues. In the knee, excision is rarely
+necessary; but in the elbow it may be called for to obtain a movable
+joint.
+
+In #inherited syphilis# the earliest joint affections are those in which
+there is an effusion into the joint, especially the knee or elbow; and
+in exceptional cases pyogenic infection may be superadded, and pus form
+in the joint.
+
+In older children, a gummatous synovitis is met with of which the most
+striking features are: its insidious development, its chronic course,
+symmetrical distribution, freedom from pain, the free mobility of the
+joint, its tendency to relapse, and its association with other
+syphilitic stigmata, especially in the eyes. The knees are the joints
+most frequently affected, and the condition usually yields readily to
+anti-syphilitic treatment without impairment of function.
+
+
+JOINT DISEASES ACCOMPANYING CERTAIN CONSTITUTIONAL CONDITIONS
+
+#Gout.#--_Arthritis Urica._--One of the manifestations of gout is that
+certain joints are liable to attacks of inflammation associated with the
+deposit of a chalk-like material composed of sodium biurate, chiefly in
+the matrix of the articular cartilage, it may be in streaks or patches
+towards the central area of the joint, or throughout the entire extent
+of the cartilage, which appears as if it had been painted over with
+plaster of Paris. As a result of this uratic infiltration, the cartilage
+loses its vitality and crumbles away, leading to the formation of what
+are known as gouty ulcers, and these may extend through the cartilage
+and invade the bone. The deposit of urates in the synovial membrane is
+attended with effusion into the joint and the formation of adhesions,
+while in the ligaments and peri-articular structures it leads to the
+formation of scar tissue. The metatarso-phalangeal joint of the great
+toe, on one or on both sides, is that most frequently affected. The
+disease is met with in men after middle life, and while common enough in
+England and Ireland, is almost unknown in hospital practice in Scotland.
+
+The _clinical features_ are characteristic. There is a sudden onset of
+excruciating pain, usually during the early hours of the morning, the
+joint becomes swollen, red, and glistening, with engorgement of the
+veins and some fever and disturbance of health and temper. In the course
+of a week or ten days there is a gradual return to the normal. Such
+attacks may recur only once a year or they may be more frequent; the
+successive attacks tend to become less acute but last longer, and the
+local phenomena persist, the joint remaining permanently swollen and
+stiff. Masses of chalk form in and around the joint, and those in the
+subcutaneous tissue may break through the skin, forming indolent ulcers
+with exposure of the chalky masses (_tophi_). The hands may become
+seriously crippled, especially when the tendon sheaths and bursae also
+are affected; the crippling resembles that resulting from arthritis
+deformans but it differs in not being symmetrical.
+
+The local _treatment_ consists in employing soothing applications and a
+Bier's bandage for two or three hours twice daily while the symptoms are
+acute; later, hot-air baths, massage, and exercises are indicated. It is
+remarkable how completely even the most deformed joints may recover
+their function. Dietetic and medicinal treatment must also be employed.
+
+#Chronic Rheumatism.#--This term is applied to a condition which
+sometimes follows upon acute articular rheumatism in persons presenting
+a family tendency to acute rheumatism or to inflammations of serous
+membranes, and manifesting other evidence of the rheumatic taint, such
+as chorea or rheumatic nodules.
+
+The changes in the joints involve almost exclusively the synovial
+membrane and the ligaments; they consist in cellular infiltration and
+exudation, resulting in the formation of new connective tissue which
+encroaches on the cavity of the joint and gives rise to adhesions, and
+by contracting causes stiffness and deformity. The articular cartilages
+may subsequently be transformed into connective tissue, with consequent
+fibrous ankylosis and obliteration of the joint. The bones are affected
+only in so far as they undergo fatty atrophy from disuse of the limb, or
+alteration in their configuration as a result of partial dislocation.
+Osseous ankylosis may occur, especially in the small joints of the hand
+and foot.
+
+The disease is generally poly-articular and may be met with in childhood
+and youth as well as in adult life. In some cases pain is so severe that
+the patient resists the least attempt at movement. In others, the
+joints, although stiff, can be moved but exhibit pronounced crackings.
+When there is much connective tissue formed in relation to the synovial
+membrane, the joint is swollen, and as the muscles waste above and
+below, the swelling is spindle-shaped. Subacute exacerbations occur from
+time to time, with fever and aggravation of the local symptoms and
+implication of other joints. After repeated recurrences, there is
+ankylosis with deformity, the patient becoming a helpless cripple. On
+account of the tendency to visceral complications, the tenure of life is
+uncertain.
+
+From the nature of the disease, _treatment_ is for the most part
+palliative. Salicylates are only of service during the exacerbations
+attended with pyrexia. The application of soda fomentations, turpentine
+cloths, or electric or hot-air baths may be useful. Improvement may
+result from the general and local therapeutics available at such places
+as Bath, Buxton, Harrogate, Strathpeffer, Wiesbaden, or Aix. In selected
+cases, a certain measure of success has followed operative interference,
+which consists in a modified excision. The deformities resulting from
+chronic rheumatism are but little amenable to surgical treatment, and
+forcible attempts to remedy stiffness or deformity are to be avoided.
+
+#Arthritis Deformans# (_Osteo-arthritis, Rheumatoid Arthritis, Rheumatic
+Gout, Malum Senile, Traumatic or Mechanical Arthritis_).--Under the term
+arthritis deformans, which was first employed by Virchow, it is
+convenient to include a number of joint affections which have many
+anatomical and clinical features in common.
+
+The disease is widely distributed in the animal kingdom, both in
+domestic species and in wild animals in the natural state such as the
+larger carnivora and the gorilla; evidence of it has also been found in
+the bones of animals buried with prehistoric man.
+
+The morbid changes in the joints present a remarkable combination of
+atrophy and degeneration on the one hand and overgrowth on the other,
+indicating a profound disturbance of nutrition in the joint structures.
+The nature of this disturbance and its etiology are imperfectly known.
+By many writers it is believed to depend upon some form of
+auto-intoxication, the toxins being absorbed from the gastro-intestinal
+tract, and those who suffer are supposed to possess what has been called
+an "arthritic diathesis."
+
+The localisation of the disease in a particular joint may be determined
+by several factors, of which trauma appears to be the most important.
+The condition is frequently observed to follow, either directly or after
+an interval, upon a lesion which involves gross injury of the joint or
+of one of the neighbouring bones. It occurs with greater frequency after
+repeated minor injuries affecting the joint and its vicinity, such as
+sprains and contusions, and particularly those sustained in laborious
+occupations. This connection between trauma and arthritis deformans led
+Arbuthnot Lane to apply to it the term _traumatic_ or _trade arthritis_.
+
+The traumatic or strain factor in the production of the disease may be
+manifested in a less obvious fashion. In the lower extremity, for
+example, _any condition which disturbs the static equilibrium of the
+limb as a whole_ would appear to predispose to the disease in one or
+other of the joints. The static equilibrium may be disturbed by such
+deformities as flat-foot or knock-knee, and badly united fractures of
+the lower extremity. In hallux valgus, the metatarso-phalangeal joint of
+the great toe undergoes changes characteristic of arthritis deformans.
+
+A number of cases have been recorded in which arthritis deformans has
+followed upon antecedent disease of the joint, such as pyogenic or
+gonorrhoeal synovitis, upon repeated haemorrhages into the knee-joint in
+bleeders, and in unreduced dislocations in which a new joint has been
+established.
+
+[Illustration: FIG. 157.--Arthritis Deformans of Elbow, showing
+destruction of articular surfaces and masses of new bone around the
+articular margins.
+
+(Anatomical Museum, University of Edinburgh.)]
+
+Lastly, Poncet and other members of the Lyons school regard arthritis
+deformans as due to an attenuated form of tuberculous infection, and
+draw attention to the fact that a tuberculous family history is often
+met with in the subjects of the disease.
+
+[Illustration: FIG. 158.--Arthritis Deformans of Knee, showing
+eburnation and grooving of articular surfaces.
+
+(Anatomical Museum, University of Edinburgh.)]
+
+_Morbid Anatomy._--The commonest type is that in which the articular
+surfaces undergo degenerative changes. The primary change involves the
+articular cartilage, which becomes softened and fibrillated and is worn
+away until the subjacent bone is exposed. If the bone is rarefied, the
+enlarged cancellous spaces are opened into and an eroded and worm-eaten
+appearance is brought about; with further use of the joint, the bone is
+worn away, so that in a ball-and-socket joint like the hip, the head of
+the femur and the acetabulum are markedly altered in size and shape.
+More commonly, the bone exposed as a result of disappearance of the
+cartilage is denser than normal, and under the influence of the
+movements of the joint, becomes smooth and polished--a change described
+as _eburnation_ of the articular surfaces (Fig. 158). In hinge-joints
+such as the knee and elbow, the influence of movement is shown by a
+series of parallel grooves corresponding to the lines of friction
+(Fig. 158).
+
+[Illustration: FIG. 159.--Hypertrophied Fringes of Synovial Membrane in
+Arthritis Deformans of Knee.
+
+(Museum of Royal College of Surgeons, Edinburgh.)]
+
+While these degenerative changes are gradually causing destruction of
+the articular surfaces, reparative and hypertrophic changes are taking
+place at the periphery. Along the line of the junction between the
+cartilage and synovial membrane, the proliferation of tissue leads to
+the formation of nodules or masses of cartilage--_ecchondroses_--which
+are subsequently converted into bone (Fig. 157). Gross alterations in
+the ends of the bone are thus brought about which can be recognised
+clinically and in skiagrams, and which tend to restrict the normal range
+of movement. The extension of the ossification into the synovial
+reflection and capsular ligament adds a collar or "lip" of new bone,
+known as "lipping" of the articular margins, and also into other
+ligaments, insertions of tendons and intermuscular septa giving rise to
+bony outgrowths or osteophytes not unlike those met with in the
+neuro-arthropathies.
+
+Proliferative changes in the synovial membrane are attended with
+increased vascularity and thickening of the membrane and an enlargement
+of its villi and fringes. When the fatty fringes are developed to an
+exaggerated degree, the condition is described as an _arborescent
+lipoma_ (Fig. 159). Individual fringes may attain the size of a hazel
+nut, and the fibro-fatty tissue of which they are composed may be
+converted into cartilage and bone; such a body may remain attached by a
+narrow pedicle or stalk, or this may be torn across and the body becomes
+loose and, unless confined in a recess of the joint, it wanders about
+and may become impacted between the articular surfaces. These changes in
+the synovial membrane are often associated with an abundant exudate or
+hydrops. These degenerative and hypertrophic changes, while usually
+attended with marked restriction of movement and sometimes by "locking"
+of the joint, practically never result in ankylosis.
+
+The _ankylosing type_ of chronic arthritis is fortunately much rarer
+than those described above, and is chiefly met with in the joints of the
+fingers and toes and in those of the vertebral column. The synovial
+membrane proliferates, grows over the cartilage, and replaces it, and
+when two such articular surfaces are in contact they tend to adhere,
+thus obliterating the joint, cavity, and resulting in fibrous or bony
+ankylosis. The changes progress slowly and, before they result in
+ankylosis, various sub-luxations and dislocations may occur with
+distortion and deformity which, in the case of the fingers, is extremely
+disabling and unsightly (Fig. 160).
+
+_Clinical Features._--It is usually observed that in patients who are
+still young the tendency is for the disease to advance with considerable
+rapidity, so that in the course of months it may cause crippling of
+several joints. The course of the disease as met with in persons past
+middle life is more chronic; it begins insidiously, and many years may
+pass before there is pronounced disability. The earliest symptom is
+stiffness, especially in the morning after rest, which passes off
+temporarily with use of the limb. As time goes on, the range of movement
+becomes restricted, and crackings occur. This stage of the disease may
+be prolonged indefinitely; if it progresses, stiffness becomes more
+pronounced, certain movements are lost, others develop in abnormal
+directions, and deformed attitudes add to the disablement. The disease
+is compatible with long life, but not with any active occupation, hence
+those of the hospital class who suffer from it tend to accumulate in
+workhouse infirmaries.
+
+_Hydrops_ is most marked in the knee, and may affect also the adjacent
+bursae. As the joint becomes distended with fluid, the ligaments are
+stretched, the limb becomes weak and unstable, and the patient complains
+of a feeling of weight, of insecurity, and of tiredness. Pain is
+occasional and evanescent, and is usually the result of some extra
+exertion, or exposure to cold and wet. This form of the disease is
+extremely chronic, and may last for an indefinite number of years. It is
+to be diagnosed from the other forms of hydrops already considered--the
+purely traumatic, the pyogenic, gonorrhoeal, tuberculous, and
+syphilitic--and from that associated with Charcot's disease.
+
+_Hypertrophied fringes and pedunculated or loose bodies_ often co-exist
+with hydrops, and give rise to characteristic clinical features,
+particularly in the knee. The fringes, especially when they assume the
+type of the arborescent lipoma, project into the cavity of the joint,
+filling up its recesses and distending its capsule so that the joint is
+swollen and slightly flexed. Pain is not a prominent feature, and the
+patient may walk fairly well. On grasping the joint while it is being
+actively flexed and extended, the fringes may be felt moving under the
+fingers. Symptoms from impaction of a loose body are exceptional.
+
+[Illustration: FIG. 160.--Arthritis Deformans of Hands, showing
+symmetry of lesions, ulnar deviation of fingers, and nodular thickening
+at inter-phalangeal joints.]
+
+_The dry form of arthritis deformans_, although specially common in the
+knee, is met with in other joints, either as a mon-articular or
+poly-articular disease; and it is also met with in the joints of the
+spine and of the fingers as well as in the temporo-mandibular joint. In
+the joints of the fingers the disease is remarkably symmetrical, and
+tends to assume a nodular type (Heberden's nodes) (Fig. 160); in younger
+subjects it assumes a more painful and progressive fusiform type
+(Fig. 161). In the larger joints the subjective symptoms usually precede
+any palpable evidence of disease, the patient complaining of stiffness,
+crackings, and aching, aggravated by changes in the weather. The
+roughness due to fibrillation of the articular cartilages causes coarse
+friction on moving the joint, or, in the knee, on moving the patella on
+the condyles of the femur. It may be months or even years before the
+lipping and other hypertrophic changes in the ends of the bones are
+recognisable, and before the joint assumes the deformed features which
+the name of the disease suggests.
+
+The capsular ligament, except in hydrops, is the seat of
+connective-tissue overgrowth, and tends to become contracted and rigid.
+Intra-articular ligaments, such as the ligamentum teres in the hip, are
+usually worn away and disappear. The surrounding muscles undergo
+atrophy, tendons become adherent to their sheaths and may be ossified,
+and the sheaths of nerves may be involved by the cicatricial changes in
+the surrounding tissues.
+
+_The X-ray appearances of arthritis deformans_ necessarily vary with the
+type of the disease and the joint affected; in the joints of the fingers
+there is a narrowing of the spaces between the articular ends of the
+bones as a result of absorption of the articular cartilage, and
+rarefaction of the cancellous tissue in the vicinity of the joints; in
+the larger joints there is "lipping" of the articular margins,
+osteophytes, and other evidence of abnormal ossification in and around
+the joint. Eburnation of the articular surfaces is shown by increase in
+the density of the shadow of the bone in the areas affected.
+
+[Illustration: FIG. 161.--Arthritis Deformans affecting several
+Joints, in a boy aet. 10.
+
+(Dr. Dickson's case.)]
+
+_Treatment._--Treatment is for the most part limited to the relief of
+symptoms. On no account should the affected joints be kept at rest by
+means of splints or other apparatus. Active movements and exercises of
+all kinds are to be persevered with. When pain is a prominent feature,
+it may be relieved either by douches of iodine and hot water (tincture
+of iodine 1 oz. to the quart), or by the application of lint saturated
+with a lotion made up of chloral hydrate, gr. v, glycerin [dram]j, water
+[ounce]j, and covered with oil-silk. Strain and over-use of the joint
+and sudden changes of temperature are to be avoided. The induction of
+hyperaemia by means of massage, the elastic bandage, and hot-air baths is
+often of service. Operative interference is indicated when the disease
+is of a severe type, when it is mon-articular, and when the general
+condition of the patient is otherwise favourable. Excision has been
+practised with success in the hip, knee, elbow, and temporo-mandibular
+joints. Limitation of movement and locking at the hip-joint when due to
+new bone round the edge of the acetabulum may be greatly relieved by
+removal of the bone--a procedure known as _cheilotomy_. Loose bodies and
+hypertrophied fringes if causing symptoms may also be removed by
+operation.
+
+When stiffness and grating on movement are prominent features we have
+found the injection of from half to one ounce of sterilised white
+vaseline afford decided relief.
+
+The patient should be nourished well, and there need be no restriction
+in the diet such as is required in gouty patients, so long as the
+digestion is not impaired. Benefit is also derived from the
+administration of cod-liver oil, and of tonics, such as strychnin,
+arsenic, and iron, and in some cases of iodide of potassium. Luff
+recommends the administration over long periods of guaiacol carbonate,
+in cachets beginning with doses of 5-10 grs. and increased to 15-20 grs.
+thrice daily. A course of treatment at one of the reputed spas--Aix,
+Bath, Buxton, Gastein, Harrogate, Strathpeffer, Wiesbaden, Wildbad--is
+often beneficial.
+
+In some cases benefit has followed the prolonged internal administration
+of liquid paraffin.
+
+On the assumption that the condition is the result of an
+auto-intoxication from the intestinal tract, saline purges and
+irrigation of the colon are indicated, and Arbuthnot Lane claims to have
+brought about improvement by short-circuiting or by resecting the colon.
+
+Residence in a warm and dry climate, with an open-air life, has been
+known to arrest the disease when other measures have failed to give
+relief.
+
+The application of radium and the ingestion of radio-active waters have
+also been recommended.
+
+#Haemophilic# or #Bleeder's Joint#.--This is a rare but characteristic
+affection met with chiefly in the knee-joint of boys who are the
+subjects of haemophilia. After some trivial injury, or even without
+apparent cause, a haemorrhage takes place into the joint. The joint is
+tensely swollen, cannot be completely extended, and is so painful that
+the patient is obliged to lie up. The temperature is often raised (101
+to 102 F.), especially if there are also haemorrhages elsewhere. The
+blood in the joint is slowly re-absorbed, and by the end of a fortnight
+or so, the symptoms completely disappear. As a rule these attacks are
+repeated; the pain attending them diminishes, but the joint becomes the
+seat of permanent changes: the synovial membrane is thickened,
+abnormally vascular, and coloured brown from the deposit of blood
+pigment; on its surface, and in parts of the articular cartilage, there
+is a deposit of rust-coloured fibrin; there may be extensive adhesions,
+and in some cases changes occur like those observed in arthritis
+deformans with erosion and ulceration of the cartilage and a form of dry
+caries of the articular surfaces, which may terminate in ankylosis.
+
+As the swelling of the joint is associated with wasting of the muscles,
+with stiffness, and with flexion, the condition closely resembles
+tuberculous disease of the synovial membrane. From errors in diagnosis
+such joints have been operated upon, with disastrous results due to
+haemorrhage.
+
+The treatment of a recent haemorrhage consists in securing absolute rest
+and applying elastic compression. The introduction of blood-serum (10-15
+c.c.) into a vein may assist in arresting the haemorrhage;
+anti-diphtheritic serum is that most readily obtainable.
+
+After an interval, measures should be adopted to promote the absorption
+of blood and to prevent stiffness and flexion; these include massage,
+movements, and extension with weight and pulley.
+
+
+JOINT DISEASES ASSOCIATED WITH LESIONS OF THE NERVOUS SYSTEM:
+NEURO-ARTHROPATHIES
+
+_In Lesions of Peripheral Nerves._--In the hand, and more rarely in the
+foot, when one or other of the main nerve-trunks has been divided or
+compressed, the joints may become swollen and painful and afterwards
+become stiff and deformed. Bony ankylosis has been observed.
+
+_In Affections of the Spinal Medulla._--In myelitis, progressive
+muscular atrophy, poliomyelitis, insular sclerosis, and in traumatic
+lesions, joint affections are occasionally met with.
+
+The occurrence of joint lesions in _locomotor ataxia_ (tabes dorsalis)
+was first described by Charcot in 1868--hence the term "Charcot's
+disease" applied to them. Although they usually develop in the ataxic
+stage, one or more years after the initial spinal symptoms, they may
+appear before there is any evidence of tabes. The onset is frequently
+determined by some injury. The joints of the lower extremity are most
+commonly affected, and the disease is bilateral in a considerable
+proportion of cases--both knees or both hips, for instance, being
+implicated.
+
+Among the theories suggested in explanation of these arthropathies the
+most recent is that by Babinski and Barre, which traces the condition to
+vascular lesions of a syphilitic type in the articular arteries.
+
+The first symptom is usually a swelling of the joint and its vicinity.
+There is no redness or heat and no pain on movement. The peri-articular
+swelling, unlike ordinary oedema, scarcely pits even on firm pressure.
+
+[Illustration: FIG. 162.--Bones of Knee-joint in advanced stage of
+Charcot's Disease. The medial part of the head of the tibia has
+disappeared.
+
+(Anatomical Museum, University of Edinburgh).]
+
+In mild cases this condition of affairs may persist for months; in
+severe cases destructive changes ensue with remarkable rapidity. The
+joint becomes enormously swollen, loses its normal contour, and the ends
+of the bones become irregularly deformed (Fig. 162). Sometimes, and
+especially in the knee, the clinical features are those of an enormous
+hydrops with fibrinous and other loose bodies and hypertrophied
+fringes--and great oedema of the peri-articular tissues (Fig. 163). The
+joint is wobbly or flail-like from stretching and destruction of the
+controlling ligaments, and is devoid of sensation. In other cases,
+wearing down and total disappearance of the ends of the bones is the
+prominent feature, attended with flail-like movements and with coarse
+grating. Dislocation is observed chiefly at the hip, and is rather a
+gross displacement with unnatural mobility than a typical dislocation,
+and it is usually possible to move the bones freely upon one another and
+to reduce the displacement. A striking feature is the extensive
+formation of new bone in the capsular ligament and surrounding muscles.
+The enormous swelling and its rapid development may suggest the growth
+of a malignant tumour. The most useful factor in diagnosis is the entire
+absence of pain, of tenderness, and of common sensibility. The freedom
+with which a tabetic patient will allow his disorganised joint to be
+handled requires to be seen to be appreciated.
+
+[Illustration: FIG. 163.--Charcot's Disease of Left Knee. The joint is
+distended with fluid and the whole limb is oedematous.]
+
+The rapidity of the destructive changes in certain cases of tabes, and
+the entire absence of joint lesions in others, would favour the view
+that special parts of the spinal medulla must be implicated in the
+former group.
+
+In _syringomyelia_, joint affections (gliomatous arthropathies) are more
+frequent than in tabes, and they usually involve the upper extremity in
+correspondence with the seat of the spinal lesion, which usually affects
+the lower cervical and upper thoracic segments. Except that the joint
+disease is seldom symmetrical, it closely resembles the arthropathy of
+tabes. The completeness of the analgesia of the articular structures
+and of the overlying soft parts is illustrated by the fact that in one
+case the patient himself was in the habit of letting out the fluid from
+his elbow with the aid of a pair of scissors, and that in another the
+joint was painlessly excised without an anaesthetic.
+
+[Illustration: FIG. 164.--Charcot's Disease of both Ankles: front view.
+Man, aet. 32.]
+
+The disease may become arrested or may go on to complete
+disorganisation; suppuration may ensue from infection through a breach
+of the surface, and in rare cases the joint has become the seat of
+tuberculosis.
+
+[Illustration: FIG. 165.--Charcot's Disease of both Ankles: back view.
+Man, aet. 32.]
+
+_Treatment_, in addition to that of the nerve lesion underlying the
+arthropathy, consists in supporting and protecting the joint by means of
+bandages, splints, and other apparatus. In the lower extremity, the use
+of crutches is helpful in taking the strain off the affected limb. When
+there is much distension of the joint, considerable relief follows upon
+withdrawal of fluid. The best possible result being rigid ankylosis in a
+good position, it may be advisable to bring this about artificially by
+arthrodesis or resection. Operation is indicated when only one joint is
+affected and when the cord lesion is such as will permit of the patient
+using the limb. The wounds heal well, but the victims of tabes are
+unfavourable subjects for operative interference, on account of their
+liability to intercurrent complications. When the limb is quite useless,
+amputation may be the best course.
+
+_In cerebral lesions_ attended with hemiplegia, joint affections,
+characterised by evanescent pain, redness, and swelling, are
+occasionally met with. The secondary changes in joints which are the
+seat of paralytic contracture are considered with the surgery of the
+Extremities.
+
+In cases of _hysteria_ and other _functional affections of the
+nervous system_, an intermittent neuropathic hydrops has been
+observed--especially in the knee. Without apparent cause, the joint
+fills with fluid and its movements become restricted, and after from two
+to eight days the swelling subsides and the joint returns to normal. A
+remarkable feature of the condition is that the effusion into the joint
+recurs at regular intervals, it may be over a period of years. Psychic
+conditions have been known to induce attacks, and sometimes to abort
+them or even to cause their disappearance. Hence it has been recommended
+that treatment by suggestion should be employed along with tonic doses
+of quinine and arsenic.
+
+
+HYSTERICAL OR MIMETIC JOINT AFFECTIONS
+
+Under this heading, Sir Benjamin Brodie, in 1822, described an affection
+of joints, characterised by the prominence of subjective symptoms and
+the absence of pathological changes. Although most frequently met with
+in young women with an impressionable nervous system, and especially
+among those in good social circumstances, it occurs occasionally in men.
+The onset may be referred to injury or exposure to cold, or may be
+associated with some disturbance of the emotions or of the generative
+organs; or the condition may be an involuntary imitation of the symptoms
+of organic joint disease presented by a relative or friend.
+
+It is characteristic that the symptoms develop abruptly without
+satisfactory cause, that they are exaggerated and wanting in harmony
+with one another, and that they do not correspond with the features of
+any of the known forms of organic disease. In some cases the only
+complaint is of severe pain; more often this is associated with
+excessive tenderness and with impairment of the functions of the joint.
+On examination the joint presents a normal appearance, but the skin
+over it is remarkably sensitive. A light touch is more likely to excite
+pain than deep and firm pressure. Stiffness is a variable feature--in
+some cases amounting to absolute rigidity, so that no ordinary force
+will elicit movement. It is characteristic of this, as of other
+neuroses, that the symptoms come and go without sufficient cause. When
+the patient's attention is diverted, the pain and stiffness may
+disappear. There is no actual swelling of the joint, although there may
+be an appearance of this from wasting of the muscles above and below. If
+the joint is kept rigid for long periods, secondary contracture may
+occur--in the knee with flexion, in the hip with flexion and adduction.
+
+The _diagnosis_ is often a matter of considerable difficulty, and the
+condition is liable to be mistaken for such organic lesions as a
+tuberculous or pyogenic focus in the bone close to the joint.
+
+The greatest difficulty is met with in the knee and hip, where the
+condition may closely simulate tuberculous disease. The use of the
+Rontgen rays, or examination of the joint under anaesthesia, is helpful.
+
+The _local treatment_ consists chiefly in improving the nutrition of the
+affected limb by means of massage, exercises, baths, and electricity.
+Splints are to be avoided. In refractory cases, benefit may follow the
+application of blisters or of Corrigan's button. The general condition
+of the patient must be treated on the same lines as in other neuroses.
+The Weir-Mitchell treatment may have to be employed in obstinate cases,
+the patient being secluded from her friends and placed in charge of a
+nurse. Complete recovery is the rule, but when the muscles are weak and
+wasted from prolonged disuse, a considerable time may elapse before the
+limb returns to normal.
+
+
+TUMOURS AND CYSTS
+
+New growths taking origin in the synovial membrane are rare, and are not
+usually diagnosed before operation. They are attended with exudation
+into the joint, and in the case of _sarcoma_ the fluid is usually
+blood-stained. If the tumour projects in a polypoidal manner into the
+joint, it may cause symptoms of loose body. One or two cases have been
+recorded in which a _cartilaginous tumour_ growing from the synovial
+membrane has erupted through the joint capsule and infiltrated the
+adjoining muscles. _Multiple cartilaginous tumours_ forming loose bodies
+are described on p. 544.
+
+_Cysts of joints_ constitute an ill-defined group which includes ganglia
+formed in relation to the capsular ligament. Cystic distension of bursae
+which communicate with the joint is most often met with in the region of
+the knee in cases of long-standing hydrops. It was suggested by Morrant
+Baker that cystic swellings may result from the hernial protrusion of
+the synovial membrane between the stretched fibres of the capsular
+ligament, and the name "Baker's cysts" has been applied to these.
+
+In the majority of cases, cysts in relation to joints give rise to
+little inconvenience and may be left alone. If interfered with at all,
+they should be excised.
+
+
+LOOSE BODIES
+
+It is convenient to describe the varieties of loose bodies under two
+heads: those composed of fibrin, and those composed of organised
+connective tissue.
+
+#Fibrinous Loose Bodies# (Corpora oryzoidea).--These are homogeneous or
+concentrically laminated masses of fibrin, sometimes resembling rice
+grains, melon seeds, or adhesive wafers, sometimes quite irregular in
+shape. Usually they are present in large numbers, but sometimes there is
+only one, and it may attain considerable dimensions. They are not
+peculiar to joints, for they are met with in tendon sheaths and bursae,
+and their origin from synovial membrane may be accepted as proved. They
+occur in tuberculosis, arthritis deformans, and in Charcot's disease,
+and their presence is almost invariably associated with an effusion of
+fluid into the joint. While they may result from the coagulation of
+fibrin-forming elements in the exudate, their occurrence in tuberculous
+hydrops would appear to be the result of coagulation necrosis, or of
+fibrinous degeneration of the surface layer of the diseased synovial
+membrane. However formed, their shape is the result of mechanical
+influences, and especially of the movement of the joint.
+
+_Clinically_, loose bodies composed of fibrin constitute an unimportant
+addition to the features of the disease with which they are associated.
+They never give rise to the classical symptoms associated with impaction
+of a loose body between the articular surfaces. Their presence may be
+recognised, especially in the knee, by the crepitating sensation
+imparted to the fingers of the hand grasping the joint while it is
+flexed and extended by the patient.
+
+The _treatment_ is directed towards the disease underlying the hydrops.
+If it is desired to empty the joint, this is best done by open
+incision.
+
+[Illustration: FIG. 166.--Radiogram of Multiple Loose Bodies in
+Knee-joint and Semi-membranosus Bursa in a man aet. 38.
+
+(Mr. J. W. Dowden's case.)]
+
+#Bodies composed of Organised Connective Tissue.#--These are
+comparatively common in joints that are already the seat of some chronic
+disease, such as arthritis deformans, Charcot's arthropathy, or synovial
+tuberculosis. They take origin almost exclusively from an erratic
+overgrowth of the fringes of the synovial membrane, and may consist
+entirely of fat, the arborescent lipoma (Fig. 159) being the most
+pronounced example of this variety. Fibrous tissue or cartilage may
+form in one or more of the fatty fringes and give rise to hard nodular
+masses, which may attain a considerable size, and in course of time may
+undergo ossification.
+
+Like other hypertrophies on a free surface, they tend to become
+pedunculated, and so acquire a limited range of movement. The pedicle
+may give way and the body become free. In this condition it may wander
+about the joint, or lie snugly in one of its recesses until disturbed by
+some sudden movement. A loose body free in a joint is capable of growth,
+deriving the necessary nutriment from the surrounding fluid. The size
+and number of the bodies vary widely. Single specimens have been known
+to attain the size of the patella. The smaller varieties may number
+considerably over a hundred.
+
+[Illustration: FIG. 167.--Loose Body from Knee-joint of man aet. 25.
+Natural size.
+
+a = Convex surface.   b = Concave surface.]
+
+In arthritis deformans a rarer type of loose body is met with, a portion
+of the lipping of one of the articular margins being detached by injury.
+In Charcot's disease, bodies composed of bone are formed in relation to
+the capsular and other ligaments, and may be made to grate upon one
+another.
+
+The _clinical features_ in this group are mainly those of the disease
+which has given rise to the loose bodies, and it is exceptional to meet
+with symptoms from impaction of the body between the articular surfaces.
+Treatment is to be directed towards the primary disease in the joint, as
+well as to the removal of the loose bodies.
+
+[Illustration: FIG. 168.--Multiple partially ossified Chondromas of
+Synovial Membrane, from Shoulder-joint, the seat of arthritis deformans,
+from a man aet. 35.]
+
+_Loose Bodies in Joints which are otherwise healthy._--It is in joints
+otherwise healthy that loose bodies causing the classical symptoms and
+calling for operative treatment are most frequently met with. They occur
+chiefly in the knee and elbow of healthy males under the age of thirty.
+The complaint may be of vague pains, of occasional cracking on moving
+the joint, or of impairment of function--usually an inability to extend
+or flex the joint completely. In many cases a clear account is given of
+the symptoms which arise when the body is impacted between the articular
+surfaces, namely, sudden onset of intense sickening pain, loss of power
+in the limb and locking of the joint, followed by effusion and other
+accompaniments of a severe sprain. On some particular movement, the
+body is disengaged, the locking disappears, and recovery takes place.
+Attacks of this kind may recur at irregular intervals, during a period
+of many years. On examining the joint, it is usually found to contain
+fluid, and there may be points of special tenderness corresponding to
+the ligaments that have been overstretched. In cases in which there has
+been recurrent attacks of locking, the ligaments become slack, the joint
+is wobbly, and the quadriceps is wasted. The patient himself, or the
+surgeon, may discover the loose body and feel it roll beneath his
+fingers, especially if it is lodged in the supra-patellar pouch in the
+knee, or on one or other side of the olecranon in the elbow. In most
+instances the patient has carefully observed his own symptoms, and is
+aware not only of the existence of the loose body, but of its erratic
+appearance at different parts of the joint. This feature serves to
+differentiate the lesions from a torn medial meniscus in which the pain
+and tenderness are always in the same spot. As the body usually contains
+bone, it is recognisable in a skiagram.
+
+[Illustration: FIG. 169.--Multiple Cartilaginous Loose Bodies from
+Knee-joint.]
+
+There are two methods of _removing the body_; the first and simpler
+method is applicable when the body can be palpated, usually in the
+supra-patellar pouch; it is preferably transfixed by a needle and can
+then be removed through a small incision; otherwise, the joint must be
+freely opened and explored, firstly to find the body and further to
+remove it.
+
+The characters of this type of loose body are remarkably constant. It is
+usually solitary, about the size of a bean or almond, concavo-convex in
+shape, the convex aspect being smooth like an articular surface, the
+concave aspect uneven and nodulated and showing reparative changes,
+healing over of the raw surface, and the new formation of fibrous
+tissue, hyaline cartilage and bone, the necessary nutriment being
+derived from the synovial fluid (Fig. 167). The body is sometimes found
+to be lodged in a defect or excavation in one of the articular surfaces,
+usually the medial condyle of the femur, from which it is readily
+shelled out by means of an elevator. It presents on section a layer of
+articular cartilage on the convex aspect and a variable thickness of
+spongy bone beneath this.
+
+The origin of these bodies is one of the most debated questions in
+surgical pathology; they obviously consist of a portion of the articular
+surface of one of the bones, but how this is detached still remains a
+mystery; some maintain that it is purely traumatic; Konig regards them
+as portions of the articular surface which have been detached by a
+morbid process which he calls "osteochondritis dessicans."
+
+_Multiple Chondromas and Osteomas of the Synovial Membrane._--In this
+rare type of loose body, the surface of the synovial membrane is studded
+with small sessile or pedunculated tumours composed of pure hyaline
+cartilage, or of bone, or of transition stages between cartilage and
+bone. They are pearly white in colour, pitted and nodular on the
+surface, rarely larger than a pea, although when compressed they may
+cake into masses of considerable size. With the movements of the joint
+many of the tumours become detached and lie in the serous exudate
+excited by their presence. They are found also in the diverticula of the
+synovial membrane, in the shoulder in the downward prolongation along
+the tendon of the biceps, in the hip in the bursal extension beneath the
+psoas.
+
+The patient complains of increasing disability of the limb, movements of
+the joint becoming more and more restricted and painful. There is
+swelling corresponding to the distended capsule of the joint, and on
+palpation the bodies moving under the fingers yield a sensation as of
+grains of rice shifting in a bag. If the bodies are so numerous as to be
+tightly packed together, the impression is that of a plastic mass having
+the shape of the synovial sac. The stiffness and the cracking on
+movement may suggest arthritis deformans, but the X-ray appearances make
+the diagnosis an easy one. We have observed two cases of this affection
+in the knee-joint of adult women, one in the shoulder-joint of an adult
+male (Fig. 168), and Caird has observed one in the hip. The treatment
+consists in opening the joint by free incision and removing the bodies.
+
+_Displacement of the menisci_ of the knee is referred to with injuries
+of that joint.
+
+
+
+
+INDEX
+
+
+  Abdominal aneurysm, 313
+    aorta, compression of, 269
+      embolus of, 93
+
+  Abscess, 46
+    acute circumscribed, 46
+    of bone, 448
+    Brodie's, 448
+    chronic, 139
+    cold, 139
+    embolic, 66
+    formation of, 47
+    Hilton's method of opening, 50
+    pointing of, 48
+    pyaemic, 287
+    residual, 141
+    of skin, multiple, 382
+    stitch, 51
+    treatment of, 49
+    tuberculous, 139, 141
+      peri-articular, 514, 517
+
+  Achillo-bursitis, 432
+
+  Achillo-dynia, 422
+
+  Acidosis, 251
+
+  Acromion bursa, 429
+
+  Actinomycosis, 126
+
+  Active hyperaemia, 39
+
+  Acupuncture in aneurysm, 308
+
+  Acute arthritis of infants, 440
+    necrosis of bone, 439
+
+  Adductor longus muscle, rupture of, 408
+
+  Adenoma, 202
+    malignant, 209
+    sebaceous, 393
+    of skin, 393
+    varieties of, 202
+
+  Adiposus dolorosa, 186
+
+  Aerobes, 19
+
+  Air embolism, 265
+    hunger, 276
+
+  Albumosuria, 195, 474, 492
+
+  Aleppo boil, 129
+
+  Alexins, 22
+
+  Ambrine, 13, 238
+
+  Amputation neuroma, 344
+
+  Anaerobes, 19
+
+  Anaesthesia, after nerve injuries, 347
+
+  Analgesia, 347
+
+  Anaphylaxis, 23
+
+  Anatomical tubercle, 134
+
+  Anatomy. _See_ Surgical Anatomy
+
+  Anel's operation for aneurysm, 307
+
+  Aneurysm, 300. _See also_ Individual Arteries
+    abdominal, 313
+    acupuncture in, 308
+    amputation in, 310
+    by anastomosis, 298
+    Anel's operation for, 307, 310
+    arterio-venous, 263
+    axillary, 318
+    of bone, 498
+    brachial, 318
+    Brasdor's operation for, 308
+    cirsoid, 299
+    Colt's method of wiring for, 309
+    compression for, 308
+    consolidated, 304, 305
+    differential diagnosis of, 305
+    diffused, 302
+    digital compression in, 308
+    excision of, 307
+    of forearm and hand, 318
+    fusiform, 301
+    gelatin injections in, 309
+    Hunter's operation for, 307
+    iliac, 318
+    of individual arteries, 312
+    inguinal, 318
+    innominate, 314
+    intracranial, 316
+    of leg and foot, 320
+    ligation of artery for, 307
+    Macewen's acupuncture for, 308
+    Matas' operation for, 307
+    Moore-Corradi method, 308
+    natural cure of, 305
+    old operation for, 307
+    of ophthalmic artery, 317
+    orbital, 317
+    pathological, 301
+    pulse in, 304
+    rupture of, 306
+    sacculated, 302
+    suppuration in, 306
+    thoracic, 312
+    traumatic, 263, 310
+    treatment of, 306
+    varicose, 311
+    Wardrop's operation for, 308
+    X-rays in diagnosis of, 304
+
+  Aneurysmal varix, 311, 316, 318, 319, 320
+
+  Angioma, 284
+    arterial, 299
+    capillary, 294
+    cavernous, 297
+    racemosum venosum, 287
+    venous, 294
+
+  Angio-neurotic oedema, 348
+    sarcoma, 199
+
+  Angler's elbow, 406
+
+  Ankle, cellulitis of, 58
+
+  Ankylosis of joints, 503. _See also_ Individual Joints
+
+  Anoci-association, 253
+
+  Anthracaemia, 121
+
+  Anthrax, 119
+
+  Anti-bacterial sera, 23
+    -diphtheritic serum, 111
+    -streptococcic serum, 23, 109
+    -tetanic serum, 117
+
+  Antibodies, 22
+
+  Antigens, 22
+
+  Antiseptics, 242
+
+  Antitoxic sera, 23
+
+  Antitoxins, 22
+
+  Antivenin, 132
+
+  Aorta, abdominal, compression of, 269
+    aneurysm of, 313
+    embolism of, 93
+    ligation of, 314
+    pulsating, 305, 314
+
+  Arborescent lipoma, 423
+
+  Arseno-billon, 163
+
+  Arteries, anatomy of, 258
+    compression of individual, 269
+    contusion of, 260
+    digital compression of, 269
+    gangrene following ligation of, 94
+    gunshot wounds of, 263
+
+  Arteries, ligation of, for aneurysm, 307
+    punctured wounds of, 262
+    repair of, 266, 268
+    rupture of, 260
+    wounds of, 261, 262
+
+  Arterio-sclerosis, 282
+
+  Arterio-venous aneurysm, 310
+
+  Arteritis, varieties of, 282
+
+  Arthritis, 501. _See also_ Individual Joints
+    acute, 506
+      of infants, 440
+    deformans, 524
+    gonococcal, 510
+    neuropathic, 532
+    ossificans, 503
+    pneumococcal, 509
+    pyogenic, 506
+    rheumatic, 523
+    rheumatoid, 524
+    septic, 506
+    scarlatinal, 508
+    trade, 525
+    traumatic, 524
+    tuberculous, 512
+    urica, 522
+
+  Arthrolysis, 505
+
+  Arthropathies, 532
+    gliomatous, 534
+
+  Arthroplasty, 505
+
+  Articular caries, 502, 514
+
+  Artificial hyperaemia, 39
+
+  Ascites, chylous, 325
+
+  Asepsis, 18
+
+  Asphyxia, local, 97
+    traumatic, 254
+
+  Atheroma, 283
+
+  Avulsion of nerves, 375
+    of tendons, 411
+
+  Axilla, cellulitis of, 58
+    hygroma of, 328
+
+  Axillary aneurysm, 318
+    artery, embolus of, 93
+    lymph glands, 336
+    nerve, injuries of, 363
+
+
+  Bacilli, 19
+
+  Bacillus aerogenes capsulatus, 99
+    anthracis, 119
+    coli communis, 27
+    diphtheriae 109
+    drum-stick, 112
+    of Ducrey, 154
+    of glanders, 123
+    Klebs-Loffler, 109
+    of malignant oedema, 101
+    mallei, 123
+    pyocyaneus, 29
+    of soft sore, 154
+    of tetanus, 112
+    tubercle, 133
+    typhosus, 29, 452
+
+  Bacteria, death of, 21
+    general characters of, 18
+    pathogenic properties of, 19
+    pyogenic, 24, 29
+
+  Bacterial intoxication, 21
+
+  Bacteriology, surgical, 17
+
+  Baker's cysts, 539
+
+  Bazin's disease, 74, 169
+
+  Beck's paste in sinuses, 145
+
+  Bed-sores, 73, 103
+
+  Bence-Jones on albumosuria, 195, 474, 492
+
+  Biceps, bursa under, 430
+    dislocation of long tendon of, 409
+    rupture of, 407
+
+  Bier's artificial hyperaemia, 38
+
+  B.I.P.P., 143
+
+  Birth palsies, 362
+
+  Biskra button, 129
+
+  Bismuth gauze, 247
+    injections in sinuses, 145
+
+  Bites of animals, 223
+
+  Black eye, 219
+
+  Bleeder's joint, 531
+
+  Bleeders, 277
+    bruises in, 218
+
+  Blisters, 376
+    purulent, 55
+
+  Blocking of nerves for shock, 252
+
+  Blood, count, 30
+    cysts, 214, 220
+    transfusion of, 11, 253
+
+  Blood vessels. _See_ Arteries and Veins
+
+  Bloodless state, treatment of, 276
+
+  Blood letting, general, 42
+
+  Boil, 379
+    Aleppo, 129
+    Delhi, 129
+
+  Bone. _See also_ Individual Bones
+    abscess of, 448
+    aneurysm of, 498
+    angioma of, 491
+    atrophy of, 479
+    bacterial diseases of, 438
+    Brodie's abscess of, 448
+    cancer of, secondary, 499
+    caries of, 437, 438
+    changes in ulcers of leg, 79
+    chondroma of, 487
+    cysts of, 477, 500
+    diseases of, 434
+      due to staphylococcus aureus, 438
+    endothelioma of, 492
+    exostoses of, 191, 481
+    fibroma of, 491
+    fragility of, 479
+    grafting, 16, 436
+    gumma of, 464
+    hydatid disease of, 467
+    hyperostosis, 435, 464
+    hypertrophic pulmonary osteo-arthropathy, 480
+    hypertrophy of, 435
+    lipoma of, 491
+    lipping of, 527
+    malacia of, 473
+    marrow, function of, 434
+    myeloma of, 491
+    myxoma of, 491
+    necrosis of, 438
+    neuropathic atrophy of, 479
+    osteoma of, 481
+    osteomalacia of, 473
+    osteomyelitis of, 65, 437, 438, 451, 453, 473
+      fibrosa, 476
+    osteoporosis of, 437
+    osteopsathyrosis, 479
+    ostitis deformans, 474
+    Paget's disease of, 474
+    periosteum, function of, 435
+    periostitis, 437
+    pulsating haematoma of, 498
+    pyogenic diseases of, 438
+    regeneration of, 436
+    rickety affections of, 468
+    sarcoma of, 492
+    sclerosis of, 435
+    scurvy affecting, 473
+    secondary tumours of, 499
+    surgical anatomy of, 434
+    staphylococcal diseases of, 438
+    syphilitic diseases of, 461, 465
+    transplantation of, 436
+    tuberculous diseases of, 454
+    tumours of, 480
+      malignant, 492, 499
+      metastatic, 499
+      thyreoid, 500
+    typhoid, infection of, 452
+    X-ray appearances in diseases of, 445, 455, 485, 491, 496
+
+  Bovine tuberculosis, 136
+
+  Brachial aneurysm, 318
+    artery, embolus of, 93
+      compression of, 269
+    birth-paralysis, 362
+    fibrositis, 413
+    neuralgia, 371
+    plexus, lesions of, 360
+
+  Brain, joint affections in lesions of, 537
+    syphilitic lesions of, 161
+
+  Branchial dermoids, 211
+
+  Brasdor's operation for aneurysm, 308
+
+  Brodie's abscess, 448
+
+  Bruises, 218
+
+  Bubo, 329
+    bullet, 153
+    of soft sores, 155
+
+  Bullet bubo, 153
+
+  Bullets, embedded, 231
+    varieties of, 230
+
+  Burnol, 238
+
+  Burns, 233
+    classification, of, 234
+    electrical, 239
+    pathology of, 233
+    by X-rays, 239
+
+  Bursae. _See also_ Individual Bursae
+    adventitious, 426
+    affections of, 426
+      individual, 428
+    diseases of, 426, 428
+    haematoma of, 426
+    hydrops of, 427
+    hygroma of, 423
+    inflammation of, 426
+    injuries of, 426
+    loose bodies in, 427
+    syphilis of, 428
+    tuberculosis of, 428
+    tumours of, 427, 428
+
+
+  Cachexia, cancerous, 207
+
+  Calcanean bursa, 432
+
+  Calcification in arteries, 282
+    in muscles, 416
+    in tuberculosis, 136
+
+  Callosities, 376
+
+  Callous ulcers, 79, 84
+
+  Cancer, 202
+    arsenic, 395
+    of bone, 499
+    cachexia in, 207
+    chimney-sweep's, 395
+    colloid, 210
+    columnar epithelial, 209
+    contagiousness of, 205
+    cystic, 210
+    definition of, 202
+    degeneration of, 205
+    encephaloid, 210
+    _en cuirasse_, 204
+    glandular, 210
+    glandular infection in, 203
+    increase of, 207
+    of lymph glands, 340
+    medullary, 210
+    melanotic, 210, 341, 397
+    paraffin, 395
+    pigmented, 210
+    radium treatment of, 208
+    rodent, 210, 395
+    scirrhous, 210
+    of skin, 394
+    spread of, 204
+    squamous epithelial, 208
+    ulceration of, 205
+    varieties of, 208
+    X-ray, 208
+
+  Cancrum oris, 102
+
+  Cantharides plaster, 42
+
+  Capillaries, anatomy of, 258
+
+  Capillary angioma, 294
+    loops, 3
+
+  Carbolic gangrene, 95
+
+  Carbon-dioxide snow, 297
+
+  Carbuncle, 380
+
+  Carcinoma. _See_ Cancer
+
+  Caries, 437, 438
+    of articular surfaces, 502, 514
+    sicca, 438
+    syphilitic, 462
+    tuberculous, 455
+
+  Carotid aneurysm, 314
+    artery, compression of, 269
+    tubercle, 269
+
+  Carpal ganglion, 214
+
+  Carron oil, 238
+
+  Cartilage, grafting of, 16
+    repair of, 7
+    ulceration of, 502, 514
+
+  Cartilaginous exostosis, 191, 481
+
+  Caseation in tuberculosis, 136
+
+  Catalepsy, 116
+
+  Catgut, infection by, 51
+    preparation of, 245
+
+  Cautery in haemorrhage, 271
+
+  Cavernous angioma, 298
+    lymphangioma, 327
+
+  Cellulitis, 52
+    in different situations, 58
+    diffuse, 52
+
+  Cephalic or Kopf tetanus, 116
+
+  Cerebro-spinal meningitis, 115
+
+  Cervical adenitis, 332
+    rib, 360
+
+  Chalk stones in gouty joints, 523
+
+  Chancre, concealed, 152, 153, 157
+    erratic, 153
+    extra-genital, 153
+    hard, 151
+    meatal, 152
+    multiple, 152
+    relapsing false indurated, 172
+    soft, 154
+    urethral, 152
+
+  Chancroid, 154
+
+  Charcoal poultice, 84
+
+  Charcot's disease, 533
+
+  Cheloid. _See_ Keloid
+
+  Chemiotaxis, 32
+
+  Chigoe, 130
+
+  Chilblain, 378
+
+  Chimney-sweep's cancer, 395
+
+  Chloroma, 200
+
+  Chondroma, 189, 487
+    multiple, 544
+
+  Chondromatosis, 488
+
+  Chondro-sarcoma, 189, 200, 487
+
+  Chordoma, 200
+
+  Choroiditis, syphilitic, 177
+
+  Chylorrhoea, 325
+
+  Chylo-thorax, 325
+
+  Chylous ascites, 325
+
+  Cicatrices, varieties of, 400
+
+  Cicatricial contraction, 4
+    tissue, 4
+
+  Circumflex nerve. _See_ Axillary Nerve
+
+  Cirsoid aneurysm, 299
+
+  Claw-hand, 369
+
+  Cloacae in bone, 443
+
+  Cocci, 18
+
+  Coeliac artery, aneurysm of, 313
+
+  Coley's fluid, 201
+
+  Collapse, 254
+
+  Collateral circulation, 267
+
+  Colles' law, 178
+
+  Colloid cancer, 210
+
+  Common peroneal nerve, 370
+
+  Compound palmar ganglion, 217, 423
+
+  Condylomata, 158, 174
+
+  Congenital fistulas, 60
+    telangiectasis, 294
+
+  Connective tissue, repair of, 6
+
+  Contracture of joints, 502
+    of muscles, 415
+    paralytic, 347
+
+  Contusions, 218
+
+  Cornea, syphilitic ulceration of, 177
+
+  Corns, 377
+
+  Corpora oryzoidea, 539
+
+  Counter-irritants, 37, 42
+
+  Craniotabes, 175, 176, 465
+
+  Crural fibrositis, 413
+
+  Crutch paralysis, 351
+
+  Cupping dry, 39
+    wet, 42
+
+  Cutis anserina, 36
+
+  Cyanosis, traumatic, 254
+
+  Cyst, 212
+    atheromatous, 389
+    Baker's, 539
+    blood 214, 220
+    of bone, 477, 500
+    dentigerous, 193
+    derma, 210
+    exudation, 212
+    ganglionic, 215
+    haemorrhagic, 220
+    hydatid, 213
+    implantation, 212
+    of joints, 538
+    lymph, 214
+    lymphatic, 219, 328
+    omental, 329
+    parasitic, 213
+    retention, 212
+    sebaceous, 212, 389
+    serous, 219
+    venous, 289
+
+  Cystic adenoma, 202
+    carcinoma, 210
+    hygroma of neck, 328
+    lymphangioma, 327, 328
+
+
+  Dactylitis, syphilitic, 176, 460, 466
+    tuberculous, 460
+
+  Dancer's sprain, 406
+
+  Deafness, syphilitic, 178
+
+  Deformities. _See_ Individual Regions
+
+  Delhi boil, 129
+
+  Delirium, in surgical patients, 255
+    traumatic, 257
+
+  Delirium tremens, 256
+
+  Dentigerous cyst, 193
+
+  Dercum on adiposus dolorosa, 186
+
+  Derma-cysts, 210
+
+  Dermatitis, 239, 292
+
+  Dermoids, 210
+
+  Diabetic gangrene, 96
+
+  Diarsenol, 163
+
+  Diapedesis of red corpuscles, 32
+
+  Diaphysial aclasis, 483
+
+  Diffuse aneurysm, 302
+    cellulitis, 52
+    fibromatosis, 194
+    lipomatosis, 187
+    neuro-fibromatosis, 355
+    osteoma, 485
+    suppuration, 52
+
+  Diphtheria, 109
+    antitoxin in, 111
+    intubation in, 111
+
+  Diplococci, 19
+
+  Dislocation of nerves, 351, 369
+    pathological, 514
+    of tendons, 408
+
+  Double cyanide gauze, 247
+
+  Drainage of wounds, 222
+
+  Dressings, surgical, 247
+
+  Drill-bone, 418
+
+  Drop-finger, 411
+    -foot, 370
+    -wrist, 365
+
+  Drunkard's palsy, 351, 364
+
+  Duchenne's paralysis, 361
+
+  Ducrey's bacillus, 154
+
+  Duodenum, ulceration of, in burns, 236
+
+  Dwarf, rickety, 469
+    syphilitic, 178
+
+
+  Eburnation of articular surfaces, 557
+
+  Ecchondroses, 527
+
+  Ecchymosis, 218
+
+  Echinococcus, 213
+
+  Echthyma, 158
+
+  Eczema, varicose, 292
+
+  Elbow, angler's, 406
+    cellulitis of, 58
+    tennis, 406
+
+  Electricity, injuries by, 239
+
+  Electrolysis in angioma, 297
+
+  Elephantiasis, varieties of, 360, 384, 386
+
+  Embolism, 281
+    air, 265
+
+  Embolism, fat, 254
+    of individual arteries, 93
+
+  Embolus, 281
+
+  Emigration of leucocytes, 32
+
+  Emotional shock, 251
+
+  Emphysema, 99, 102
+
+  Emprosthotonos, 214
+
+  Empyema of joints, 501, 518
+
+  Encephaloid cancer, 210
+
+  Endarteritis obliterans, 282
+    syphilitic, 161
+
+  Endo-aneurysmorrhaphy, 307
+
+  Endothelioma, 196
+    of bone, 492
+
+  Epicritic sensibility of nerves, 343
+
+  Epidermis, grafting, 12
+    repair of, 4
+
+  Epiphysial cartilage, 434
+    junction, 434
+      in rickets, 469
+
+  Epiphysiolysis, 440
+
+  Epiphysitis, 437
+    syphilitic, 465
+
+  Epithelial tumours, 201
+
+  Epithelioma, 208
+    chimney-sweep's, 395
+    lupus, 384
+    paraffin, 395
+    in scars, 402
+    sinus, 500
+    of skin, 394
+    trade, 395
+    varieties of, 208
+    X-ray, 395
+
+  Epithelium grafting, 12
+    repair of, 6
+
+  Epulis, 491
+
+  Erb's paralysis, 361
+
+  Erysipelas, varieties of, 107
+
+  Erythema pernio, 378
+    nodosum, 442
+
+  Evaporating lotions, 41
+
+  Exfoliation, 438
+
+  Exophthalmos, pulsating, 317
+
+  Exostosis, 191, 481
+    bursata, 481
+    cancellous, 481
+    cartilaginous, 191, 481
+    false, 192
+    ivory, 481
+    multiple, 483
+    spongy, 191, 481
+    subungual, 191, 404, 481
+
+  Explosives, wounds by, 231
+
+  External iliac artery, embolus of, 93
+
+  External popliteal nerve. _See_ Common Peroneal Nerve
+
+  Extravasation of blood, 259
+
+  Exudates, varieties of, 33
+
+  Exudation cysts, 212
+
+  Eye, syphilitic lesions of, 160, 176, 177
+
+
+  Facial artery, compression of, 269
+    erysipelas, 107
+
+  Fainting, 249
+
+  Farcy, 125
+
+  Fascia, grafting of, 16
+
+  Fat embolism, 254
+    grafting of, 16
+
+  Fatty hernia, 187
+    tumours, 184
+
+  Feet, trench, 96
+
+  Femoral aneurysm, 318
+    artery compression of, 269
+    embolus of, 93
+    lymph glands, 323
+
+  Fever, 35
+
+  Fibro-adenoma, 202
+
+  Fibroblasts, 3
+
+  Fibroid, recurrent, of Paget, 199, 392, 420
+    uterine, 195
+
+  Fibroma, 194
+    of bone, 491
+    diffuse, 194
+    recurrent, of Paget, 199, 392, 420
+    of skin, 391
+    varieties of, 194
+
+  Fibromatosis, diffuse, 194
+
+  Fibro-myoma, 195
+
+  Fibro-sarcoma, 199
+
+  Fibrositis, varieties of, 372, 412
+
+  Filaria Bancrofti, 326
+
+  Filarial disease, 326
+
+  Finger, chancre of, 154
+    drop-, 411
+    mallet-, 411
+
+  Fingers, gouty affections of, 523
+    whitlow of, 55
+
+  Finsen light treatment, 138
+
+  Firearms, wounds by, 225, 227, 230
+
+  First intention, healing by, 2
+
+  Fistula, 60
+    congenital, 60
+    lymphatic, 325
+    varieties of, 60
+
+  Fluctuation, 49
+
+  Fomentations, 37, 41
+
+  Foot, cellulitis of, 58
+    drop-, 370
+    Madura, 129
+    perforating ulcer of, 73
+
+  Forci-pressure in haemorrhage, 271
+
+  Forearm, aneurysm of, 318
+    cellulitis of, 58
+
+  Foreign bodies, embedded, 6, 231
+
+  Fracture, pathological, 444
+
+  Fraenkel's pneumococcus, 28
+
+  Fragilitas ossium, 479
+
+  Friedlander's pneumo-bacillus, 28
+
+  Frost-bite, gangrene from, 95
+
+  Furunculus orientalis, 129
+
+
+  Galyl, 163
+
+  Ganglion, 214, 215, 217
+    compound palmar, 217, 423
+
+  Ganglionic neuroma, 353
+
+  Gangrene, 86
+    acute infective, 99
+      emphysematous, 102
+    from angio-sclerosis, 98
+    bacterial varieties of, 99
+    from burns and scalds, 95
+    cancrum oris, 102
+    carbolic, 95
+    from chemical agents, 95
+    clinical types of, 86
+      varieties of, 88
+    from constriction of vessels, 94
+    diabetic, 96
+    dry, 86
+    embolic, 92
+    from ergot, 98
+    from frost-bite, 95
+    gas, 102
+    from interference with circulation, 86
+    following ligation of arteries, 94
+    line of demarcation in, 87
+    malignant oedema, 101
+    moist, 87
+    noma, 102
+    phagedaena, 153
+    Raynaud's disease, 97
+    senile, 88
+    traumatic, 94
+    from trench feet, 96
+    white, 93
+    from whitlow, 99
+
+  Gas gangrene, 102
+
+  Gasserian ganglion, removal of, 375
+
+  Gauze, varieties of, 247
+
+  Gauze, sterilisation of, 245
+
+  Gelatin, injection of, in aneurysm, 309
+    in haemophilia, 280
+
+  Gelatinous degeneration of joints, 515
+
+  Giant cells, 3
+
+  Glanders, 123
+
+  Glands, lymph. _See_ Lymph Glands
+
+  Glioma, 196
+
+  Gliomatous arthropathies, 534
+
+  Glio-sarcoma, 200
+
+  Gloves in surgery, 244
+
+  Gluteal aneurysm, 319
+    fibrositis, 372, 413
+
+  Glycogen reaction, 30
+
+  Glycosuria in perforating ulcer, 73
+
+  Golfer's back, 405
+
+  Gonorrhoeal bursitis, 428
+    joint lesions, 510
+    lymphangitis, 325
+    myositis, 416
+    ophthalmia, joint lesions following, 510
+    rheumatism, 510
+    teno-synovitis, 423
+
+  Gout, joint affections in, 522
+
+  Gouty bursitis, 428
+    joints, 522
+    teno-synovitis, 422
+    tophi, 523
+    ulcers, 77
+
+  Grafting of bone, 436
+    of epithelium, 12
+    of mucous membrane, 16
+    of skin, 11
+    of tissues, 10
+
+  Granulation, healing by, 5
+    tissue, formation of, 2
+      syphilitic, 146
+      tuberculous, 136
+
+  Granulations, 2
+
+  Granuloma, 42
+
+  Groin, cellulitis of, 59
+    filarial disease in lymphatics of, 326
+
+  Growing pains, 451
+
+  Growth fever, 451
+
+  Gumma, 168
+    of bone, 464
+    peri-bursal, 521
+    periosteal, 521
+    peri-synovial, 521
+    subcutaneous, 76
+    syphilitic, 168
+
+  Gummatous infiltration, 168
+
+  Gunshot wounds, 225, 227, 230
+
+
+  Haematemesis, 259
+    post-operative, 275
+
+  Haematoma, 220
+    bursal, 426
+    pulsating, of bone, 498
+
+  Haematuria, 259
+
+  Haemophilia, 277
+
+  Haemophilic joint, 531
+
+  Haemoptysis, 259
+
+  Haemorrhage, 266
+    arrest of, 266, 270, 272, 274
+    arterial, 259
+    capillary, 260
+    cautery in, 271
+    constitutional effects of, 275
+    digital compression in, 269
+    external, 259
+    forci-pressure in, 271
+    intermediate, 272
+    internal, 259
+    ligature in, 270
+    in operations, 269
+    prevention of, 269
+    primary, 266
+    reactionary, 272
+    saline infusions in, 276
+    secondary, 273
+    styptics in, 271
+    torsion in, 271
+    tourniquets in, 270, 272
+    toxic, 275
+    from varicose veins, 292
+    venous, 259
+
+  Haemorrhagic diathesis, 277
+
+  Haemostatics, 271
+
+  Hair, syphilitic lesions of, 159
+
+  Hand, claw-, 369
+
+  Hands, disinfection of, 244
+
+  Hard chancre, 151
+
+  Healing by blood-clot, 6
+    by first intention, 2
+    by granulation, 5
+    by primary union, 2
+    rate of, 9
+    under scab, 6
+    by second intention, 5
+    sore, 69, 81
+    ulcer, 77
+    by union of granulating surfaces, 5
+
+  Heart, massage of, 265
+
+  Heberden's nodes, 529
+
+  Hectic fever, 62
+
+  Heliotherapy, 139
+
+  Hernia, fatty, 187
+    of muscle, 408
+
+  Herpes, syphilitic, 156
+
+  Hilton's method of opening abscess, 50
+
+  Hodgkin's disease, 377
+
+  Horns, varieties of, 389, 391
+
+  Housemaid's knee, 426, 431
+
+  Hunter's operation for aneurysm, 307
+
+  Hutchinson's teeth, 177
+
+  Hydatid cysts, 213
+      of bone, 467
+      of muscle, 421
+    thrill, 214
+
+  Hydrocele of neck, 328
+
+  Hydrophobia, 115, 118
+
+  Hydrops, 501, 518
+
+  Hygroma of axilla, 328
+    bursal, 427
+    of neck, 328
+
+  Hyperaemia, 32
+    active, 39
+    artificial, 36
+    passive, 38
+    in tuberculosis, 138
+
+  Hyperostosis, 435
+    syphilitic, 464
+
+  Hypertrophic pulmonary osteo-arthropathy, 480
+
+  Hysterical joint affections, 537
+
+
+  Ice-bags, 41
+
+  Ichthyma, syphilitic, 158
+
+  Igni-puncture in naevus, 297
+
+  Iliac aneurysm, 318
+
+  Immunity, 22
+
+  Imperial drink, 40
+
+  Implantation cysts, 212
+
+  Infantile scurvy, 473
+
+  Infection, accidental, 241
+    by catgut, 51
+    mixed, 20
+    prevention of, 243
+    of wounds, 241
+
+  Inflammation, 31
+    changes in, 32
+    chronic, 42
+    clinical aspects of, 33
+    constitutional disturbance in, 35
+    general principles of treatment in, 36, 39
+
+  Inflammation, leucocytosis in, 36
+    stages of, 32
+
+  Infusion of saline solution, 276
+
+  Ingrowing toe-nail, 403
+
+  Inguinal aneurysm, 318
+    lymph glands, 323
+
+  Injuries, 218. _See also_ Individual Tissues and Regions
+    constitutional effects of, 249
+
+  Innominate aneurysm, 314
+
+  Inoculation tubercle, 382
+
+  Insects, poisoning by, 130
+
+  Instruments, sterilisation of, 245
+
+  Intercostal fibrositis, 413
+
+  Intermittent claudication of vessels, 98
+
+  Internal popliteal nerve. _See_ Tibial Nerve
+
+  Interstitial keratitis, 177
+
+  Intestine, repair of, 9
+
+  Intoxication, bacterial, 21
+
+  Intracranial aneurysm, 316
+
+  Intra-cystic growths, 202
+
+  Intubation of larynx, 111
+
+  Involucrum, 443
+
+  Iodine, catgut, 246
+    for disinfection of skin, 245
+    reaction, 30
+
+  Iodoform gauze, 247
+    injection of, 142
+    in joint diseases, 519
+
+  Iritis, syphilitic, 160
+
+  Irrigation, continuous, 54
+
+  Irritable ulcers, 79
+
+  Ischaemic contracture of muscles, 415
+
+  Ischial bursa, 430
+
+  Ischias scoliotica, 372
+
+  Ivory exostosis, 481
+
+
+  Jaws, actinomycosis of, 127
+    changes in, in rickets, 470
+    cystic tumours of, 193
+
+  Jigger, 130
+
+  Joints. _See also_ Individual Joints
+    ankylosis of, 503
+    bacterial diseases of, 506
+    bleeder's, 531
+    Charcot's disease of, 533
+    chondromata, multiple, of, 544
+    contracture of, 502
+    cysts of, 538
+    developmental errors of, 505
+    diseases of, general, 501, 506
+    disorganisation of, 502
+    empyema of, 501
+    gelatinous degeneration of, 515
+    gliomatous arthropathies, 534
+    gonococcal affections of, 510
+    gouty affections of, 522
+    haemophilic, 531
+    hydrops of, 501
+    hysterical affections of, 537
+    impaired mobility of, 502
+    iodoform in diseases of, 519
+    loose bodies in, 529, 539
+    mimetic affections of, 537
+    nerve lesions affecting, 532
+    neuro-arthropathies, 532
+    osteo-arthritis, 524
+    pneumococcal infection of, 509
+    pyaemic affections of, 508
+    pyogenic diseases of, 506
+    rheumatic affections of, 523, 524
+    rigidity of, 502
+    scarlet fever, infection of, in 508
+    spinal diseases affecting, 532
+    starting pains in, 502, 517
+    synostosis, 503
+    syphilitic diseases of, 521
+    tuberculous diseases of, 512
+    tumours of, 538
+    typhoid infection of, 508
+    white swelling of, 515, 518
+
+  Jumper's sprain, 406
+
+
+  Keloid, 194, 401
+
+  Keratitis, interstitial, in syphilis, 177
+
+  Keratoma of nail bed, 391
+
+  Kharsivan, 163
+
+  Klapp's suction bells, 39
+
+  Klebs-Loffler bacillus, 109
+
+  Klumpke's paralysis, 361
+
+  Knee, cellulitis of, 58
+    ganglion of, 215
+    housemaid's, 426, 431
+
+  Kopf or cephalic tetanus, 116
+
+  Kyphosis, 471
+
+
+  Labourer's back, 405
+
+  Larynx, syphilis of, 177
+
+  Leeches, 41
+
+  Leg ulcer, 72
+    varicose veins of, 287
+
+  Leiter's lead tubes, 41
+
+  Leontiasis ossea, 485
+
+  Leucocytes, emigration of, 32
+    varieties of, 29
+    wandering, 3
+
+  Leucocythaemia, 340
+
+  Leucocytosis, 22, 29
+    absence of, 30
+    digestion, 30
+    after haemorrhage, 30
+    local, 32
+    physiological, 29, 30
+    post-operative, 30
+
+  Leucopenia, 30
+
+  Leucoplakia, 167
+
+  Lightning stroke, 240
+
+  Line of demarcation in gangrene, 87
+
+  Lingual dermoids, 211
+
+  Lipoma, 184
+    arborescent, 423
+    of bone, 187, 491
+    diffuse, 187
+    intra-muscular, 188
+    multiple, 186
+    nasi, 393
+    periosteal, 187
+    subcutaneous, 184, 186
+    subserous, 187
+    subsynovial, 187
+
+  Lipomatosis, diffuse, 187
+
+  Lipping of bone, 527
+
+  Liquor epispasticus, 42
+    puris, 45
+
+  Listerian methods of wound treatment, 242
+
+  Locking of joints, 505
+
+  Lock-jaw, 113
+
+  Locomotor ataxia, joint lesions in, 532
+
+  Long thoracic nerve, injuries of, 363
+
+  Loose bodies in bursae, 427
+    in joints, 529, 539
+    in tendon sheaths, 423
+    varieties of, 539
+
+  Lotion, evaporating, 41
+
+  Luargol, 163
+
+  Luetin, 149
+
+  Lumbago, 412
+
+  Lumbo-sacral fibrositis, 412
+
+  Lupus, 134, 382
+    epithelioma, 384
+    syphilitic, 169
+    tuberculous, 382
+    varieties of, 383, 393
+
+  Lymph, 321
+    cysts, 214
+    glands, cancer of, 340
+      diseases of, 329
+      functions of, 221
+      sarcoma of, 341
+      surgical anatomy of, 321
+      syphilitic diseases of, 337
+      tuberculosis of, 331
+      tumours of, 340
+    oedema, 325
+    scrotum, 389
+    vessels, diseases of, 325
+      injuries of, 323
+
+  Lymphadenitis, 53, 329
+
+  Lymphadenoma, 337
+
+  Lymphangiectasis, 214, 326
+
+  Lymphangioma, varieties of, 327
+
+  Lymphangioplasty, 325, 386
+
+  Lymphangio-sarcoma, 199
+
+  Lymphangitis, 325
+    septic, 53
+    varieties of, 325
+
+  Lymphatic cyst, 328
+    fistula, 324
+    oedema, 325
+
+  Lymphatics, 321
+
+  Lymphocytosis, 29
+
+  Lymphorrhagia, 323
+
+  Lympho-sarcoma, 199, 340
+
+
+  Macewen's method of compressing abdominal aorta, 269
+
+  Macrophages, 22
+
+  Madura foot, 129
+  _Main en griffe_, 369
+
+  Malacia of bones, 473
+
+  Malignant adenoma, 209
+    cachexia, 207
+    oedema, 101
+    pustule, 120
+    tumours, 183
+    ulcers, 77
+
+  Mallein test, 125
+
+  Mallet-finger, 411
+
+  Malum senile, 524
+
+  Marriage and syphilis, 167
+
+  Matas' operation for aneurysm, 307
+
+  Median nerve, lesions of, 367
+
+  Medullary cancer, 210
+
+  Melaena, 259
+
+  Melanotic cancer, 210, 397
+    sarcoma, 200
+
+  Melon-seed bodies, 539
+
+  Meningitis, basal, 115
+    cerebro-spinal, 115
+
+  Mercury in syphilis, administration of, 165
+
+  Metchnikoff's cream, 157
+
+  Michel's clips, 222
+
+  Micrococci, 18
+
+  Micrococcus tetragenus, 29
+
+  Micro-organisms, 18
+
+  Microphages, 22
+
+  Mimetic joint affections, 537
+
+  Miner's elbow, 426
+
+  Mitchell's operation for varicose veins, 294
+
+  Mixed infection, 20
+    naevus, 295
+    venereal infection, 156
+
+  Moist gangrene, 87
+
+  Moles, 390
+    naevoid, 295
+
+  Molluscum fibrosum, 194, 359, 391
+
+  Moore-Corradi method of treating aneurysm, 308
+
+  Mosetig-Moorhof on filling of bone cavities, 447
+
+  Mother's mark, 294
+
+  Muco-pus, 52
+
+  Mucous membrane, grafting of, 16
+      suppuration in, 51
+    patches, 160, 174
+
+  Multilocular cystic tumours of jaw, 193
+
+  Mummification, 86
+
+  Muscle, affections of, 405
+    atrophy of, 412
+    calcification of, 416
+    congenital absence of, 411
+    contracture of, 415
+    contusion of, 405
+    diseases of, 411
+    gonorrhoea of, 416
+    grafting of, 16
+    hernia of, 408
+    hydatid cysts of, 421
+    inflammation of, 415
+    injuries of, 405
+    ossification in, 416
+    repair of, 8
+    rheumatism of, 412
+    rupture of, 405, 406
+    sprain of, 405
+    syphilis of, 416
+    tuberculosis of, 416
+    tumours of, 420
+    wounds of, 409
+
+  Muscular rheumatism, 412
+
+  Musculo-cutaneous nerve, 364
+
+  Musculo-spiral nerve. _See_ Radial Nerve
+
+  Mustard leaves, 42
+
+  Mycetoma, 129
+
+  Myelitis, syphilitic, 161
+
+  Myeloma, 195, 491
+    of bone, 491
+    of tendon sheaths, 424
+
+  Myoma, 195
+
+  Myo-sarcoma, 200
+
+  Myositis ossificans, 416, 418
+    varieties of, 415
+
+  Myxo-adenoma, 202
+
+  Myxoma, 194
+    of bone, 491
+
+  Myxo-sarcoma, 200
+
+
+  Naevoid mole, 295
+
+  Naevus, 294
+    electrolysis of, 297
+    operations for, 298
+    radium treatment of, 297
+    varieties of, 294
+
+  Nail fold, whitlow of, 56
+    horns, 391
+
+  Nails, affections of, 402
+    ingrowing, 403
+    regeneration of, 7
+    syphilitic lesions of, 159, 402
+
+  Nasal bones, syphilitic disease of, 188, 462
+
+  Naso-pharyngeal polypus, 491
+
+  Natal sore, 129
+
+  Neck, cystic hygroma of, 328
+    glands of, diseases, 332
+    hydrocele of, 328
+    lipomatosis of, 187
+    painful stiff-, 413
+
+  Necrosis, acute, 439
+    of bone, 438
+    quiet, of Paget, 452
+    syphilitic, 462
+
+  Neo-diarsenol, 163
+    -kharsivan, 163
+    -salvarsan, 163
+
+  Neoplasms, 181
+
+  Nerve of Bell. _See_ Long Thoracic Nerve
+
+  Nerves, 342. _See also_ Individual Nerves
+    alcohol injections of, 374
+    anatomy of, 342
+    avulsion of, 375
+    blocking of, 251, 252
+    bullet wounds of, 346
+    contusion of, 345
+    crushing of, 345
+    diseases of, 352
+    dislocation of, 351, 369
+    effects of division of, 344
+    gun-shot wounds of, 346
+    grafting of, 16
+    implicated in scar tissue, 345
+    individual, surgery of, 360
+    injuries of, 344
+    joint affections in lesions of, 532
+    reaction of degeneration, 347
+    regeneration of, 9, 346
+    in scar tissue, 345
+    sensibility, forms of, 343
+    subcutaneous injuries of, 350
+    suture of, primary, 348
+      secondary, 349
+    Tinel's sign, 349
+    torn, 345
+    tumours of, 353
+    ulcers in lesions of, 73, 82
+
+  Neuralgia, varieties of, 371
+
+  Neurectomy, 375
+
+  Neuritis, multiple peripheral, varieties of, 352
+    traumatic, 352
+
+  Neuro-arthropathies, 352. _See also_ Individual Joints
+
+  Neuro-fibromatosis, 355, 359
+
+  Neurolysis, 345
+
+  Neuroma, stump, 344
+    varieties of, 353
+    "914," 613
+
+  Nodes, periosteal, 464
+    Heberden's 529
+
+  Noma, 102
+
+  Nose, sebaceous adenoma of, 393
+
+  Novo-arseno-billon, 163
+
+  Nucleinate of soda, 29
+
+
+  Odontoma, 192
+    varieties of, 193
+
+  O'Dwyer's intubation apparatus, 111
+
+  Oedema, 32, 34
+    angio-neurotic, 348
+    lymphatic, 325
+    malignant, 101
+    persistent, 109
+
+  Olecranon bursa, 428
+
+  Omental cyst, 329
+
+  Onychia, varieties of, 402
+
+  Operations during shock, 252
+
+  Opisthotonos, 114
+
+  Opsonins, 22
+
+  Orbital aneurysm, 317
+
+  Orthotonos, 114
+
+  Ossification in muscles, tendons, and fasciae, 416
+
+  Ossifying junction, 434
+
+  Osteo-arthritis, 524
+    syphilitic, 522
+
+  Osteo-arthropathy, pulmonary, 480
+
+  Osteochondritis dessicans, 544
+
+  Osteogenesis imperfecta, 479
+
+  Osteoid sarcoma, 200
+
+  Osteoma, 191, 481
+    cancellous, 191
+    compact, 192
+    diffuse, 485
+    ivory, 192
+    multiple, 544
+    in muscles and tendons, 416
+    spongy, 191
+    subungual, 191, 404, 481
+
+  Osteomalacia, varieties of, 473
+
+  Osteomyelitis, 65, 437
+    acute, 65, 438, 451, 453
+    after amputation, 453
+    bipolar, 439
+    fibrosa, 476
+    gummatous, 462
+    from infection from soft parts, 453
+    pyogenic, 438
+    relapsing, 448
+    sequelae of, 443
+    streptococcal, 451
+    tuberculous, 456, 458
+    in typhoid fever, 452
+
+  Osteophytes, 435
+
+  Osteoporosis, 437
+
+  Osteopsathyrosis, 479
+
+  Osteosarcoma, 200
+
+  Osteosclerosis, 435
+
+  Ostitis deformans, 474
+    rarefying, 474
+
+  Ovarian dermoids, 211
+
+  Ovary, grafting of, 16
+
+  Ozoena, 176
+
+
+  Pachydermatocele, 360
+
+  Paget's disease of bone, 474
+    of nipple, 397
+    recurrent fibroma, 199, 392, 420
+
+  Pain, starting, in joint disease, 502, 517
+    varieties of, 35
+
+  Painful subcutaneous nodules, 354, 392
+
+  Palate, syphilitic lesions of, 178, 462
+
+  Palmar ganglion, compound, 217, 423
+
+  Papilloma, varieties of, 201, 392
+
+  Paraffin cancer, 395
+
+  Paralysis, brachial birth, 362
+    Erb-Duchenne, 361
+    Klumpke's, 361
+    post-anaesthetic, 360
+    pseudo, of syphilis, 174, 466
+
+  Parasitic bacteria, 20
+    cysts, 213
+
+  Paronychia. _See_ Onychia
+
+  Parotid abscess in pyaemia, 66
+    lymph glands, 321
+    tumours, 195
+
+  Parotitis, 66
+
+  Parrot's nodes, 175, 465
+
+  Passive hyperaemia, Bier's, 38
+
+  Pasteur's treatment for hydrophobia, 119
+
+  Pelvis, rickety changes in, 471
+
+  Perforating ulcer, 73, 82
+
+  Perichondritis, syphilitic, 465
+
+  Peri-lymphangitis, 325
+
+  Periosteum, function of, 434
+    gumma of, 464
+    in rickets, 469
+
+  Periostitis, 437. _See also_ Osteomyelitis
+    syphilitic, 461
+    tuberculous, 455
+
+  Peripheral neuritis, 352
+
+  Peroneal nerve, 370
+
+  Peronei tendons, dislocation of, 409
+
+  Petrifying sarcoma, 200
+
+  Phagedaena, 153
+
+  Phagedaenic ulcers, 80, 85
+
+  Phagocytes, 3, 22
+
+  Phagocytosis, 22
+
+  Phimosis, with hard chancre, 152
+    with soft sores, 155
+
+  Phlebitis, 285, 292
+
+  Phlegmasia alba dolens, 286
+
+  Picric acid, 13, 237
+
+  Pigeon-breast, 471
+
+  Plantaris, rupture of, 408
+
+  Pleurodynia, 413
+
+  Pleurosthotonos, 114
+
+  Pneumo-bacillus, Friedlander's bacteria, 28
+
+  Pneumococcal arthritis, 509
+
+  Pneumococcus, 28
+
+  Polypi, 195
+
+  Popliteal aneurysm, 320
+    artery, embolus of, 93
+    bursae, 432
+    lymph glands, 323
+    nerves. _See_ Common Peroneal Nerve and Tibial Nerve
+
+  Port-wine stain, 294
+
+  Post-anaesthetic paralysis, 360
+    -anal dimple, 211
+
+  Posterior auricular lymph glands, 322
+
+  Post-rectal dermoids, 211
+
+  Potato-nose, 393
+
+  Poultice, 37
+    charcoal, 84
+
+  Pre-auricular lymph glands, 322
+
+  Prepatellar bursa, 431
+
+  Pressure sores, 70, 82
+
+  Primary union of wounds, 2
+
+  Protopathic sensibility of nerves, 343
+
+  Proud flesh, 79
+
+  Psammoma, 200
+
+  Pseudo-leucaemia, 337
+
+  Pseudo-paralysis of syphilis, 174, 466
+
+  Psoas bursa, 430
+
+  Pulmonary osteo-arthropathy, 480
+
+  Pulsating aorta, 305, 314
+    exophthalmos, 317
+    haematoma of bone, 498
+
+  Punctured wounds, 222
+
+  Purpura, 280
+
+  Purulent blister, 55
+
+  Pus, 45
+    varieties of, 46
+
+  Pyaemia, 64
+    abscess in joints in, 508
+
+  Pyogenic bacteria, 24, 29
+
+
+  Quadriceps extensor femoris, rupture of, 408
+
+
+  Rabies, 118
+
+  Rachitis, 468
+    adolescentium, 472
+
+  Radial nerve, lesions of, 364
+
+  Radium, in lupus, 385
+    in cancer, 208
+    in naevus, 297
+    ulceration from, 239
+
+  Ranula, 329
+
+  Rarefying ostitis, 437
+
+  Ray fungus, 126
+
+  Raynaud's disease, 97
+
+  Reaction of degeneration, 347
+
+  Reactionary haemorrhage, 272
+
+  Recklinghausen's disease, 355
+
+  Recurrent fibroid of Paget, 199, 392, 420
+
+  Repair. _See_ Individual Tissues
+    conditions interfering with, 17
+    after loss of tissue, 4
+    modifications of, 4
+    of separated parts, 5
+
+  Rest, 17
+
+  Rests, foetal, 181
+
+  Retention cysts, 212
+
+  Retro-pharyngeal lymph glands, 322
+
+  Reverdin's method of skin-grafting, 13
+
+  Rhabdomyoma, 196
+
+  Rheumatic arthritis, 524
+    fever, 509
+    gout, 524
+    torticollis, 413
+
+  Rheumatism, acute, 509
+    chronic, 523
+    gonorrhoeal, 510
+    muscular, 412
+    scarlatinal, 508
+
+  Rheumatoid arthritis, 524
+
+  Rhinophyma, 393
+
+  Rickets, 468
+    bone lesions in, 469
+    changes in skeleton in, 470
+    late, 472
+    scurvy, 473
+
+  Rickety, dwarf, 469
+    pelvis, 471
+    rosary, 469
+    scoliosis, 471
+
+  Rider's bone, 418
+    sprain, 407
+
+  Rigidity of joints, 502
+
+  Rigor, 36
+
+  Risus sardonicus, 114
+
+  Rodent cancer, 210, 395
+    ulcer, 210, 395
+
+  Rontgen rays. _See_ X-rays
+
+  Rose or erysipelas, 107
+
+  Roseola, syphilitic, 158
+
+  Rupia, syphilitic, 158
+
+
+  Sabre-blade deformity of tibia, 466
+
+  Sacculated aneurysm, 302
+
+  Saddle-nose deformity, 174
+
+  Saline infusions in haemorrhage, 276
+
+  Salvarsan in syphilis, 162
+
+  Sapraemia, 60
+    chronic, 62
+
+  Saprophytic bacteria, 20
+
+  Sarcoma, 197
+    of bone, 492
+    inoperable, 201
+    of joints, 538
+    of lymph glands, 341
+    melanotic, 200
+    periosteal, 493
+    of skin, 398
+    of synovial membrane, 538
+    of tendon sheaths, 424
+    varieties, 199
+
+  Scab, healing under, 6
+
+  Scalds, 233
+
+  Scapula, winged, 363
+
+  Scarlet fever, joint lesions in, 508
+
+  Scars. _See_ Cicatrices
+
+  Sciatic nerve, lesions of, 370
+
+  Sciatica, 371
+
+  Scirrhous cancer, 210
+
+  Sclavo's serum, 123
+
+  Scoliosis, rickety, 471
+    in sciatica, 372
+
+  Scorbutic ulcers, 77
+
+  Scrotum, elephantiasis of, 389
+
+  Sculler's sprain, 406
+
+  Scurvy, 473
+    rickets, 473
+
+  Sebaceous adenoma, 393
+    cysts, 389
+    horns, 389
+
+  Secondary haemorrhage, 273
+    syphilis, 151, 147
+
+  Selenium in malignant tumours, 201, 208
+
+  Semilunar ganglion, 375
+
+  Semi-membranosus bursa, 432
+
+  Sepsis, 18
+
+  Septicaemia, 53, 63
+
+  Sequestrectomy, 446
+
+  Sequestrum of bone, 438
+
+  Serratus anterior muscle, paralysis of, 363
+
+  Serum, anti-diphtheritic, 109
+    anti-bacterial, 23
+    anti-tetanic, 117
+    disease, 23
+    in haemophilia, 280
+    polyvalent, 23
+    Sclavo's, for anthrax, 123
+    treatment, 23
+
+  Seton, 217
+
+  Shell wounds, 231
+
+  Shock, 250
+    delayed, 252
+
+  Shoulder, fibrositis of, 413
+
+  Sinus, 59
+    epithelioma, 500
+    tuberculous, 143
+
+  "606," 162
+
+  Skewers for prevention of haemorrhage, 270
+
+  Skin, 376
+    abscesses of, 382
+    actinomycosis of, 126
+    cancer of, 394, 398
+    dermoids, 210
+    grafting of, 11, 14
+    preparation of, for operation, 244
+    repair of, 6
+    sporotrichosis of, 385
+    structure of, 376
+    syphilitic lesions of, 157, 166
+    tuberculosis of, 382, 385
+    tumours of, 391
+
+  Skull, bossing of, 465
+    craniotabes of, 175, 176, 465
+    diffuse osteoma of, 485
+    natiform, 176
+    Parrot's nodes, 465
+    syphilitic disease of, 462
+    unilateral hypertrophy of, 487
+
+  Slough, 86
+
+  Snake-bites, 131
+
+  Snuffles, 173
+
+  Soft chancre, 154
+    corns, 377
+    sore, 154
+
+  Spas, 531
+
+  Spasmodic tic, 373
+
+  Sphagnum moss, 247
+
+  Spinal arthropathies, 532
+    cord, joint affections in lesions of, 532
+    repair of, 9
+    syphilis of, 161
+
+  Spine, changes in rickets, 471
+
+  Spirilla, 19
+
+  Spirochaete pallida, 147
+
+  Spironema pallidum, 147
+
+  Splenic fever, 119
+
+  Spores, 18
+
+  Sporotrichosis, 385
+
+  Sprain of muscle, 405, 407
+
+  Sprinter's sprain, 406
+
+  Staphylococci, 19, 24, 438
+
+  Staphylococcus albus, 26
+    aureus, 25
+
+  Starting pains in joints, 502, 517
+
+  Stasis, 32
+
+  Sterilisation, surgical, 243
+
+  Sterno-mastoid lymph glands, 322
+
+  Stitch abscess, 51
+
+  Stitches. _See_ Sutures
+
+  Streptococci, 19, 24
+
+  Streptococcus pyogenes, 26
+
+  Streptothrix actinomyces, 126
+
+  Strychnin poisoning, 115
+
+  Stump neuroma, 344
+
+  Styptics, 271
+
+  Sub-acromial bursa, 429
+
+  Sub-calcanean bursa, 433
+
+  Subclavian aneurysm, 317
+
+  Sub-crural bursa, 430
+
+  Sub-deltoid bursa, 429
+
+  Submaxillary lymph glands, 322
+
+  Submental lymph glands, 322
+
+  Sub-patellar bursa, 431
+
+  Subscapularis bursa, 430
+
+  Subungual exostosis, 191, 404, 481
+
+  Suction bells, 39
+
+  Suppuration, 45
+    chronic, 59
+    diffuse, 52
+    in mucous membranes, 52
+    in wounds, 50
+
+  Supra-clavicular lymph glands, 322
+
+  Supra-hyoid lymph glands, 322
+
+  Supra-scapular nerve, lesions of, 364
+
+  Surgery, definition of, 1
+    Listerian, 242
+
+  Surgical anatomy of blood vessels, 258
+    of bone, 434
+    of epiphyses, 434
+    of lymphatics, 321
+    of nerves, 342
+    of skin, 376
+
+  Surgical bacteriology, 17, 18
+    shock, 250
+
+  Sutures, 221
+    sterilisation of, 245
+
+  Sweat-glands, tumours of, 393
+
+  Syncope, 249
+    local, 97
+
+  Synostosis, 503
+
+  Synovial membrane, tumours of, 538
+
+  Synovitis, 501, 506
+    gonococcal, 510
+    septic, 506
+    serous, 506, 507
+    suppurative, 507
+    syphilitic, 521
+
+  Syphilis, 147. _See also_ Individual Tissues and Organs
+
+  Syphilis, acquired, 146, 149
+      in infants, 179
+    arsenical preparations in, 162
+    arteritis in, 282
+    bones, lesions in, 461, 465
+    brain, lesions in, 161
+    of bursae, 428
+    cirrhosis in, 168
+    Colles' law, 178
+    contracture of muscle in, 416
+    dactylitis in, 176, 460, 466
+    epiphysitis of infants, 465
+    extra-genital, 153
+    in female, 152, 164
+    gumma, 168, 462
+    hydrops in, 521
+    incubation of, 151
+    in infants, 179
+    inherited, 146, 172
+      contagiousness of, 178
+      diagnosis of, 178
+      facies of, 174, 175
+      lesions of bone in, 465
+        eyes in, 176, 177
+        joints in, 522
+        skin in, 173, 174
+        teeth in, 177
+      treatment of, 179
+    insontium, 153
+    intermediate stage of, 167
+    interstitial keratitis in, 177
+    iodides in, 171
+    iritis in, 166
+    joint lesions in, 521
+    of larynx, 177
+    lupus, 169
+    lymphadenitis, 153, 337
+    lymphangitis, 326
+    in male, 152
+    malignant, 161
+    and marriage, 167
+    mercury in, 164
+    mixed infection, 156
+    of mouth, 166
+    of mucous membranes, 160, 173, 174
+    mucous patches, 160, 174
+    of muscle, 416
+    of nails, 159
+    of nose, 188
+    onychia in, 403
+    osteo-arthritis, 522
+    of palate, 178, 462
+    phagedaena, 153
+    phimosis in, 152
+    in pregnant women, 164
+    primary, 151
+      diagnosis of, 155
+      lesion of, 146, 151
+      treatment of, 163
+    prophylaxis of, 149
+    pseudo-paralysis of, 174, 466
+    reminders, 167
+    second attacks of, 172
+    secondary, 151, 157
+      diagnosis of, 161
+      lesions of eye in, 160
+        hair in, 159
+        nails in, 159, 402
+        skin in, 162
+      treatment of, 162
+    serum diagnosis, 149
+    skin affections in, 157, 166
+    skull, lesions of, 462
+    spirochaete pallida in, 147
+    stages of, 150
+    stomatitis, 174
+    synovitis, 521
+    teeth in, 177
+    of tendon sheaths, 424
+    tertiary, 151, 167
+      diagnosis of, 167
+      general manifestations of, 167
+      lesions of mucous membrane in, 171
+        skin in, 168, 169
+      treatment of, 171
+      ulcer, 169
+    ulcers in, 76, 83, 169
+    virus of, 147
+    Wassermann reaction in, 156
+
+  Syphiloma, 168
+
+  Syringomyelia, joint lesions in, 534
+
+
+  Tabes dorsales, joint lesions in, 532
+
+  Taenia echinococcus, 213
+
+  Tailor's ankle, 432
+
+  Tailor's bottom, 426, 430
+
+  Tarsal ganglion, 215
+
+  Tarsus, tuberculosis of, 459
+
+  Teeth in inherited syphilis, 177
+
+  Telangiectasis, congenital, 294
+
+  Temperature in surgical diseases, 35, 40
+
+  Temporal artery, compression of, 269
+
+  Tenderness, 34
+
+  Tendinitis, 416
+
+  Tendon sheaths, affections of, 421
+    syphilitic affections of, 424
+    tuberculosis of, 423, 424
+    tumours of, 424
+    whitlow of, 57
+
+  Tendons. _See also_ Individual Tendons
+    avulsion of, 411
+    calcification in, 416
+    diseases of, 411
+    dislocation of, 408
+    ganglion of, 217
+    grafting of, 16
+    inflammation of, 416
+    ossification of, 416
+    repair of, 8
+    rupture of, 406, 408
+    tumours of, 420
+    wounds of, 409
+
+  Tennis-player's elbow, 406
+
+  Teno-synovitis, varieties of, 421
+
+  Teratoma, 212
+
+  Tertiary syphilis, 151, 167
+
+  Tetanus, varieties of, 112
+
+  Tetany, 116
+
+  Thiersch's method of skin-grafting, 12
+
+  Thirst, treatment of, 40
+
+  Thoracic aneurysm, 312
+    duct, subcutaneous rupture of, 325
+      surgical anatomy of, 324
+      wounds of, 325
+
+  Thorax, rickety changes in, 469
+
+  Thrombo-phlebitis, 285
+
+  Thrombosis, 32, 281, 285, 292
+
+  Thyreoid gland, grafting of, 16
+    secondary tumours derived from, 500
+
+  Tibia, sabre-blade deformity of, 466
+
+  Tibial nerve, lesions of, 371
+
+  Tic, spasmodic, 373
+
+  Tinel's sign, 349
+
+  Toe-nail, ingrowing, 403
+
+  Toes, gouty affections of, 522
+    syphilitic dactylitis of, 176, 460, 466
+    tuberculous dactylitis, 460
+
+  Tomato tumour, 393
+
+  Tophi, gouty, 523
+
+  Torsion of blood vessels, 271
+
+  Torticollis, rheumatic, 413
+
+  Tourniquet, varieties of, 270, 272
+
+  Toxaemia, 21
+
+  Toxins, 21, 33
+
+  Tracheal tug in aneurysm, 312
+
+  Tracheotomy, 111
+
+  Trade arthritis, 525
+    bursitis, 426
+    epithelionia, 395
+
+  Transfusion of blood, 276
+
+  Transplantation of tissues, 10
+
+  Trench feet, 96
+
+  Trendelenburg's operation for varicose veins, 293
+
+  Treponema pallidum, 147
+
+  Trifacial neuralgia, 373
+
+  Trigeminal neuralgia, 373
+
+  Trismus, 117
+
+  Trochanteric bursa, 430
+
+  Trophic changes after nerve injuries, 348
+    ulcer, 73
+
+  Tropical elephantiasis, 386
+
+  Trunk neuroma, 354
+
+  Tubercle, anatomical, 134
+    bacillus, 133
+
+  Tuberculin, 138
+
+  Tuberculosis, 133. _See also_ Individual Tissues and Organs
+    bacillus of, 133
+    of bone, 454, 456, 458
+    bovine, 136
+    of bursae, 428
+    calcification in, 136
+    caseation in, 136
+    general, 135
+    human, 136
+    of joints, 512
+    of lymph glands, 331
+    of lymph vessels, 326
+    modes of infection, 136
+    of muscle, 416
+    of nails, 403
+    open-air treatment of, 137
+    passive hyperaemia in, 138
+    principles of treatment of, 137
+    of skin, 382, 385
+    of tendon sheaths, 423, 424
+    trauma in causation of, 135
+    vaccine treatment in, 138
+
+  Tuberculous abscess, 139
+    arthritic fever, 516
+    dactylitis, 460
+    granulation tissue, 136
+    lupus, 382
+    lymphadenitis, 331
+    lymphangitis, 326
+    onychia, 403
+    sinus, 143
+
+  Tuberculous ulcers, 73, 83
+
+  Tubulo-dermoids, 211
+
+  Tumor albus, 518
+
+  Tumours, 181. _See also_ Individual Tumours and Tissues
+
+  Typhoid, joint lesions in, 508
+    osteomyelitis in, 452
+
+
+  Ulceration, of cartilage, 502, 514
+    definition of, 68
+
+  Ulcers, 68
+    ambulatory treatment of, 85
+    Bazin's disease, 74, 169
+    bone changes in, 79
+    callous, 79, 84
+    cancerous, 205
+    classification of, 70
+    clinical examination of, 68
+    conditions of, 77
+    crateriform, 395
+    duodenal, in burns, 236
+    epithelioma in, 500
+    healing, 77
+    gouty, 77
+    due to imperfect circulation, 71, 82
+    due to imperfect nerve-supply, 73, 82
+    inflamed, 79, 85
+    irritable, 79, 85
+    leg, 72, 169
+    malignant, 77
+    perforating, 73, 82
+    phagedaenic, 80, 85
+    pressure, 70
+    from radium, 70
+    rodent, 395
+    from Rontgen rays, 70
+    scorbutic, 77
+    skin-grafting, 14
+    spreading, 79
+    syphilitic, 76, 83, 158, 160, 169
+    traumatic, 70, 81
+    treatment of, 80
+    trophic, 73
+    tuberculous, 73, 83
+    varicose, 72
+    weak, 77, 83
+
+  Ulnar nerve, lesions of, 368
+
+  Uterine fibroids, 195
+
+
+  Vaccine treatment, 23, 40
+
+  Varicose aneurysm, 311
+    eczema, 292
+    ulcer, 72
+    veins, 287
+
+  Varix, 287
+
+  Veins, anatomy of, 258
+    entrance of air into, 265
+    injuries of, 264
+    repair of, 269
+    rupture of, 264
+    thrombosis of, 281
+    varicose, 287
+    wounds of, 264
+
+  Veldt sores, 382
+
+  Venereal disease. _See_ Syphilis
+    soft sore, 154
+
+  Venesection, 42
+
+  Venous cysts, 289
+
+  Verruca, 392
+
+  Vibrion septique, 101
+
+  Villous papilloma, 201
+
+  Volkmann's ischaemic contracture, 415
+
+  Vulva, diphtheria of, 111
+
+
+  Wardrop's operation for aneurysm, 308
+
+  Wart, 201, 392
+    venereal, 393
+    X-ray, 239
+
+  Wassermann's reaction, 156, 162
+
+  Weaver's bottom, 426, 430
+
+  Weir-Mitchell treatment in hysterical joint affections, 538
+
+  Wens, 389
+
+  Wet-cupping, 42
+
+  White swelling of joints, 515, 518
+
+  Whitlow, 55
+    gangrene from, 99
+    at nail fold, 56
+    purulent blister, 55
+    subcutaneous, 56
+    subperiosteal, 58
+    of tendon sheaths, 57
+    thecal, 57
+
+  Whitlow, of toes, 55
+    varieties of, 55
+
+  Winged scapula, 363
+
+  Wool-sorter's disease, 121
+
+  Wounds, 220. _See also_ Individual Tissues and Regions
+    acute suppuration in, 50
+    bullet, 229
+    contused, 218, 223
+    drainage of, 222
+    by electricity, 239
+    by explosives, 231
+    by firearms, 225, 227, 230
+    incised, 221
+    infection of, 107
+    lacerated, 223
+    open method of treating, 247, 248
+    pistol-shot, 226
+    punctured, 222
+    shell, 231
+    treatment, 241
+    in warfare, 225, 230
+
+  Wrist, drop-, 365
+
+  Wry-neck, rheumatic, 413
+
+
+  Xanthoma, 188
+
+  X-rays, burns by, 239
+    cancer from, 395
+    dermatitis from, 239
+    ulcers from, 239
+    warts from, 239
+    in diagnosis of aneurysm, 304
+      arthritis deformans, 530
+      bone diseases, 445
+        tumours, 485, 491, 496
+        tuberculosis, 455
+      foreign bodies, 233
+      joint tuberculosis, 516
+    in treatment of cancer, 208
+      lupus, 385
+      sarcoma, 201
+      tuberculosis, 138
+
+
+
+
+
+End of the Project Gutenberg EBook of Manual of Surgery, by 
+Alexis Thomson and Alexander Miles
+
+*** END OF THIS PROJECT GUTENBERG EBOOK MANUAL OF SURGERY ***
+
+***** This file should be named 17921.txt or 17921.zip *****
+This and all associated files of various formats will be found in:
+        http://www.gutenberg.org/1/7/9/2/17921/
+
+Produced by Jonathan Ingram, Laura Wisewell and the Online
+Distributed Proofreading Team at http://www.pgdp.net
+
+
+Updated editions will replace the previous one--the old editions
+will be renamed.
+
+Creating the works from public domain print editions means that no
+one owns a United States copyright in these works, so the Foundation
+(and you!) can copy and distribute it in the United States without
+permission and without paying copyright royalties.  Special rules,
+set forth in the General Terms of Use part of this license, apply to
+copying and distributing Project Gutenberg-tm electronic works to
+protect the PROJECT GUTENBERG-tm concept and trademark.  Project
+Gutenberg is a registered trademark, and may not be used if you
+charge for the eBooks, unless you receive specific permission.  If you
+do not charge anything for copies of this eBook, complying with the
+rules is very easy.  You may use this eBook for nearly any purpose
+such as creation of derivative works, reports, performances and
+research.  They may be modified and printed and given away--you may do
+practically ANYTHING with public domain eBooks.  Redistribution is
+subject to the trademark license, especially commercial
+redistribution.
+
+
+
+*** START: FULL LICENSE ***
+
+THE FULL PROJECT GUTENBERG LICENSE
+PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK
+
+To protect the Project Gutenberg-tm mission of promoting the free
+distribution of electronic works, by using or distributing this work
+(or any other work associated in any way with the phrase "Project
+Gutenberg"), you agree to comply with all the terms of the Full Project
+Gutenberg-tm License (available with this file or online at
+http://gutenberg.org/license).
+
+
+Section 1.  General Terms of Use and Redistributing Project Gutenberg-tm
+electronic works
+
+1.A.  By reading or using any part of this Project Gutenberg-tm
+electronic work, you indicate that you have read, understand, agree to
+and accept all the terms of this license and intellectual property
+(trademark/copyright) agreement.  If you do not agree to abide by all
+the terms of this agreement, you must cease using and return or destroy
+all copies of Project Gutenberg-tm electronic works in your possession.
+If you paid a fee for obtaining a copy of or access to a Project
+Gutenberg-tm electronic work and you do not agree to be bound by the
+terms of this agreement, you may obtain a refund from the person or
+entity to whom you paid the fee as set forth in paragraph 1.E.8.
+
+1.B.  "Project Gutenberg" is a registered trademark.  It may only be
+used on or associated in any way with an electronic work by people who
+agree to be bound by the terms of this agreement.  There are a few
+things that you can do with most Project Gutenberg-tm electronic works
+even without complying with the full terms of this agreement.  See
+paragraph 1.C below.  There are a lot of things you can do with Project
+Gutenberg-tm electronic works if you follow the terms of this agreement
+and help preserve free future access to Project Gutenberg-tm electronic
+works.  See paragraph 1.E below.
+
+1.C.  The Project Gutenberg Literary Archive Foundation ("the Foundation"
+or PGLAF), owns a compilation copyright in the collection of Project
+Gutenberg-tm electronic works.  Nearly all the individual works in the
+collection are in the public domain in the United States.  If an
+individual work is in the public domain in the United States and you are
+located in the United States, we do not claim a right to prevent you from
+copying, distributing, performing, displaying or creating derivative
+works based on the work as long as all references to Project Gutenberg
+are removed.  Of course, we hope that you will support the Project
+Gutenberg-tm mission of promoting free access to electronic works by
+freely sharing Project Gutenberg-tm works in compliance with the terms of
+this agreement for keeping the Project Gutenberg-tm name associated with
+the work.  You can easily comply with the terms of this agreement by
+keeping this work in the same format with its attached full Project
+Gutenberg-tm License when you share it without charge with others.
+
+1.D.  The copyright laws of the place where you are located also govern
+what you can do with this work.  Copyright laws in most countries are in
+a constant state of change.  If you are outside the United States, check
+the laws of your country in addition to the terms of this agreement
+before downloading, copying, displaying, performing, distributing or
+creating derivative works based on this work or any other Project
+Gutenberg-tm work.  The Foundation makes no representations concerning
+the copyright status of any work in any country outside the United
+States.
+
+1.E.  Unless you have removed all references to Project Gutenberg:
+
+1.E.1.  The following sentence, with active links to, or other immediate
+access to, the full Project Gutenberg-tm License must appear prominently
+whenever any copy of a Project Gutenberg-tm work (any work on which the
+phrase "Project Gutenberg" appears, or with which the phrase "Project
+Gutenberg" is associated) is accessed, displayed, performed, viewed,
+copied or distributed:
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+1.E.2.  If an individual Project Gutenberg-tm electronic work is derived
+from the public domain (does not contain a notice indicating that it is
+posted with permission of the copyright holder), the work can be copied
+and distributed to anyone in the United States without paying any fees
+or charges.  If you are redistributing or providing access to a work
+with the phrase "Project Gutenberg" associated with or appearing on the
+work, you must comply either with the requirements of paragraphs 1.E.1
+through 1.E.7 or obtain permission for the use of the work and the
+Project Gutenberg-tm trademark as set forth in paragraphs 1.E.8 or
+1.E.9.
+
+1.E.3.  If an individual Project Gutenberg-tm electronic work is posted
+with the permission of the copyright holder, your use and distribution
+must comply with both paragraphs 1.E.1 through 1.E.7 and any additional
+terms imposed by the copyright holder.  Additional terms will be linked
+to the Project Gutenberg-tm License for all works posted with the
+permission of the copyright holder found at the beginning of this work.
+
+1.E.4.  Do not unlink or detach or remove the full Project Gutenberg-tm
+License terms from this work, or any files containing a part of this
+work or any other work associated with Project Gutenberg-tm.
+
+1.E.5.  Do not copy, display, perform, distribute or redistribute this
+electronic work, or any part of this electronic work, without
+prominently displaying the sentence set forth in paragraph 1.E.1 with
+active links or immediate access to the full terms of the Project
+Gutenberg-tm License.
+
+1.E.6.  You may convert to and distribute this work in any binary,
+compressed, marked up, nonproprietary or proprietary form, including any
+word processing or hypertext form.  However, if you provide access to or
+distribute copies of a Project Gutenberg-tm work in a format other than
+"Plain Vanilla ASCII" or other format used in the official version
+posted on the official Project Gutenberg-tm web site (www.gutenberg.org),
+you must, at no additional cost, fee or expense to the user, provide a
+copy, a means of exporting a copy, or a means of obtaining a copy upon
+request, of the work in its original "Plain Vanilla ASCII" or other
+form.  Any alternate format must include the full Project Gutenberg-tm
+License as specified in paragraph 1.E.1.
+
+1.E.7.  Do not charge a fee for access to, viewing, displaying,
+performing, copying or distributing any Project Gutenberg-tm works
+unless you comply with paragraph 1.E.8 or 1.E.9.
+
+1.E.8.  You may charge a reasonable fee for copies of or providing
+access to or distributing Project Gutenberg-tm electronic works provided
+that
+
+- You pay a royalty fee of 20% of the gross profits you derive from
+     the use of Project Gutenberg-tm works calculated using the method
+     you already use to calculate your applicable taxes.  The fee is
+     owed to the owner of the Project Gutenberg-tm trademark, but he
+     has agreed to donate royalties under this paragraph to the
+     Project Gutenberg Literary Archive Foundation.  Royalty payments
+     must be paid within 60 days following each date on which you
+     prepare (or are legally required to prepare) your periodic tax
+     returns.  Royalty payments should be clearly marked as such and
+     sent to the Project Gutenberg Literary Archive Foundation at the
+     address specified in Section 4, "Information about donations to
+     the Project Gutenberg Literary Archive Foundation."
+
+- You provide a full refund of any money paid by a user who notifies
+     you in writing (or by e-mail) within 30 days of receipt that s/he
+     does not agree to the terms of the full Project Gutenberg-tm
+     License.  You must require such a user to return or
+     destroy all copies of the works possessed in a physical medium
+     and discontinue all use of and all access to other copies of
+     Project Gutenberg-tm works.
+
+- You provide, in accordance with paragraph 1.F.3, a full refund of any
+     money paid for a work or a replacement copy, if a defect in the
+     electronic work is discovered and reported to you within 90 days
+     of receipt of the work.
+
+- You comply with all other terms of this agreement for free
+     distribution of Project Gutenberg-tm works.
+
+1.E.9.  If you wish to charge a fee or distribute a Project Gutenberg-tm
+electronic work or group of works on different terms than are set
+forth in this agreement, you must obtain permission in writing from
+both the Project Gutenberg Literary Archive Foundation and Michael
+Hart, the owner of the Project Gutenberg-tm trademark.  Contact the
+Foundation as set forth in Section 3 below.
+
+1.F.
+
+1.F.1.  Project Gutenberg volunteers and employees expend considerable
+effort to identify, do copyright research on, transcribe and proofread
+public domain works in creating the Project Gutenberg-tm
+collection.  Despite these efforts, Project Gutenberg-tm electronic
+works, and the medium on which they may be stored, may contain
+"Defects," such as, but not limited to, incomplete, inaccurate or
+corrupt data, transcription errors, a copyright or other intellectual
+property infringement, a defective or damaged disk or other medium, a
+computer virus, or computer codes that damage or cannot be read by
+your equipment.
+
+1.F.2.  LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the "Right
+of Replacement or Refund" described in paragraph 1.F.3, the Project
+Gutenberg Literary Archive Foundation, the owner of the Project
+Gutenberg-tm trademark, and any other party distributing a Project
+Gutenberg-tm electronic work under this agreement, disclaim all
+liability to you for damages, costs and expenses, including legal
+fees.  YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT
+LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE
+PROVIDED IN PARAGRAPH F3.  YOU AGREE THAT THE FOUNDATION, THE
+TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE
+LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR
+INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH
+DAMAGE.
+
+1.F.3.  LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a
+defect in this electronic work within 90 days of receiving it, you can
+receive a refund of the money (if any) you paid for it by sending a
+written explanation to the person you received the work from.  If you
+received the work on a physical medium, you must return the medium with
+your written explanation.  The person or entity that provided you with
+the defective work may elect to provide a replacement copy in lieu of a
+refund.  If you received the work electronically, the person or entity
+providing it to you may choose to give you a second opportunity to
+receive the work electronically in lieu of a refund.  If the second copy
+is also defective, you may demand a refund in writing without further
+opportunities to fix the problem.
+
+1.F.4.  Except for the limited right of replacement or refund set forth
+in paragraph 1.F.3, this work is provided to you 'AS-IS', WITH NO OTHER
+WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO
+WARRANTIES OF MERCHANTIBILITY OR FITNESS FOR ANY PURPOSE.
+
+1.F.5.  Some states do not allow disclaimers of certain implied
+warranties or the exclusion or limitation of certain types of damages.
+If any disclaimer or limitation set forth in this agreement violates the
+law of the state applicable to this agreement, the agreement shall be
+interpreted to make the maximum disclaimer or limitation permitted by
+the applicable state law.  The invalidity or unenforceability of any
+provision of this agreement shall not void the remaining provisions.
+
+1.F.6.  INDEMNITY - You agree to indemnify and hold the Foundation, the
+trademark owner, any agent or employee of the Foundation, anyone
+providing copies of Project Gutenberg-tm electronic works in accordance
+with this agreement, and any volunteers associated with the production,
+promotion and distribution of Project Gutenberg-tm electronic works,
+harmless from all liability, costs and expenses, including legal fees,
+that arise directly or indirectly from any of the following which you do
+or cause to occur: (a) distribution of this or any Project Gutenberg-tm
+work, (b) alteration, modification, or additions or deletions to any
+Project Gutenberg-tm work, and (c) any Defect you cause.
+
+
+Section  2.  Information about the Mission of Project Gutenberg-tm
+
+Project Gutenberg-tm is synonymous with the free distribution of
+electronic works in formats readable by the widest variety of computers
+including obsolete, old, middle-aged and new computers.  It exists
+because of the efforts of hundreds of volunteers and donations from
+people in all walks of life.
+
+Volunteers and financial support to provide volunteers with the
+assistance they need, is critical to reaching Project Gutenberg-tm's
+goals and ensuring that the Project Gutenberg-tm collection will
+remain freely available for generations to come.  In 2001, the Project
+Gutenberg Literary Archive Foundation was created to provide a secure
+and permanent future for Project Gutenberg-tm and future generations.
+To learn more about the Project Gutenberg Literary Archive Foundation
+and how your efforts and donations can help, see Sections 3 and 4
+and the Foundation web page at http://www.pglaf.org.
+
+
+Section 3.  Information about the Project Gutenberg Literary Archive
+Foundation
+
+The Project Gutenberg Literary Archive Foundation is a non profit
+501(c)(3) educational corporation organized under the laws of the
+state of Mississippi and granted tax exempt status by the Internal
+Revenue Service.  The Foundation's EIN or federal tax identification
+number is 64-6221541.  Its 501(c)(3) letter is posted at
+http://pglaf.org/fundraising.  Contributions to the Project Gutenberg
+Literary Archive Foundation are tax deductible to the full extent
+permitted by U.S. federal laws and your state's laws.
+
+The Foundation's principal office is located at 4557 Melan Dr. S.
+Fairbanks, AK, 99712., but its volunteers and employees are scattered
+throughout numerous locations.  Its business office is located at
+809 North 1500 West, Salt Lake City, UT 84116, (801) 596-1887, email
+business@pglaf.org.  Email contact links and up to date contact
+information can be found at the Foundation's web site and official
+page at http://pglaf.org
+
+For additional contact information:
+     Dr. Gregory B. Newby
+     Chief Executive and Director
+     gbnewby@pglaf.org
+
+Section 4.  Information about Donations to the Project Gutenberg
+Literary Archive Foundation
+
+Project Gutenberg-tm depends upon and cannot survive without wide
+spread public support and donations to carry out its mission of
+increasing the number of public domain and licensed works that can be
+freely distributed in machine readable form accessible by the widest
+array of equipment including outdated equipment.  Many small donations
+($1 to $5,000) are particularly important to maintaining tax exempt
+status with the IRS.
+
+The Foundation is committed to complying with the laws regulating
+charities and charitable donations in all 50 states of the United
+States.  Compliance requirements are not uniform and it takes a
+considerable effort, much paperwork and many fees to meet and keep up
+with these requirements.  We do not solicit donations in locations
+where we have not received written confirmation of compliance.  To
+SEND DONATIONS or determine the status of compliance for any
+particular state visit http://pglaf.org
+
+While we cannot and do not solicit contributions from states where we
+have not met the solicitation requirements, we know of no prohibition
+against accepting unsolicited donations from donors in such states who
+approach us with offers to donate.
+
+International donations are gratefully accepted, but we cannot make
+any statements concerning tax treatment of donations received from
+outside the United States.  U.S. laws alone swamp our small staff.
+
+Please check the Project Gutenberg Web pages for current donation
+methods and addresses.  Donations are accepted in a number of other
+ways including checks, online payments and credit card donations.
+To donate, please visit: http://pglaf.org/donate
+
+
+Section 5.  General Information About Project Gutenberg-tm electronic
+works.
+
+Professor Michael S. Hart is the originator of the Project Gutenberg-tm
+concept of a library of electronic works that could be freely shared
+with anyone.  For thirty years, he produced and distributed Project
+Gutenberg-tm eBooks with only a loose network of volunteer support.
+
+Project Gutenberg-tm eBooks are often created from several printed
+editions, all of which are confirmed as Public Domain in the U.S.
+unless a copyright notice is included.  Thus, we do not necessarily
+keep eBooks in compliance with any particular paper edition.
+
+Most people start at our Web site which has the main PG search facility:
+
+     http://www.gutenberg.org
+
+This Web site includes information about Project Gutenberg-tm,
+including how to make donations to the Project Gutenberg Literary
+Archive Foundation, how to help produce our new eBooks, and how to
+subscribe to our email newsletter to hear about new eBooks.
+
+*** END: FULL LICENSE ***
+
author	Fudgerboy <91767657+Fudgerboy@users.noreply.github.com>	2024-04-14 05:02:38 +0000
committer	Fudgerboy <91767657+Fudgerboy@users.noreply.github.com>	2024-04-14 05:02:38 +0000
commit	248d296234dc7ce76294c677bf2ca5e76c2f50d1 (patch)
tree	5a38d5a5eb4cd6075e10de1583fde289c144cc91 /wk5/pset/speller/texts/surgery.txt
parent	ba93a5dca5f93fe7b5761c251037d4f1860f9a43 (diff)